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

10/23/2018 Outline Cases in Sport Related • Case 1: Concussion Management – 16 y/o FB Player, helmet to helmet contact The Team Approach • Case 2: – 17 y/o Cheerleader, MVA • Case 3: Panel: - Aimee Custer, PsyD – 48 y/o Cyclist, Bike accident - Amy Hamilton, ATC - Carly Mattson, DPT - Alex Noll, DO - Justin Tatman, ATC; Moderator Case 1: Initial Findings • Patient Demographics: • Player remained down after MOI, visibly moving but slow to his feet; no LOC – 16 year old, male • MOI: • AT removed player from field, and began sideline evaluation – 11 th grade – While attempting to • Sideline findings included: – Football, outside make a tackle, – Symptoms: HA, pressure in head, photophobia, tinnitus, dizzy, “feeling linebacker opposing player ducked not right” causing own teammate – History of two previously – Signs: constricted pupils, dizzy/unsteady, continues to grasp head diagnosed concussions to hit him helmet-to- – Maddock’s Questions: 1/5, appears unable to orient self with helmet • Injury occurred Friday surroundings; AT familiar with patient affect which is notable different – Unanticipated 8/31/18, during 3 rd • Removed from play; helmet taken by AT, coaches notified rotational force quarter of varsity game • Coaches, parents and patient instructed full evaluation will take place after the game Initial Findings, recommendations: Referral • SCAT 5, after game: • Eval Tuesday 9/4/18: • F/u evaluation by AT on Monday 9/10/18 indicated – Symptoms: 15/22 – SCAT5 repeated minimal improvement from initial presentation • Severity 43/132 – VOMS – No resolution or reduction of symptoms/severity, – Orientation: 4/5 worsening sleep pattern, frustration, anxiety, and stress – ImPACT Post Injury 1 – Immediate recall: 11/15 related to missing sport and mounting school workload • Academic accomms from AT – Concentration: 2/4 to school nurse/admin • Patient and parents exhibit increasing concern due to – Withheld from sports/PE/band lack of symptoms resolution, concussion history, and – Neuro Screen: Normal – Full days of school as tolerated – mBESS: 18/30 errors desire to return to “important” FB season – Avoid busy environments • Unable to maintain SL • Patient referred to specialty clinic 9/12/18 for further – Take breaks as needed – Delated recall: 1/5 evaluation (12 days since DOI) 1

10/23/2018 Clinic Presentation 9/13/18: 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: Recommendations/Referrals V ESTIBULAR • 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 Physical Activity Progression Conclusion • Vestibular Therapy: • Patient clinic visit on 10/1/18 – Progress vestibular-oculomotor exercises – Symptoms – Add sport specific component – Subjective reporting – BCTT, DVA, Neurocom at visit on 9/28/18 – ImPACT: WNL to baseline – VOMS: Objectively and subjectively WNL • Exertion with AT: • Patient cleared for full return to sport (Step 5) – Steps 2-4 of stepwise return, prior to clearance for contact on 10/1/18. – If remains asymptomatic, cleared to play in game on Friday 10/5/18 (5 weeks since DOI) 2

10/23/2018 Case 2: Initial Findings • Patient demographics • Patient was evaluated on scene by EMS, placed in C- collar, and transferred to ED via ambulance – 17 year old, female • MOI – 12 th grade • ED findings: – MVA – Cheer/dance team; – Negative CT for cervical spine pathology – Patient was driver of a thespian club – Normal CT of head/brain; no findings of intracranial lesion car that was rear-ended – No concussion history or pathology; Chiari 1 malformation (pre-morbid) in a snow storm – Hx of amblyopia and – Wearing seatbelt • Released same day; told to follow up with PCP or TBI anxiety – Airbags were not clinic • Accident occurred deployed Tuesday, 2/13/2018 • Whiplash mechanism Patient History Impression • 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 Referrals OCULAR • Referred for consult with neurobehavioral optometry ANXIETY/ MOOD • 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 3

10/23/2018 Treatment Plan Conclusion • Patient’s physical activity goals are to return to cheer (spring • Steady improvement over 8 week period, practice and competitions) and theater club (spring musical, follow up in clinic every 2-4 weeks dancer/singer) • Cleared for full return to cheer/dance (4/23/18) – Communication with school AT to progress physical activity – 10 weeks after DOI – AT provide basic cervical management program – ImPACT: High average scores except visual memory – Patient given detailed recommendations for each step of stepwise – VOMS: WNL return to complete on her own at gym/home • Continue VT to conclusion • Psychology appointment, once a week, every other week • 504 Plan in place for remained of year – May continue past clearance 1 x month if desired • Vision therapy recommended for 12-20 weeks • Continue psychology plan through end of school year – Initiate therapy, attend weekly, complete HEP daily • Follow up post VT to establish baseline neurocognitive data and address 504 plan Case 3: Initial Findings • Patient • Patient did not seek immediate medical care; • MOI: cycling accident demographics: was able to walk/ride away from MOI – Patient side swiped by a unanticipated car, – 48 year old, female • Reported to PCP 5 days after MOI due to causing her to fall onto – Cyclist, physically complaints of daily HA, cognitive dysfunction, pavement over front of active handle bars mood changes, and sleep alterations, as well – History of migraines – Going approx. 12 mph as orthopedic injury (scaphoid fx) – Wearing helmet – Works as IT • Managed by PCP for 4 weeks, including: • Unsure if she hit her consultant at – Work recommendations, migraine medication head on the ground iBigTechCompany Patient History Clinic Impression • Migraines • Patient referred to specialty clinic after 4 – Diagnosed at age 35; imaging performed by neurologist weeks due to lack of improvement, worsening – No active medication plan, OTC Excedrin as needed – Familiar with triggers and avoidance/prevention techniques HA, and inability to perform occupational • Physical Activity Preferences tasks – Works out 3-5 times per week; prefers cycling, includes weight lifting, yoga, Pilates, running, and playing with kids • Car Sickness POST- COGNITIVE/ V ESTIBULAR CERVICAL TRAUMATIC FATIGUE – Worsened over past 5-10 years; specific seats or multitasking MIGRAINE • Work environment – 50% desk work including computer screen use; 50% meetings, training sessions, other activities 4

10/23/2018 Treatment and Referrals Progression • Imaging? • Follow up in clinic 2-4 weeks; adjust work accommodations as needed • Medication intervention • Progress exertion through PT weekly • Return to work accommodations • Communicate with OT for work needs and • Referral to PT for cervical management, final clearance for driving vestibular progression, exertion progression • Education patient regarding pre-morbid • Referral to OT for return to driving program exasperation vs. concussion symptoms and cognitive therapy Specialty Clinics Conclusion Internal ( contract sites ) Internal & & External External • Cleared for full return to work without restrictions – 16 week after DOI • Migraine management plan • Follow up as needed Behavioral Athletic Psychiatry, Neuro – Speech, Training, Exertion Physical Vestibular Oculomotor Psychology, Optometry Sports Neurology Occupational Therapy Therapy Therapy Rehab Behavioral Medicine Vision Therapy Health Team Therapy Thank You! 5