Concussion Research-NCAA and DoD Concussion Study

Transcription

1 Jim Messerly DO

2 Nothing to Disclose

3 Concussion Research-NCAA and DoD Concussion Study May 29, 2014: The NCAA and the US Department of Defense announce a landmark $30 million initiative to enhance the safety of student athletes and service members. The study will enroll 37,000 male and female NCAA student athletes over the three-year study. Participants will receive a comprehensive preseason evaluation for concussion and will be monitored in the event of an injury. The investigation will be the largest ever of its type, offering critical insights into the risks, treatment and management of concussion.

4 NCAA/DoD Concussion Study Continued About 30 different NCAA schools will be involved. In addition, the University of North Carolina, UCLA, Virginia Tech and the University of Wisconsin, will participate in advanced research of athletes who play football, soccer, ice hockey or lacrosse sports with a higher incidence of concussion. These athletes will wear sensors in their helmets or, in non-helmet sports, somewhere on their body during games to count how often, how hard and from what direction they are hit, and in addition to baseline information, they will have MRI scanning of the brain to monitor changes in structure and function; blood work to identify biomarkers that could be used as indicators of concussion or recovery; and genetic studies that may reveal whether some people are more susceptible to concussion or have tendency for delayed recover afterward. Data will be shared with the Federal Interagency Traumatic Brain Injury Research system operated by the NIH.

5 Best Practice for Concussion: Consensus Based Standard of Care Physical and Cognitive Rest Vestibular/Ocular Motor Screening (VOMS) Clinical Trajectories for Targeted Rehabilitation

6 Treatment of Concussion- Rest International Concussion in Sports Group: The cornerstone of concussion management is physical and cognitive rest until the acute symptoms resolve and then a graded program of exertion prior to medical clearance and return to play. British Journal Sports Medicine 2013; 47(5):250-8

7 Treatment of Concussion- Rest Study Benefits of Strict Rest After Acute Concussion: A Randomized Study; Pediatrics, February 2015 Vol 135, (2): concussion patients age presenting to a pediatric ED within 24 hours of concussion were randomized to strict rest for 5 days versus usual care (1-2 days rest, followed by stepwise return to activity).

8 Treatment of Concussion- Rest Study Continued Results: There was no clinically significant difference in neurocognitive or balance outcomes. However, the intervention group (strict rest for 5 days) reported more daily postconcussion symptoms and slower symptom resolution. Conclusion: Recommending strict rest [for 5 days] for adolescents immediately after concussion offered no added benefit over the usual care [1-2 days of rest]. Adolescents symptom reporting was influenced by recommending strict rest.

9 Treatment of Concussion- Rest Acute Cognitive and Physical Rest May Not Improve Concussion Recovery Time. J Head Trauma Rehabilitation 2015, Jul concussion patients in the rest group were withheld from activities, including classes, for the remainder of the injury day and the following day, whereas 25 patients in the no- rest group were not provided any post injury accommodations.

10 Treatment of Concussion- Rest Study Continued Conclusion: A prescribed day of cognitive and physical rest was not effective in reducing postconcussion recovery time. These results agree with a previous study and suggest that light activity postconcussion may not be deleterious to the concussion recovery process.

11 Current Recommendations for Rest Postconcussion No two concussions are alike. At initial diagnosis of concussion, it is very difficult to predict how severe the symptoms will be and how long the symptoms will last. Rest treatment should individualized somewhere between Cocoon therapy and no activity restrictions with frequent follow-up advancing noncontact activity slowly.

12 Concussion Treatment- Rest Key Concepts: Some rest is helpful. Out of school 1-3 days, then ½ days and advance as tolerated. Schools will provide assistance with missed school work. Avoid prolonged screen use still warranted, i.e. Cell phones, Computers- Video games. Maintain good sleep schedule- Avoid prolonged napping. Very light activity such as walking or stationary bike for min probably OK even when still having some symptoms if symptoms do not worsen. Bottom line- If symptoms worsen with an activity, then stop that activity. Prolonged rest from activity may actually prolong recovery.

