Concussion Recovery: The Essential Role of School-Based Occupational Therapy Practitioners

Concussion Injuries

A concussion, or mild traumatic brain injury, results from a direct or indirect hit to the head, neck, face, or body (Andreas et al., 2021; DeMatteo et al., 2020) and is often the consequence of a sports or leisure injury. Concussed youth may experience lingering physical, cognitive, and emotional symptoms that disrupt engagement or challenge performance in leisure, sports, and educational occupations (Andreas et al., 2021; Moen et al., 2022; Wildgoose et al., 2022). Lingering cognitive symptoms may be categorized as executive dysfunction impairments that involve difficulty completing novel tasks, identifying and correcting errors, planning and prioritizing, setting goals, organizing, problem-solving, concentrating, self-monitoring, orienting, and memory (Cramm et al., 2013; Martinez & Small 2014; Urbanik, 2023). Physical symptoms of concussion are often experienced as headache, dizziness, nausea, fatigue and sleep disturbances, sensory sensitivity to sounds, and visual disturbances, whereas emotional symptoms are often experienced as depression, anxiety, and difficulty identifying and describing feelings (Buck, 2022; Urbanik, 2023). These neurological, physical, cognitive, and emotional symptoms may resolve within 1 mo postinjury but can persist beyond that time frame (Andreas et al., 2021; Moen et al., 2022).

Factors That Influence Reengagement in Educational Activities

Variability in educators’, coaches’, and parents’ knowledge can influence the timeliness of diagnosis and management of concussion. For instance, youth may withdraw or become hesitant to reengage in preinjury occupations even when it may be safe to do so because of self-perceived concerns surrounding reinjury or exacerbation of symptoms (Moen et al., 2022). This lack of engagement prolongs recovery and can produce “depression, anxiety, social isolation, loss of academic standing, and physical deconditioning” (DeMatteo et al., 2020, p. 8). Conversely, some postconcussed students return to learning too rapidly and exert too much cognitive activity too quickly, resulting in the exacerbation of concussion symptoms that essentially prolong recovery (Master et al., 2012). Postconcussed youths’ experiences surrounding their return to educational occupations can guide school-based occupational therapy practitioners’ design of “successful intervention approaches and improved service delivery” (Moen et al., 2022, p. 2).

Contextual Considerations

School-based occupational therapy is an existing support system within the school structure that postconcussed youth can receive through a process of procedures that adhere to the specific state’s occupational therapy practice act and the Individuals With Disabilities Education Improvement Act of 2004 (IDEA; Pub. L. 108-446). In fact, the American Occupational Therapy Association (AOTA; 2017), in the document “Guidelines for Occupational Therapy Services in Early Intervention and Schools,” clearly defined the role of school-based occupational therapy as being influenced by legislation such as IDEA (2004), the Every Student Succeeds Act of 2015 (Pub. L. 114-95), Section 504 of the Rehabilitation Act Amendments of 2004 (Pub. L. 108-364), and the ADA Amendments Act of 2008 (Pub. L. 110-325).

The contributions of school-based practitioners who work at the systems level to “identify the child’s current performance in his/her occupations, the affordances and barriers to successful engagement, and the priorities and concerns of parents and school staff to develop goals for the child” (AOTA, 2017, p. 4) correspond to occupational therapy practice guidelines (AOTA, 2020) with respect to designing interventions that offer a continuum of collaborative support to the educational team when a postconcussed student is experiencing barriers to participation in educational occupations. Intervention approaches include the development of universal design for learning (UDL) strategies, such as task modification, accommodations to promote participation, and modified learning environments (Finn, 2019), that align with the capabilities of the postconcussed youth during the recovery phase to promote inclusive participation. The same context of support can be offered to coaches so that postconcussed youth can safely reengage in play through modified physical activity or alternative team roles during the recovery phase. Best-practice guidelines recognize the “unique contribution [of occupational therapy] to the multidisciplinary team” (Finn, 2019, p. 13) and the role occupational therapy plays in helping students return to the classroom (Acord-Vira et al., 2021).

Occupational Needs

Evidence has emerged that recognizes the risk of prolonged occupational deprivation on postconcussed youths’ emotional, physical, and mental health. Several scholars have highlighted the benefit of occupation-based approaches, citing the importance of analyzing occupational performance; promoting goodness of fit among the person, environment, and task; facilitating a gradual resumption of activity that includes pacing and opportunities to rest; and developing environmental or activity adaptations to facilitate a recovery that promotes academic progression and mental well-being (Andreas et al., 2021; Copley et al., 2010; Finn, 2019; Gillooly, 2016; Martinez & Small, 2014). The Canadian Occupational Performance Measure (COPM; Law et al., 2019), the Cognitive Orientation to daily Occupational Performance (CO-OP) approach (Hunt et al., 2019), and a multitiered system of support (MTSS; Copley et al., 2010; Cramm et al., 2013) are occupation-based approaches that facilitate recovery in postconcussed youth. These approaches complement updated concussion management protocols, which emphasize a shortened period of physical and cognitive rest (24–48 hr) followed by a gradual return to occupation through symptom-guided light activity and aerobic exercise (DeMatteo et al., 2020). The updated protocols draw attention to the rapid recovery rate of postconcussed youth by endorsing interventions that include safe reengagement in occupation. Psychological benefits can result from the youth’s ability to participate in tasks that facilitate social belonging and a return to “tasks they love, want and need to do” (DeMatteo et al., 2020, p. 8).

