Outline Cases in Sport Related Case 1: Concussion Management 16 - - PDF document

10/23/2018 1

Panel:

• Aimee Custer, PsyD
• Amy Hamilton, ATC
• Carly Mattson, DPT
• Alex Noll, DO
• Justin Tatman, ATC; Moderator

Cases in Sport Related Concussion Management The Team Approach Outline

• Case 1:

– 16 y/o FB Player, helmet to helmet contact

• Case 2:

– 17 y/o Cheerleader, MVA

• Case 3:

– 48 y/o Cyclist, Bike accident

Case 1:

• MOI:

– While attempting to make a tackle,

• pposing player ducked

causing own teammate to hit him helmet-to- helmet – Unanticipated rotational force

• Patient Demographics:

– 16 year old, male – 11th grade – Football, outside linebacker – History of two previously diagnosed concussions

• Injury occurred Friday

8/31/18, during 3rd quarter of varsity game

Initial Findings

• Player remained down after MOI, visibly moving but slow to

his feet; no LOC

• AT removed player from field, and began sideline evaluation
• Sideline findings included:

– Symptoms: HA, pressure in head, photophobia, tinnitus, dizzy, “feeling not right” – Signs: constricted pupils, dizzy/unsteady, continues to grasp head – Maddock’s Questions: 1/5, appears unable to orient self with surroundings; AT familiar with patient affect which is notable different

• Removed from play; helmet taken by AT, coaches notified
• Coaches, parents and patient instructed full evaluation will

take place after the game

Initial Findings, recommendations:

• SCAT 5, after game:

– Symptoms: 15/22

• Severity 43/132

– Orientation: 4/5 – Immediate recall: 11/15 – Concentration: 2/4 – Neuro Screen: Normal – mBESS: 18/30 errors

• Unable to maintain SL

– Delated recall: 1/5

• Eval Tuesday 9/4/18:

– SCAT5 repeated – VOMS – ImPACT Post Injury 1

• Academic accomms from AT

to school nurse/admin

– Withheld from sports/PE/band – Full days of school as tolerated – Avoid busy environments – Take breaks as needed

Referral

• F/u evaluation by AT on Monday 9/10/18 indicated

minimal improvement from initial presentation

– No resolution or reduction of symptoms/severity, worsening sleep pattern, frustration, anxiety, and stress related to missing sport and mounting school workload

• Patient and parents exhibit increasing concern due to

lack of symptoms resolution, concussion history, and desire to return to “important” FB season

• Patient referred to specialty clinic 9/12/18 for further

evaluation (12 days since DOI)

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Patient History from Clinical Interview 9/13/18:

• Patient has a history of two previously diagnosed concussions

– First one Spring 2014, Second Fall 2016 – MOI sports (baseball bat to head as catcher, football practice drill)

• Denied LOC, amnesia, and/or confusion for both previous injuries

– Both resolved within 2-3 weeks, player made full return to sport and school without referral for formal treatment for both injuries; denies lingering or unresolved symptoms related to these injuries

• Average student (A’s to C’s; 3.1 GPA currently)
• Plans to play football in college; Division 2 or 3
• Patient and parent deny personal and family history of:

– HA/migraines, oculomotor disorders, motion sickness, psychological conditions, or neurological conditions

Clinic Presentation 9/13/18: Clinic Presentation 9/13/18: Recommendations/Referrals

• Academic Accommodations

– Updated, given to parents/student, told to communicate with school nurse/admin/AT

• Behavioral Management
• Rx medications vs. supplements and OTC
• Referral to Vestibular Therapy

– R/O of peripheral and cervicogenic dizziness – Treatment of specific central vestibular dysfunction – Communication to AT for early aerobic intervention

VESTIBULAR

Physical Activity Progression

• Vestibular Therapy:

– Progress vestibular-oculomotor exercises – Add sport specific component – BCTT, DVA, Neurocom at visit on 9/28/18

• Exertion with AT:

– Steps 2-4 of stepwise return, prior to clearance for contact

Conclusion

• Patient clinic visit on 10/1/18

– Symptoms – Subjective reporting – ImPACT: WNL to baseline – VOMS: Objectively and subjectively WNL

• Patient cleared for full return to sport (Step 5)
• n 10/1/18.

