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Clinic hones methods of detecting and treating concussions, helping athletes recover and facilitating instructors’ understanding of brain trauma

Nearly 1,000 students, most in the ŷ���ڱ���Ƶ Club Sports Program, have benefited from a cutting-edge clinic that tests for and treats concussions. Those who have suffered concussions are getting timely treatment, which helps them recover and stay in school.

The  (SLHS) department at the University of ŷ���ڱ���Ƶ Boulder hosts many programs assisting children and adults with issues relating to their speech, language and hearing abilities.It is also home to a concussion clinic run by Kathryn Hardin, a clinical assistant professor who started the program when she joined the faculty at ŷ���ڱ���Ƶ-Boulder full-time four years ago.

Hardin’s clinic has gained national attention due to its work understanding the effects of concussions on student learning and retention. The pre- and post-concussion testing and therapy the clinic has provided to nearly 1,000 students over the past three years has helped student-athletes navigate the healing process while staying in class and retaining their ability to learn.

Hardin, acting as an advocate for injured students and communicating with instructors on a faculty-to-faculty basis, has helped instructors understand the effects of concussions on student learning. This has been key in ensuring student success and retention.

Focusing on student brains

The impetus for beginning the study was controversy over a widely accepted computerized test administered to athletes—including those in the NFL—called the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) test.

Studies had begun to indicate that the test might not have been as accurate in testing athletes as initially projected, and news also broke that several of the test’s creators were on the NFL concussion board.

If you don’t have those risk factors, chances are less likely that they will get a concussion.”

“It’s really abstract and not academic or functional really in any way,” Hardin says of the ImPACT test. “I wanted to come up with something that could be more directly applicable to students.”

Hardin also wanted to open the clinic because students who suffer concussions (also called mild traumatic brain injuries) are sent to the local hospital. She says hospitals offer great care, but it can take students six to eight weeks to be seen for follow-up, out-patient support.

“At that point you’re done,” Hardin explains. “You have flunked out of your coursework for the semester, or, even if you’ve been managing to keep it together, you’re not doing as well as you wanted to, and if you’re looking at graduate school down the road, you’ve shot yourself in the foot.”

When she joined the faculty full-time, Hardin wanted to be able to take care of students directly, on campus. ŷ���ڱ���Ƶ-Boulder Club Sports, which gives students the chance to compete against other intercollegiate teams, also wanted to find better ways to care for their student-athletes post-concussion.

Club Sports had used ImPACT in the past, and Hardin says the head trainer, Jaclyn Adams, wanted something different. Club Sports contacted Wardenburg Health Center, which directed them to Hardin.

Club Sports requires that students in sports with the highest rates of injury (the high-impact sports) take part in the concussion clinic Hardin runs.

The students, from nine required sports—men’s and women’s rugby, men’s and women’s ice hockey, men’s and women’s soccer, men’s lacrosse, freestyle skiing and tae kwon do—must visit the clinic after the roster is set in the fall, before they are cleared to play.

“Which is pretty compelling,” says Hardin. Hardin notes that Club Sports coaches support the clinic, and the students express great satisfaction about how the clinic helps them recover.

Developing an accurate baseline test

Most concussions are relatively mild, so specialists need targeted tests to detect brain injury, Hardin says. They need baseline readings (before brain injury is sustained). The baseline assessments test cognition, the visual-vestibular relationship and balance.

Hardin developed the cognitive-baseline assessment using common academic tools like the Woodcock-Johnson that test things important for students: processing speed, attention, word finding, learning new material, “All the things you need in class.”

The relationship between eyes and ears, the visual-vestibular system, is also key to the baseline reading. When a concussion occurs, the brain shakes in a linear fashion, but also twists. Unlike a stroke, which causes a small part of the brain to die, a concussion causes a little bit of everything to malfunction.

Concussion assessments at the ŷ���ڱ���Ƶ-Boulder clinic include balance tests. An iPhone is strapped to the chest of the student and an accelerometer measures the balance during complicated standing poses.

The last part of the assessment tests balance. An iPhone is strapped to the chest of the student and an accelerometer measures the balance during complicated standing poses.

“We’re the first place outside of the Mayo-Clinic to be doing this,” notes Hardin.

Hardin also notes that neurological susceptibility must be taken into account. She explains that whatever is “quirky” about you to begin with is likely to be affected after a concussion. Students with poor memory to begin with will likely struggle with their memory after mild traumatic brain injury.

Hardin has found that people with a history of head injury, a learning disability such as ADHD, and a history of headaches or migraines typically take longer to recover—and are also more likely to be injured in the first place.

“If you don’t have those risk factors, chances are less likely that they will get a concussion,” says Hardin. Scientists are still studying why this might be, but one theory is that people who have to allocate resources in their brain to compensate for areas that are already particularly affected, struggle to allocate resources further.

They may not have as much “reserve” to deal with the injury. A complementary theory is that these individuals are inherently more vulnerable to neurologic disruption.

Another measure that students undergo may sound silly. When students first come to the clinic, they are given a wordless picture book of Cinderella and asked to tell the story.

“I’ve heard some pretty amazing rugby-player Cinderella stories,” Hardin jokes.

She notes that when people come back and retell the story after a concussion, the group of people who are not cleared right away—who need a longer recovery—actually told a differently structured story before they set foot on the field. The structure and efficiency of language are different from a person’s who didn’t have “risk factors” beforehand.

Hardin says this research is potentially very important—it may even cause some parents to reconsider letting their children play high-contact sports if they have learning disorders or family histories of migraines.