13 Vestibular/Ocular Motor Screening (VOMS) A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions- Preliminary Findings. Am J Sports Med Oct;42(10): UPMC Sports Medicine Concussion Program. Conclusion: The VOMS demonstrated internal consistency as well as sensitivity in identifying patients with concussions. The current findings provide preliminary support for the utility of the VOMS as a brief vestibular/ocular motor screen after sports related concussions. The VOMS may augment current assessment tools and may serve as a single component of a comprehensive approach to the assessment of concussions.

14 Vestibular/Ocular Motor Screening (VOMS) Smooth Pursuits (Horizontal and Vertical)- Tests the ability to follow a slowly moving target. Vestibular-Ocular Reflex (VOR) Test (Horizontal and Vertical)- Assesses the ability to stabilize vision as the head moves. Saccades (Horizontal and Vertical)- Tests the ability of the eyes to move quickly between targets. Visual Motion Sensitivity Test- Tests visual motion sensitivity and the ability to inhibit vestibular induced eye movements using vision. Convergence- Measures the ability to view a near target without double vision. Note symptoms with testing.

15 Smooth Pursuits

16 Vestibular-Ocular Reflex (VOR) Test

17 Saccades- Horizontal

18 Saccades- Vertical

19 Convergence

20 Visual Motion Sensitivity (VMS) Test

21 Concussion Clinical Trajectories

22 Clinical Trajectories Targeted Treatment Pathways

23 Concussion Clinical Trajectories- Cognitive/Fatigue Diagnosis Symptoms: fatigue, fogginess, decreased energy, generalized headache, end of the day increase in symptoms and potential sleep deficits. Questions: Do you have a generalized headache that increases as the day progresses? Do you feel more fatigued than normal at the end of the day? Do you feel more distractible in school been normal?

24 Concussion Clinical Trajectories Cognitive/Fatigue Treatment Cognitive and physical rest with a regulated schedule (i.e. no napping). Cognitive therapy may be warranted in more protracted cases. Pharmacological treatment: Neurostimulants: Amantadine (effects dopamine receptors in the brain). Standard dosing is 100 mg at breakfast for 5 days, then 100 mg at breakfast and lunch. Continue for 4-6 weeks or longer if needed. More traditional neurostimulants such as methylphenidate or Adderall could also be considered.

25 Concussion Clinical Trajectories- Anxiety/Mood Symptoms of anxiety: Ruminative thoughts, hypervigilance, fastidiousness and feelings of being overwhelmed. Symptoms of depression: Sadness, hopelessness and sleep disturbance. Questions: Do you have a history of anxiety? Family history? How often do you take inventory of your symptoms? Do you have difficulty turning off your thoughts? Do you difficulty falling asleep at night because of rumination or inability to stop thinking?

26 Concussion Clinical Trajectories- Anxiety/Mood Treatment Anxiety: Reassurance, regular sleep schedule, good diet and hydration, stress management/cognitive behavioral therapy and supervised exertion. Pharmacotherapy: SSRIs are mainstay of treatment. Depressed mood: Reassurance, regular sleep schedule, regular sleep schedule, good diet and hydration. Psychotherapy may be needed. Pharmacotherapy can include SSRIs. Blackbox warning- watch for increased restlessness and agitation and sleep disturbance Fluoxetine has very long half life and may be activating Paroxetine may be the most sedating and can cause weight gain Citalopram max dose of 40 mg due to possible QT elongation Sertraline may cause GI issues

27 Concussion Clinical Trajectories- Migraine Symptoms: Throbbing Headache, nausea and photosensitivity or phonosensitivity Questions: Did you get migraines before the injury? Do you have a family history of migraines? Are you having difficulty falling asleep/staying asleep? Are you experiencing more stress than usual?

28 Concussion Clinical Trajectories- Migraine Treatment Pharmacologic interventions: Tricyclic antidepressants such as amitriptyline or nortriptyline 10 mg in the evenings increasing every 3 days to 30 mg SSRIs: Citalopram, Escitalopram, Sertraline Anticonvulsants: Topamax or Gabapentin Beta-blockers: Propanolol Calcium channel blockers: Verapamil Encourage physical activity as tolerated, Sleep hygiene, Regular diet and hydration, Stress management

29 Concussion Clinical Trajectories- Cervical Symptoms: May be occipital headache and neck pain X-rays with flexion/extension views MRI scanning may be needed Treatment: Physical therapy/chiropractic/ DO care NSAIDs Muscle relaxants Gabapentin

30 Concussion Clinical Trajectories- Ocular-Motor Symptoms: Frontal headaches, pressure behind eyes, fatigue, distractibility, difficulty with visually-based classes i.e. mathematics, difficulty focusing Questions: Do you feel frontal pressure in your head behind her eyes when reading, doing computer work, or taking notes in class? Do you have blurred or fuzzy vision while reading or difficulty reading? Are you having difficulty in mathematics and science?