– If remains asymptomatic, cleared to play in game

• n Friday 10/5/18 (5 weeks since DOI)

10/23/2018 3

Case 2:

• Patient demographics

– 17 year old, female – 12th grade – Cheer/dance team; thespian club – No concussion history – Hx of amblyopia and anxiety

• Accident occurred

Tuesday, 2/13/2018

• MOI

– MVA – Patient was driver of a car that was rear-ended in a snow storm – Wearing seatbelt – Airbags were not deployed

• Whiplash mechanism

Initial Findings

• Patient was evaluated on scene by EMS, placed in C-

collar, and transferred to ED via ambulance

• ED findings:

– Negative CT for cervical spine pathology – Normal CT of head/brain; no findings of intracranial lesion

• r pathology; Chiari 1 malformation (pre-morbid)
• Released same day; told to follow up with PCP or TBI

clinic

Patient History

• No pHx of concussion or TBI
• Patient has a history of R eye amblyopia

– Patching during childhood, 4-5 years old – Wears glasses/contacts – Hx of difficulty with reading and math

• Hx of anxiety; currently managed by:

– Medication – Counseling

Impression Impression

ANXIETY/ MOOD

OCULAR

Referrals

• Referred for consult with neurobehavioral optometry
• Limitations with visual tasks/screens
• Psychology

– Continue with individual psychotherapy – Consider addition of Healing Touch/Integrative Health

• Academic accommodations; mention of possible

need for initiation of formal 504 plan in future

• Communication with AT regarding exertion

progression and to advocate for student

10/23/2018 4

Treatment Plan

• Patient’s physical activity goals are to return to cheer (spring

practice and competitions) and theater club (spring musical, dancer/singer)

– Communication with school AT to progress physical activity – AT provide basic cervical management program – Patient given detailed recommendations for each step of stepwise return to complete on her own at gym/home

• Psychology appointment, once a week, every other week

– May continue past clearance 1 x month if desired

• Vision therapy recommended for 12-20 weeks

– Initiate therapy, attend weekly, complete HEP daily

Conclusion

• Steady improvement over 8 week period,

follow up in clinic every 2-4 weeks

• Cleared for full return to cheer/dance (4/23/18)

– 10 weeks after DOI – ImPACT: High average scores except visual memory – VOMS: WNL

• Continue VT to conclusion
• 504 Plan in place for remained of year
• Continue psychology plan through end of school year
• Follow up post VT to establish baseline neurocognitive data

and address 504 plan

Case 3:

• Patient

demographics:

– 48 year old, female – Cyclist, physically active – History of migraines – Works as IT consultant at iBigTechCompany

• MOI: cycling accident

– Patient side swiped by a unanticipated car, causing her to fall onto pavement over front of handle bars – Going approx. 12 mph – Wearing helmet

• Unsure if she hit her

head on the ground

Initial Findings

• Patient did not seek immediate medical care;

was able to walk/ride away from MOI

• Reported to PCP 5 days after MOI due to

complaints of daily HA, cognitive dysfunction, mood changes, and sleep alterations, as well as orthopedic injury (scaphoid fx)

• Managed by PCP for 4 weeks, including:

– Work recommendations, migraine medication

Patient History

• Migraines

– Diagnosed at age 35; imaging performed by neurologist – No active medication plan, OTC Excedrin as needed – Familiar with triggers and avoidance/prevention techniques

• Physical Activity Preferences

– Works out 3-5 times per week; prefers cycling, includes weight lifting, yoga, Pilates, running, and playing with kids

• Car Sickness

– Worsened over past 5-10 years; specific seats or multitasking

• Work environment

– 50% desk work including computer screen use; 50% meetings, training sessions, other activities

Clinic Impression

• Patient referred to specialty clinic after 4

weeks due to lack of improvement, worsening HA, and inability to perform occupational tasks

POST- TRAUMATIC MIGRAINE

VESTIBULAR

CERVICAL COGNITIVE/ FATIGUE

10/23/2018 5

Treatment and Referrals

• Imaging?
• Medication intervention
• Return to work accommodations
• Referral to PT for cervical management,

vestibular progression, exertion progression

• Referral to OT for return to driving program

and cognitive therapy

Progression

• Follow up in clinic 2-4 weeks; adjust work

accommodations as needed

• Progress exertion through PT weekly
• Communicate with OT for work needs and

final clearance for driving

• Education patient regarding pre-morbid

exasperation vs. concussion symptoms

Conclusion

• Cleared for full return to work without

restrictions

– 16 week after DOI

• Migraine management plan
• Follow up as needed

Specialty Clinics

Athletic Training, Sports Medicine Team Exertion Therapy Physical Therapy Vestibular Therapy Oculomotor Rehab Behavioral Neuro – Optometry Vision Therapy Neurology Psychiatry, Psychology, Behavioral Health Speech, Occupational Therapy

Internal & External Internal (contract sites) & External

Thank You!