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Virginia Concussion Initiative Works Alongside Schools to Develop Protocols Guidelines (Part Two)

One of the key reasons for the Virginia Concussion Initiative was the realization that the one- size-fits-all approach from some of the national and even international messaging sources don’t always consider local resources and the ability of local communities and medical providers to have the ability to quickly implement best practices in their particular community.

Explains Dr. Shane V. Caswell, who has spearheaded this initiative, “Our first thing that we addressed was to understand the barriers to implementing best practices in our Virginia schools.”

Challenges facing school districts include rapidly changing science, a difficulty keeping pace with constantly changing requirements, and marshalling necessary resources and personnel to implement best practices and concussion management within the schools.

“We worked closely alongside our schools from a 360 degree perspective gathering information from all stakeholders involved in concussion management in the schools,” says Dr. Caswell.

What they learned within the first couple of phases of the Virginia Concussion Initiative was that school districts want tools that can be tailored to fit what they can realistically provide.

“We realized that schools needed tools that could be modified, that could be templates for them to use,” he explains. “Tools are being developed for primary schools all the way through secondary schools and individuals with developmental disabilities, as well as some pre-K assessment tools.  The tools range from how to appropriately form a concussion management team in your school division, to how to develop policy, and we have created some model policies for schools. We’ve attempted to be mindful of things such as whether or not it’s a large school, a small school, highly resourced, not as well resourced, and providing tools for the web that are modifiable, so that they can be downloaded and used as needed.”

Tools are available through a web-based resource that’s been vetted by the Virginia Concussion Initiative team of experts. The goal is that schools have a one-stop shop where they access the tools that meet their particular needs in providing effective best practice concussion management for students.

“This should, we expect, reduce some of the confusion and the many voices on the topic of concussion management best practices and the advancement of the science to be more useful for all of our schools and meet them where they are at,” says Dr. Caswell.

Virginia Concussion Initiative Includes Telementoring for Medical Communities (Part three)

For the past few years, a group of medical professionals and educators have been working together to develop effective concussion management tools for schools in Virginia.

The head of the Virginia Concussion Initiative (VCI), Dr. Shane V. Caswell, says the group has developed an a la carte menu of tools that schools can select from that best fit their particular situation, resources, personnel, etc. “We’ve developed tools, and guidance that will provide suggestions as to the types of tools that they should consider using, for concussion assessment. Appropriate, effective patient interviewing techniques will be included and suggested not only for school providers but also for teachers on how to talk to kids about concussion,” explains Dr. Caswell.

For example, there is a set of recommendations for teachers to help them identify symptoms of children in their classroom who may be experiencing concussion-related symptoms. And there is information for parents and caregivers to help them ask the right questions when taking their child to the doctor with a possible concussion, and what information they should report back to the school.

On the medical side of the equation, telementoring programming is being developed that will specifically target community providers and school-based medical providers. Says Dr. Caswell, “One of our goals is to bring these two groups together, through this telementoring community and to create local networks to create awareness from the school’s perspective about what are the local resources available in the community, and who are the local experts, and experts available throughout the state.”

Zoom technology will be used to bring together community members from various backgrounds to work with experts on the VCI, to identify ways in which they can facilitate communication between medical providers in the local community and in the schools and how they can best serve the teachers and the schools and the students, in their community.

“We’re all here to help support young minds of Virginia, right? We’re all here to try to ensure, that kids, number one, don’t suffer a concussion as much as we can, reduce the risk of it. But if they do that, they can recover as quickly and as fully as possible,” says Dr. Caswell.

Virginia’s Concussion Initiative Strives to Standardize Student Care

To assist school districts in developing concussion protocols that work best for their districts and provide a quality standardized level of student care, the Virginia Concussion Initiative (VCI) was formed.

The initiative’s overarching goal is to support Virginia’s school divisions, helping them develop and implement more effective policies that help not only the students, but also their families on how to better manage concussion when it occurs in a student, explains Shane V. Caswell, PhD, ATC, CSCS Professor, who is heading up the Virginia Concussion Initiative.