31 Concussion Clinical Trajectories- Ocular-Motor Diagnosis: Persisting symptoms with VOMS especially smooth pursuits and saccades testing and evidence of convergence or accomadative insufficiency. Low scores on ImPACT Visual Memory and Reaction Time. Neuroophthalmology consultation may be helpful Treatment: Convergence/ Accomadative training, dynamic physical exertion protocol

32 Concussion Clinical Trajectories- Vestibular Symptoms: Dizziness, fogginess, nausea, feeling of being detached, anxiety Questions: Do busy environments cause you to feel dizzy, off balance, or nauseated? Do you become dizzy when looking up or down, turning her head, lying down in bed, rolling over in bed, or getting out of bed? Are you experiencing motion sickness? Does moving quickly make you dizzy?

33 Concussion Clinical Trajectories- Vestibular Diagnosis: Difficulty with horizontal and/or vertical gaze stability on VOMS, optokinetic sensitivity, balance deficits. Nystagmus- Dix Hallpike. Lower scores in processing speed and reaction time composites on ImPACT Treatment: Vestibular therapy, Possible pharmacological treatment if emotional overlay

34 Concussion Case Presentation #1 E.H. is a 13-year-old male who is in A/B student who suffered a head injury on 10/29/15. He plays goalie on a youth hockey team. During practice, he turned around to pick up pucks out of the net and as he turned back, he was hit in the helmet by a puck from a slap shot at short range. He dropped to his knees after the injury, but was able to skate off the ice under his own power. He complained of headache, dizziness, photophobia and blurred vision. He was kept home from school on the day after his head injury. His parents were instructed in appropriate physical and cognitive rest recommendations and advised to use scheduled Tylenol for headaches. He did attend a few hours of school on 11/02/15 with some increased symptoms mainly of headache and photosensitivity. His physical exam on 11/02/15 provoked symptoms of dizziness and headaches with VOMS smooth pursuits, gaze stability and saccades testing. Convergence and accommodation testing were normal. Neuro exam was normal.

35 Concussion Case #1- Initial Postconcussion ImPACT

36 Concussion Case #1- Symptom Score

37 Concussion Case #1- Treatment Appropriate Physical and Cognitive Rest Tylenol 2 tablets 3 times a day School accommodations: Limit school attendance to 2-4 hours per day advancing slowly as tolerated. Note for school stating that the patient had a concussion and will need help with missed school work Very gradual return to noncontact physical activity as symptoms improve anticipating out of hockey for at least 2-3 weeks Recheck in 2 weeks

38 Concussion Case #1-2 Week Recheck Now 2.5 weeks postconcussion: Patient reports feeling 85% recovered. Headaches have improved now using Tylenol when necessary. Attended half-day school for 1 week and now attending full days of school. Does complain of some problems with brain function reporting having difficulty remembering things shortterm, but also took a math test recently and missed questions on older material. He did increase his physical activity doing some stretching with the team, walking, stair running and using the elliptical without complaint of increased symptoms. Physical Exam: VOMS was normal without symptoms.

39 Concussion Case #1- Post-Injury ImPACT #2

40 Concussion Case #1- Follow-up Symptom Score

41 Concussion Case #1- Post-Injury #3 and Post-Injury #4 ImPACT

42 Concussion Case Presentation #2 A.K. is a 13-year-old male with a pre-injury history of some intermittent headaches, anxiety, depression and possible dyslexia who suffered a head injury on 09/03/15. He was playing on his junior high football team when his head struck the ground causing a headache. He was removed from the game. The following day, he did attend school and also participated in football practice, but noted headache, dizziness and nausea after doing somersaults during a football drill. He was evaluated in the emergency department. CT scanning of the head was negative. He was diagnosed with concussion and advised in the use of Tylenol and was given Zofran for his nausea. He was advised to remain out of football. He was evaluated through Concussion Clinic on 09/10/15 with minimal improvement of his symptoms. He complained of fairly prominent facial numbness. Physical exam: VOMS testing reproduced increased symptoms of dizziness and facial numbness. Convergence was increased at 25 cm. Neuro exam was normal.

