Heads in the Game: Concussion effects are becoming much better understood
Michael Collins, right, reviews the comparison of concussion test scores with Gaige Pavlocak and his father, Jeff, in September during their second visit with Dr. Collins at the UPMC Sports Medicine complex on Pittsburgh's South Side.
Gaige Pavlocak undergoes a vestibular evaluation at the UMPC Sports Medicine center
Physical therapy resident Pam Dunlap evaluates Gaige Pavlocak's balance
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Every Tuesday and Wednesday, for the five hours total for which a school district gets reimbursed by the state, a Southmoreland High School math teacher brings books, coursework and specialized instruction to the Mount Pleasant home of Gaige Pavlocak, 15.
Gaige, despite recent improvements in his symptoms, health and outlook, has been academically exiled to his home for more than six weeks because of the post-concussion effects still lingering from a helmet-to-helmet collision on the third day of high-school football camp.
That was Aug. 18, 101 days ago.
Such an extended period away from school -- after attempts at half days and full days at Southmoreland -- plays havoc with the academic progress of a high-school sophomore, much less his teenage psyche, friendships, everything.
"The homebound education, that's one of our concerns right now," father Jeff Pavlocak said. "But it seems to be going pretty well."
Gaige is one of unspecified hundreds of Pennsylvania students and athletes being educated at home or in some modified fashion because of a concussion.
And the numbers could be significantly higher.
Brenda Eagan Brown oversees the free, statewide BrainSTEPS program that helps to meet the educational needs of students across the commonwealth recovering from a traumatic brain injury.
Half of the students they serve, from preschool through high school, are concussion sufferers.
When the program started four years ago under both the Pennsylvania departments of Education and Health, she said, "originally we thought our focus would be working with students who suffered severe traumatic brain injuries and were coming out of rehab. Now 50 percent of all the traumatic brain injuries that we serve [are] concussions.
"Many times, it's the students with concussions who are not getting better. Or taking a long time to get better."
Therein rests a twofold problem, said the coordinator of the program whose acronym stands for Strategies Teaching Educators, Parents and Students.
Many of those same people who qualify for state BrainSTEPS or homebound education assistance either:
• Don't comprehend the potential academic effects upon a student post-concussion -- a period normally three weeks or later following the initial injury.
• Or don't realize the gravity of a concussion, period.
"We have students who have never lost a second of consciousness who are doing far worse in school than students who were in a coma for a day or two, those considered severely, traumatically brain injured," Mrs. Eagan Brown said. "If nothing else, people need to understand that the medical diagnosis of concussion has nothing to do with educational outcome. At all." Rather, she said, it's the symptoms that remain or the chemical imbalance and the biomechanical problems that are slow to heal in the brain -- hence the days, weeks and months it may take some students to return to normal.
"The biggest barrier is public perception is based on what they see in movies. Like Wile E. Coyote: He hits his head, sees stars and then he's all right. Or Dorothy in 'The Wizard of Oz:' She got knocked out -- she had a brain injury when the window sill hit her on the head during the tornado -- and then she had a good dream, woke up and she was fine."
Statistics are the grains of sand beneath a brain injury whose research remains new, shallow and difficult to grasp. It is, for the most part, a science studied barely the past 10 years. The Pennsylvania Department of Health reported that more than 3,700 children aged 21 and under were hospitalized with a traumatic brain injury in 2004 and more than 3,900 in 2006, the most recent years of study.
Mrs. Eagan Brown said more than 400 names were recently input into the BrainSTEPS database, accounting for children they have assisted recently. "But that is not indicative of how many students we've served in the past four years. I know it's more than that. Without a doubt."
It could be higher still, she said, if more of Pennsylvania's 501 school districts either knew of or better utilized her program.
After regular, painful headaches ended Gaige's attempt to attend classes for half-days, Mr. Pavlocak said Southmoreland High officials initially asked for Gaige to return to school after hours for tutoring. Problem was, as with most post-concussion sufferers, light and noise sensitivity even in a relatively empty school can cause symptoms to return -- a condition that stymies an already lagging recovery. Once the family agreed to have an adult present during home-tutoring sessions, the Tuesday-Wednesday routine was set in place. Under homebound education, often invoked utilizing Section 504 of the federal disability Rehabilitation Act, re-evaluation is required every three months. However, the Pavlocaks hope Gaige will be allowed -- after his early December appointment with his specialist -- to return to school next month, albeit on half-days to start.