In 2014, Virginia lawmakers enacted the Student Athlete Protection Act to ensure that student athletes who sustain concussions are accurately diagnosed, given time to heal, and supported until they are symptom free. The Act required the state’s Board of Education to develop Concussion Guidelines to provide a framework for Virginia’s school districts in managing student concussions. A hallmark effort within this initiative is the Virginia Department of Health-VCI partnership with the Virginia Department of Education (VDOE) to update the 2016 Virginia Board of Education (VBOE) Guidelines for Policies on Concussions in Students. Most recently in 2021, the Guidelines established best practices for concussion recognition and management in school divisions pursuant to House Bill 1930.

“Sometimes we come at it from different perspectives. I’ve seen many instances where the same recommendation from a concussion specialist is interpreted different ways or implemented different ways by different teachers,” says John Reynolds MS, ATC, VATL Athletic Training Program Administrator, Fairfax County Public Schools.

Standardizing the approach to return to play and return to learn are the goals, while being mindful of the fact that different counties in Virginia have access to different resources. The team of experts working on the Virginia Concussion Initiative is developing materials and tools for professionals to use to help students.

“These tool kits are devised around a group of stakeholders in school, from school leaders to schoolteachers, to school-based medical personnel, and also community-based providers, as well as moms and dads and families at home who can learn more from these tools about how to better manage and care for children in the schools who suffer a concussion,” says Dr. Caswell.  “It’s important that we think about concussion, not just from the sporting sense, but from the standpoint of how this injury, this traumatic brain injury is affecting the child’s development, their learning, their social interactions, and that we help to respond accordingly to support their recovery.”

Virginia Key Stakeholders Develop Protocols for Schools and Concussion (Part One)

Dr. Shane V. Caswell vaguely remembers many years ago, playing ice hockey, hitting the boards headfirst, and losing consciousness. He was carried off the ice and returned to the game about five minutes later. Fortunately, times are changing, and people realize that a concussion is a brain injury that should be taken seriously.

Lucky for Dr. Caswell, PhD, ATC, CSCS Professor, the team mom insisted that he be taken out of play. However, he was back on the ice the next day.  Years later, as he was studying to become a sports medicine professional, he reflected on that experience.


“As we learn more about concussion, I reflect back on this experience and realize how poorly my situation was managed because at the time we just didn’t know any better and that I’m really grateful to have had a good outcome,” he says.


It’s possible that this early experience helped inform his choice to focus professionally on pediatric sports medicine and in particular risk reduction of head injuries. Lately, he’s also been busy spearheading the Virginia Concussion Initiative, a collective approach by medical professionals and educators, with key input and information provided by parents and athletic coaches, to develop concussion protocols that work best for the state’s school districts and provide a quality standardized level of student care.


The initiative’s tagline is “Supporting Young Minds of Virginia” and the overarching goal is to empower Virginia schools and their local communities to successfully implement best practices for concussion prevention and management, says Dr. Caswell.


It’s been particular crucial to work closely with the schools to gather input from those working on the ground who want to ensure that the students in their schools can participate in school sports safely and that proper concussion management is in place, that it is supported by all key stakeholders, and that best practices are made available as they become available. “Obviously, implementation will vary across school districts because our state has so many different demographic regions. Guidelines are being developed in a way that schools can implement them in a matter that is realistic for their particular situation,” says Dr. Caswell.

Staying Steady on Your Feet; Preventing Falls as You Age

Falls are common and costly, especially among Americans age 65 and older. But falls are preventable and do not have to be an inevitable part of aging.

Every second of every day, an older adult (age 65+) suffers a fall in the U.S.—making falls the leading cause of injury and injury death in this age group, according to the Centers for Disease Control. Falls have become a public health concern, especially among the aging population.

The CDC offers these facts about falls among older adults:

  • More than 35 million older adults fall each year—resulting in thousands of deaths.
  • A significant percentage of these falls result in an injury, such as broken bones or a head injury.

Falls are not a normal part of aging. You can keep on your feet and avoid the risk of a fall. Take steps to stay safe and independent longer. Senior centers and fitness centers often offer classes specifically targeted to helping older adults retain muscle strength and balance, both of which are critical for avoiding falls.