43 Concussion Case #2 ImPACT

44 Concussion Case #2- Treatment Appropriate physical and cognitive rest Tylenol 2 tablets 3 times a day on a scheduled basis. Could try Aleve 2 in the AM and 1 in the PM if Tylenol not helping Return to school recommendations for part-time school attendance advancing slowly as tolerated. Rest in the nurse's office if needed. Assistance with missed school work. Physical activity- very light noncontact activity recommended (mainly brief walking).

45 Concussion Case #2- Recheck 09/17/15- Now 2 weeks postconcussion. Continued symptoms of headaches, nausea, photophobia. Problems sleeping. Unable to tolerate bus ride to school. Only able to tolerate about 2 hours of school. Still complained of facial tingling. Exam still shows prominent symptoms (headache and facial tingling) with VOMS. Neuro exam remained normal. Treatment- continued relative rest. Trial of Nortriptyline 10 mg at bedtime for possible migraine headaches and for problem with sleep. 09/25/15- Phone call: Nortriptyline was not helpful for her headaches or other symptoms. Episode of vomiting at school. Facial numbness seems to be worsening. 09/30/15- MRI scan of the brain was obtained and was negative.

46 Concussion Case #2- Recheck 10/01/15-4 weeks postconcussion: Patient continues to complain of headaches which are worse at the end of his shortened school days. He states he is able to focus his eyes well at school. His previous motion sickness on car rides to school has improved. He is able to rotate quickly without increased symptoms. He was able to walk over a mile without increased symptoms. Father expresses concern that the patient may need to repeat the eighth grade because of missed school. Physical exam: VOMS reproduced much less symptoms. Convergence was improved to 7 cm. ImPACT scores remained quite low. Clinical trajectories were discussed with concern for component of migraine headache and depression. Patient was started on low-dose Lexapro 5 mg. Continue on Tylenol 2 tablets 3 times a day as needed. Continue with school accommodations. Referral for formal neuropsych testing was recommended and scheduled for early December 2015.

47 Concussion Case #2- Recheck 10/15/15 6 weeks postconcussion. Symptoms finally starting to improve with much less light sensitivity. Still with recurring headaches at school. He has been able to tolerate a few days of full school attendance. Still having difficulty tolerating the bus ride. Complains of ongoing fatigue. Continuing on Lexapro which he feels has been helpful. Formal neuropsych testing scheduled for 12/07/15. Exam- Much less symptoms with VOMS, but still complained of some facial numbness with testing. Convergence testing normal.

48 Concussion Case #2- Recheck ImPACT

49 Concussion Case #2- Recheck 11/05/15- Now 9 weeks postconcussion: The patient's father had called previously stating the patient slipped in the shower and hit his head on 10/25/15 with some increased symptoms. Surprisingly, his symptoms improved rapidly and had essentially resolved over the past week. The patient was tolerating full school well and felt that he was doing well in school. He felt that he was 100% recovered. Physical exam showed VOMS normal without symptoms. ImPACT scores were improved, but still low in visual memory, visual motor speed and reaction time composite categories. The patient was advised to advance his noncontact activity slowly. School note recommended continued assistance with makeup work.

50 Concussion Case #2- Final ImPACT

51 Concussion Case Presentation #3 G.C. is a 16-year-old female with a history of head injury on 10/26/15. The patient was playing a game in PE class when a larger male student contacted her causing her to fall backward and strike her head on the gym floor. She noted immediate symptoms of headache, dizziness and nausea. She was evaluated on the day of her injury through the walk-in clinic. She was diagnosed with concussion and appropriate rest recommendations were made. She rested at home from school for 1 day and then returned to a full day of school. She then worked in the office at school during her fall break. She underwent ImPACT testing at her school on 10/29/15 with global moderate decreased ImPACT scores and a markedly elevated symptom score of 95, but did have an elevated baseline symptom score of 73. The patient does have a history of Crohn's disease and some chronic upper back pain.