Mr. Pavlocak said Gaige for now seems to be caught up and faring well despite all the class time missed. If assignments perplex him or questions remain, he communicates with those teachers via e-mail. In early stages with some patients, however, including Gaige a month ago, teenage staples such as e-mailing, texting and reading are off limits if they induce headaches or other symptoms.
Michael "Micky" Collins, the assistant director of the UPMC Sports Medicine concussion program and Gaige's specialist, hears tales of schools that oppose academic modifications for kids with concussions. So when the Pavlocaks described to him how Southmoreland High administrators seemed willing to work with them, Dr. Collins grinned and exclaimed, "I wish I could bottle this school."
At Southmoreland High, guidance counselor Ted Mizik and his colleagues "consider it a part of life in school" to accommodate students with concussions, he said. The 700-student school experienced "significantly more" cases last year, he added, than the six to 10 kids currently with concussions, incurred beyond football.
"Any concussion is just brutal right now," Mr. Mizik continued. "We've had students affected for the whole school year."
It isn't simply a physical recovery, either. Emotions get roiled. Futures get bogged, or derailed.
"I'll tell you, it's a big deal when you have a 10th-grader who's in the gifted program and on track for a scholarship and gets a severe concussion during soccer," Mrs. Eagan Brown said. "Say they're only out of school for a semester, which is very common. That can completely throw them off that scholarship route. It's horrible."
Where BrainSTEPS trains, formulates an academic plan and follows up with students and families, districts using homebound find themselves tailoring individual plans for each student with a concussion so he or she can return to function fully in a classroom, let alone a field or court.
The Pittsburgh Public Schools, for instance, have a half-dozen students under a homebound instruction plan due to concussions sustained anywhere from accidents to sports. "And it'll grow," said Janet Yuhasz, the district's health coordinator, citing the upcoming basketball season as one factor.
The idea is to limit the school time missed from months to weeks to days to hours to nothing.
"The best thing is to get the child re-integrated into school at the best possible time for them. We're trying to hit the mark for that," Mrs. Yuhasz said. "Sometimes, it upsets the parents or teachers [if the homebound period drags on]. But we're protecting that child, and we're doing everything we can for that child."
The path varies.
"There isn't a one-size-fits-all," said John Wyllie, principal of the Butler Area Intermediate High, encompassing freshmen and sophomores where "unfortunately, we seem to have quite a bit of experience" with concussions.
"Every time is different," Mr. Mizik of Southmoreland said. "It's amazing."
Not only are there many Pennsylvania school-district officials who don't know about or have yet to tap into the BrainSTEPS program, a far greater number of educators still fail to see a need to modify coursework for any students with concussions.
"What I've found is, anywhere we have resistance -- and we meet resistance, because of that public perception -- 'Oh, they're fine,' 'They look fine,' 'The doctor said they're going to be fine' -- once we do awareness training, to let them know this is real and serious, the compassion tends to change [for the better]," Mrs. Eagan Brown said.
"We aren't teaching teachers anything they don't already know. All we're saying is, let's try these accommodations you already use with other students."
Most, if not all, of these academic accommodations are borrowed from success with students facing challenges in sight or hearing, or disabled students.
Among the modifications often used:
• Partial school days. Mr. Wyllie spoke of one student returning at the bare minimum to start, one period. Most often, children start back at two half-days a week, possibly three -- mostly in the mornings -- before the onset of headaches, dizziness or fatigue.
• Repeating a class, dropping a class for a semester or choosing an incomplete. That can be "heartbreaking and devastating" at times, Mrs. Brown said.
• Getting a set of books for home. Students with lingering balance/vestibular problems might be endangered by walking down flights of stairs with a book-filled backpack.
• Altering homework. It can be halted completely, lightened overall or pared in certain areas.
• Altering note-taking. Students try books and lectures on tape, a copy of the teacher's notes, even a copy of the teacher's Power Point presentation.
• Altering tests. That could mean fewer questions or problems, extending the time allowed, or presenting the test in a way that doesn't aggravate symptoms, such as an oral exam for a student who gets headaches from reading. Sometimes, the solution is as simple as a separate, quiet classroom.
• Restricting stimuli such as light, sound and crowds.
"I would say as recently as five years ago, it was very rare for a student to miss any length of school time after a concussion," said Mr. Wyllie of Butler. But, even then, he remembers hearing teachers talk about how such children initially had difficulty returning. Between greater awareness and medical gains, he sees light at the end of the dark, painful tunnel of concussions.
"I would say certainly the last two school years, the number of students who are being treated has absolutely risen -- it's not so much that there are more [instances] of them, it's that they're identified better. And the response has gotten better. We know more about it."
First Published November 29, 2010 12:00 am