Here are some other ways to protect yourself from falls as you age:

  • Talk openly with your doctor about fall risks and prevention.
  • Tell your doctor right away if you have fallen, if you’re afraid you might fall, or if you feel unsteady.
  • Review all of your medicines with your doctor or pharmacist and discuss any side effects like feeling dizzy or sleepy.
  • Have your eyes checked annually and update your glasses, as needed. Conditions like cataracts and glaucoma limit your vision.
  • Have your feet checked. Discuss proper footwear with your doctor and ask whether seeing a foot specialist (podiatrist) is advised.

Make Your Home Safe

  • Get rid of trip hazards. Keep floors clutter free.
  • Add grab bars in the bathroom.
  • Have handrails and lights installed on all staircases.

Check out the Centers for Disease Control website for more information about fall prevention. Visit: https://www.cdc.gov/injury/features/older-adult-falls/index.html.

Pre-Existing Conditions And Concussion Treatment (Part Two)

Most individuals who have sustained a concussion will recover within four weeks. Medical professionals are studying the “outlier population” of people who, for one reason or another, take longer to recover.

For some, it is a matter of age. The elderly population recovers more slowly from traumatic brain injuries. For others, concussion recovery can be complicated by a pre-existing medical condition related to the brain.

Dr. Nathan Cook, Pediatric Neuropsychologist, Sports Concussion Program, Massachusetts General Hospital for Children, is part of the Virginia Concussion Initiative and works primarily with “outlier” cases, which he describes as children and young people who take longer than the usual four weeks to recover from a concussion.

The challenge in treating this population is in being able to distinguish between symptoms caused by the concussion, and symptoms related to a pre-existing condition. Balance issues and headache are two of the more typical examples.

Dr. Cook explains that when a young person who suffers from anxiety and headaches, for instance, sustains a concussion, the injury will by its nature bring along symptoms such as chronic headache and perhaps sleep difficulty. “A concussion might turn up the volume on mood irritability, nervousness or tension. This can make things more difficult for a student who is already vulnerable because of one or more pre-existing mental health conditions.”

“So you can imagine you’re kind of getting by at school really quite stressed, struggling with these other concerns, and then you have an injury and that’s just one extra barrier. And so now you start to fall behind on schoolwork or fall further behind on schoolwork. Things can begin to compound more quickly.  In that case, we might also think about helping negotiate a school plan, helping to advocate for that student in school, help determine what sort of accommodation supports might be beneficial for that particular youth,” says Dr. Cook.

He explains that a major complexity with patients who present with pre-existing conditions is determining the point at which it is safe for them to return to sports play, including whether to return specifically to contact sports.

“That’s really a key difference clinically in terms of determining recovery from a treatment and rehab standpoint. The menu of options that we’re choosing from wouldn’t differ necessarily, but maybe the variety, and number of activities that we’re going to try to integrate into a rehab plan and, or the intensity of the treatment rehab might differ. For example, generally the majority of pediatric concussions can recover quite swiftly in days or weeks, and we wouldn’t be thinking about the need to get that patient involved with mental health support, for example. But with someone who already has preexisting anxiety, maybe even sub-threshold mild anxiety, psychological health treatment may be indicated over a period of time.”

It is a relatively new field of study with much still to be learned, he concludes.

Concussion Danger Signs

The Centers for Disease Control’s website, Heads Up, focuses on keeping kids and teens safe and healthy, particularly from head injuries and concussion. The site helps parents, teachers, coaches, etc., recognize, respond to and even minimize the risk of serious head injury, including concussion.

There are times when despite all precautions, a child or teen will suffer a concussion, which the CDC describes as a collection of blood (hematoma) that may form on the brain after a bump, blow, or jolt to the head or body. If this happens, the CDC advises that you call 9-1-1 right away, or take your child or teen to the emergency department if he or she exhibits one or more particular danger signs after suffering a bump, blow or jolt to their head or body.