Yet more research has to be done, she notes. Exercise and sports are highly beneficial for different areas of the brain and body, so lots of factors have to be considered before someone gives up an athletic endeavor as a precautionary measure.

Helping faculty understand concussion effects on learning

In the past three years, Hardin’s clinic has seen 700 to 800 Club Sports students and more than 100 referrals from Wardenburg (of many non-athletically sustained concussions). Hardin notes that Wardenburg Health Center has greatly expanded their concussion care, which has been extremely beneficial for the students to have convenient access to on-campus care.

The clinic also gets occasional referrals from the Department of Intercollegiate Athletics.

When students come back to the clinic after suffering a concussion, Hardin, along with a physician and trainers, gauge what’s been affected in the student’s brain. She says the baseline testing has been really sensitive at detecting both deficits in cognition and physical symptoms in people with concussions.

As a result, Hardin says they’re able to get students back to play their sports more quickly. But, as Hardin is quick to say, “I’m more interested in making sure they stay in school.”

As a of the screening and treatment, students can get back to play their sports more quickly. But, as Hardin is quick to say, “I’m more interested in making sure they stay in school.”

Concussion injuries are not typically handled by the ŷ���ڱ���Ƶ Disability Services Office, since concussions are considered a temporary injury. As a result, Hardin feels students need someone to advocate for them to their professors and help faculty understand what is going on when a student sustains a mild traumatic brain injury.

“I have to say, the faculty are really, really supportive,” says Hardin.

Hardin is that advocate. Once a student sustains a concussion, Hardin, with the student’s permission, emails the instructor.

“Since it’s a medical event, we don’t give a lot of information—’so-and-so, your student, has sustained a concussion’—we give them the date—and then give them a broad, general education about a college student’s recovery, and the things that are particularly impaired with that student.”

She says that in general, concussed students can’t pay attention in class, are fatigued, have trouble looking down and up (the motion makes them feel seasick) and are sensitive to light.

Disability services recommends that instructors use discretion and be flexible to help students recover, and Hardin says that often instructors ask for more information about how student learning is affected by concussive injuries.

Hardin says the next step is to give the instructors updates on their students, if they’re recovering well, or will need more time. Honesty is important to the process.

“Faculty have been so embracing of this,” says Hardin. “We want to be honest when a student’s ready to be back in class.”

Strategies for recovery

Recovery takes time. Until the age of 24, a brain isn’t considered “mature.” Its primary job is to grow and learn. When a concussion happens, the brain needs to then balance learning and growing with healing, whereas a “mature” brain can focus on just healing.

Hardin says that the idea of complete rest for someone after a concussion is no longer endorsed—active rehab is best. Initially, they take steps to settle down the physiological system of the student.

Concussed students wear sunglasses to avoid bright light and wear attenuated earplugs that filter out background noise. They ensure the students are getting enough sleep and eating enough—something many people neglect after they’ve received a mild-traumatic brain injury.

Adjusting for decreased glucose is important for the brain’s recovery. Students are also encouraged to wear baseball caps for several days to help them block unnecessary visual background and focus on what’s directly in front of them.

“What your brain improves at is what you ask it to do,” explains Hardin. In therapy, Hardin and her team of graduate students help students navigate how much class is the right amount of class, and find strategies to study and learn even while recovering.

Those strategies include using a piece of paper with a hole in it to focus on small sections of text at a time, organizing notes in a different way than they usually do, and making notes associating topics they’re learning about with an emotional memory connected to them. Hardin says emotional memory is much less affected after a concussion than declarative memory.

Growing influence, recognition

The clinic has been remarkably successful. Not only has it seen and assisted a great number of ŷ���ڱ���Ƶ-Boulder Club Sport athletes, it has developed a network of faculty working together to understand the effects a concussion has on student learning.

Hardin notes that Club Sport athletes are particularly vested in recovering from concussions, because they’re not typically on a career path to playing sports at a professional level. They don’t want their injuries harming their studies.

Other universities, like the University of Wisconsin-Madison and Chapman University, have set up programs similar to Hardin’s clinic. In Orange County, the program is being expanded to high schools.

Hardin hopes that one day they may be able to expand the program to schools within the Boulder Valley School District. She says that middle and high schools are familiar with models like the Woodcock-Johnson test, as it is commonly used by school psychologists, so the transition wouldn’t be difficult.

The clinic’s work has also been widely recognized as a model for training clinical graduate students. In 2013, it received an award for being the outstanding clinical program for the state of ŷ���ڱ���Ƶ, and was also nominated for the Louis M. DiCarlo Award for Clinical Achievement in Speech-Language Pathology.

This November, Hardin is slated to speak at the national Speech-Language Pathology convention. Only three speakers are selected for the pre-convention, so the opportunity is considered a high honor.

The clinic receives funding from the Center to Advance Research and Teaching in the Social Sciences, the Dean’s Fund for Excellence, and also receives a steeply discounted payment from Club Sports.

“After all, this is something we want to offer and encourage,” says Hardin.

Though her work has caught national attention and honor and helped improve the recovery process of hundreds of students, Hardin is humble about her clinic’s work.

“There’s still so much we don’t know,” she notes. But with progress that shows no signs of slowing, Hardin and her clinic are making great strides in understanding the effects of mild traumatic brain injuries on student-athlete brains.

Magdalena Rost, a student majoring in classics and English, is an intern for ŷ���ڱ���Ƶ Arts & Sciences Magazine.