A Feasible Delivery Model

Postconcussed youth require a structure of support within the general education setting that often involves accommodations (Gioia et al., 2016) that are supported by occupation-based approaches that are individualized, person centered, strengths based, collaborative, and context driven (Hunt et al., 2019; Lynch et al., 2023; Moen et al., 2022). One such approach is a multitiered model that emphasizes participation in learning for at-risk students (Lynch et al., 2023) by in corporating a graded approach that includes UDL, modifications of teaching materials, and individualized support that capitalizes on the postconcussed student’s needs. Although differences in multitiered models occur within the context of each school, occupational therapy practitioners who provide collaborative coaching and capacity-building to educators produce positive outcomes for at-risk students (Lynch et al., 2023).

Tier I school-based occupational therapy support (Kearney & Childs, 2021) begins with health-promoting educational activities that foster concussion awareness. Health- promoting activities may include the use of visual aids, informational handouts, in-service education, and the development of concussion education programs that increase knowledge (Hickling et al., 2020) within the student body and among educational staff, coaches, and administrators. Concussion awareness and prevention programs may include lunch-and-learn activities that provide education on concussion assessment protocols during team sports, communication protocols for suspected concussion injuries, and assessing the proper fit of sports gear, as well as assemblies that educate the student body on concussion signs, symptoms, and prevention.

Tier II school-based occupational therapy support may be provided after an initial occupational therapy screening request is received and caregiver permission has been obtained. Screening takes place within the educational context; can be initiated at any time; and can be requested by a variety of familial, educational, or medical sources if a postconcussed student begins to experience participation challenges. The screening process may include a summary of supports that have already been provided, a listing of participation-related concerns, observation of the postconcussed youth performing within the natural educational context, and interviews with educational staff and the postconcussed youth. Tier II supports may include task and environmental modifications; assistive technology, including reading and writing aids; modified schedules; incorporating relaxation activities into daily routines; discussing energy conservation and sleep hygiene strategies; social reengagement below the symptom threshold; identifying symptom-alleviating strategies that support nutritional health and mitigate cognitive and physical fatigue; exploration of alternative team roles; and graduated participation in team drills below the symptom threshold throughout the youth’s recovery.

Tier III school-based occupational therapy support is offered to a postconcussed youth if the educational team determines that more individualized support is needed, and it initiates the process of school-based occupational therapy evaluation and direct intervention. The evaluation process begins in accordance with the occupational therapy practitioner’s state practice guidelines and in conjunction with the postconcussed youth’s school district evaluation procedures. It involves collaboration with other allied health professionals involved in the postconcussed youth’s care.

Assessment and Intervention

A school-based occupational therapy programming model could emphasize the use of the Dove–Hawk Model of Allostatic Load for Youth With Persistent Concussion Symptoms (Paniccia & Reed, 2017), AOTA’s (2021) Occupational Profile, the COPM, and the CO-OP approach as integral components of programming for postconcussed youth, although additional occupation-based assessments and interventions may be included in postconcussion service delivery. The Dove–Hawk Model of Allostatic Load for Youth with Persistent Concussion Symptoms describes how person-related factors can produce behavior profiles that influence recovery and emphasizes a focus on self-management, the creation of personal boundaries, and the development of realistic expectations to guide effective return to activity. Postconcussed youth who exhibit a passive dove profile may withdraw from activity for fear of reinjury or symptom exacerbation, whereas postconcussed youth who exhibit an active hawk profile may ignore symptoms and initiate a hasty return to preinjury activity. Postconcussed youth recovery can be prolonged in both of these scenarios. School-based occupational therapy practitioners can facilitate an intervention that supports knowledge of concussion recovery guidelines; symptom management; and a graded approach to meaningful occupation below the symptom threshold through task and environmental adaptations that are occupation centered, solution focused, and designed to maximize student participation (Acord-Vira et al., 2021; Lynch et al., 2023).

The CO-OP takes a similar self-management approach to facilitate reengagement in occupations that can positively contribute to postconcussion recovery through collaborative goal setting rather than activity restriction; hence, reengagement in occupation is symptom guided (Hunt et al., 2019; Roelke et al., 2022). Occupational therapy practitioners facilitate reengagement in occupation by helping postconcussed youth “identify their goal, develop a plan to address the goal, carry out the plan, and then determine how their plan is working” (Roelke et al., 2022, p. 388).

Goal Setting

Collaborative problem-solving that includes postconcussed youth and their families in the goal-setting process is fundamental to occupational therapy practice and “has been associated with increased motivation to participate in rehabilitation” (Wheeler et al., 2022, p. 3). Educational interventions can be guided by an understanding of caregivers’ perceptions of concussion recovery and learning challenges associated with caring for the postconcussed youth, as well as identification of intervention strategies that can be easily embedded into natural routines to support recovery (Paniccia & Reed, 2017). For example, interventions that provide concussion education, increase caregiver knowledge, and clarify caregiving roles can be effective strategies to support recovery (Acord-Vira et al., 2022). Educational handouts and visual aids guide individualized interventions and inform caregivers and postconcussed youth of recovery guidelines that address nutritional strategies that support brain health; sleep hygiene strategies; physical activity; energy conservation; coping strategies; social reengagement; visual strategies and adaptations that support classroom performance; and relaxation strategies that can be embedded into classroom routines.