Dangerous Signs & Symptoms of a Concussion

  • One pupil larger than the other.
  • Drowsiness or inability to wake up.
  • A headache that gets worse and does not go away.
  • Slurred speech, weakness, numbness, or decreased coordination.
  • Repeated vomiting or nausea, convulsions or seizures (shaking or twitching).
  • Unusual behavior, increased confusion, restlessness, or agitation.
  • Loss of consciousness (passed out/knocked out). Even a brief loss of consciousness should be taken seriously.

For more information, check out the Heads Up site at:  https://www.cdc.gov/headsup/index.html

Pre-Existing Conditions May Lengthen Concussion Recovery (Part One of Two)

A concussion can often worsen symptoms in an adult or child who has pre-existing conditions that affect the brain, such as learning disorders, attention deficit, depression, anxiety and migraines.

Dr. Nathan Cook, Pediatric Neuropsychologist, Sports Concussion Program, Massachusetts General Hospital for Children, is part of the Virginia Concussion Initiative and works primarily with “outlier” cases, which he describes as children and young people who take longer than the usual four weeks to recover from a concussion.

These are children and young people who are suffering persistent, chronic headaches, oculomotor dysfunction or difficulty with eyes, vision, balance and other issues.

One of the robust predictors of prolonged recovery from sports-related concussion is a pre-existing mental health history, says Dr. Cook.

In the absence of pre-existing conditions, individuals recover from concussion within two to four weeks and treatment consists of scaling back on activities and finding that “sweet spot” between rest, recovery and gradually increasing activity.

But the situation can be quite different for complex cases. For example, children and teens with ADHD often have challenges with balance testing, in the absence of a head injury. The data available through the Virginia Concussion Initiative, specifically through collaborating with Dr. Caswell at George Mason, allowed for the collection of a huge amount of information on pre-existing conditions among Virginia students.

“We were able to match students with ADHD to basically same age teammates, in other words, students on the same team from the same school, same age, very strong similarities so that we could isolate the ADHD factor. And in fact, the research bears this out, that those students with ADHD did perform differently. Specifically, they had more errors on the balance test that is commonly used in concussion called The Modified Balance Error Scoring System.”

This was in the absence of head injury and represented a preseason baseline testing. It’s critical to have this sort of baseline testing so that months later, if an injury occurs, health providers can be aware of what might be related to the student’s pre-existing health condition versus what might reflect continued dysfunction related to concussion or neurotrauma. And sometimes when it’s too difficult to tell, the focus must simply be on treatment, says Dr. Cook.

Part Two will discuss other pre-existing conditions and concussion treatment.

CDC Offers Prevention Tips To Protect Yourself from a Concussion

There are many ways to reduce the chances of sustaining a traumatic brain injury. Here are several, provided by the U.S. Centers for Disease Control.

    1. Buckle Up Every Ride – Wear a seat belt every time you drive – or ride – in a motor vehicle.
    2. Never drive while under the influence of alcohol or drugs.
    3. Wear a helmet, or appropriate headgear, when you or your children:
      • Ride a bike, motorcycle, snowmobile, scooter, or use an all-terrain vehicle;
      • Play a contact sport, such as football, ice hockey, or boxing;
      • Use in-line skates or ride a skateboard;
      • Bat and run bases in baseball or softball;
      • Ride a horse; or
      • Ski or snowboard.
    4. Prevent Older Adult Falls
      • Talk to your doctor to evaluate your risk for falling, and talk with them about specific things you can do to reduce your risk for a fall.
      • Ask your doctor or pharmacist to review your medicines to see if any might make you dizzy or sleepy. This should include prescription medicines, over-the counter medicines, herbal supplements, and vitamins.
      • Have your eyes checked at least once a year and update your eyeglasses if needed.
      • Do strength and balance exercises to make your legs stronger and improve your balance.
      • Make your home safer. Add handrailings where needed. Remove or secure area rugs.
    5. Make living and play areas safer for children
      • Install window guards to keep young children from falling out of open windows.
      • Use safety gates at the top and bottom of stairs when young children are around.
      • Make sure your child’s playground has soft material under it, such as hardwood mulch or sand.