52 Concussion Case Presentation #3 She was evaluated through the Concussion Clinic on 11/05/15 (10 days postconcussion) with main complaints of photophobia and phonophobia. She was taking Tylenol as needed for pain. VOMS did reproduce mild increased symptoms of headache and dizziness. Convergence testing was 10 cm. ImPACT testing was performed which showed significant overall improvement compared with previous testing. The patient and her mother were encouraged that the ImPACT scores showed significant improvement. The patient was advised to continue in school as tolerated and rest in the nurse's office if needed. She was advised to try very light activity such as very short walks or stationary biking. Tylenol, 2 tablets TID on a more regular basis was recommended.

53 Concussion Case #3- ImPACT

54 Concussion Case #3- Symptom Score

55 Concussion Case #3- Follow-up Follow-up on 11/19/15 (3 weeks postconcussion):the patient was in full attendance at school and working her co-op job. She complained of persisting symptoms of headache, dizziness, sleep issues, photophobia and difficulty concentrating. She also described episodes of dizziness/vertigo with a spinning sensation and associated pain in the superior aspect of her head. She was taking Tylenol as needed. VOMS testing continued to reproduce mild symptoms. Convergence testing was increased to 18 cm. ImPACT scores were essentially stable when compared with previous office visit 2 weeks prior. MRI of the brain was ordered because of dizzy spells. Recommendations were for continued school as tolerated with very light activity as tolerated. Continue Tylenol 2 tablets TID. Phone call 11/20/15 with worsening of the above symptoms symptoms. Reassurance was given and recommendation for obtaining the MRI scan of the brain as scheduled.

56 Concussion Case #3 MRI of the brain was obtained on 11/25/15 showing: #1. 8 mm focus in the posterior aspect of the right middle cranial fossa abutting the tentorium cerebelli which is low in signal on the T2 and GRE sequences and may represent a dural calcification, hemorrhagic focus. #2. Cerebellar tonsillar ectopia with the tonsils extending 2 mm past the foramen magnum. The patient was scheduled for Pediatric Neurology consultation. Ongoing continued conservative management was recommended.

57 Concussion Case #3- Follow-up Follow-up on 12/03/15 (5 weeks postconcussion): The patient still complained of headaches, dizziness and fatigue. She did admit that her Crohn's disease was causing increased stress in her life. She was worried about getting caught up in school. Her guidance counselor was aware of her concussion and academic accommodations. Clinical trajectory diagram was reviewed with concerns for anxiety/mood, cognitive/fatigue and vestibular/dizziness categories prolonging the patient's symptoms. Counseling was recommended. Antidepressant medication was discussed, but not started. No ImPACT testing was performed.

58 Concussion Case #3 Final Follow-up Follow-up on 12/17/15 (7 weeks postconcussion): The patient's symptoms were improved. She was no longer having daily headaches. She was only having one dizzy spell per day. She felt 99% recovered. She was looking forward to the Christmas break and wanted to attend a winter camp. She was scheduled to meet with her guidance counselor concerning academic issues. VOMS testing did not reproduce any symptoms. Convergence testing was improved to 6 cm. ImPACT was performed. She was advised to continue to increase her activity slowly as tolerated including attending the winter camp. She was planning to try and get caught up with her schoolwork over the Christmas break. Follow-up with the pediatric neurology consultation for the presumed incidental brain findings on MRI scan.

59 Concussion Case #3- Final ImPACT

60 Concussion Case #4 K.T. is a 15-year-old male with a history of previous concussions in 2014 and 2011 who suffered another concussion injury on 09/03/15. He was playing quarterback on the JV football team when he suffered a helmet to helmet contact and then fell striking his head on the ground. He was able to get up under his own power, but was then removed from the game by the referee. He was evaluated on the sideline with SAC scores of 23/30 and 24/30 with a symptom score of 61. Because of the level of his symptoms, the patient was sent to the emergency department for further evaluation. CT scanning of the head and cervical spine were obtained and were negative. Concussion management recommendations were given including remaining home from school the following day and then getting close follow-up. The patient attended part-time classes until 09/09/15 when he attended a full day of class and was sent home early because of increased symptoms.

61 Concussion Case #4- Evaluation The patient was initially evaluated through the concussion clinic on 09/10/15 (1 week postconcussion). The patient admitted that his current concussion seemed worse than his previous concussion in His symptom score remained high at 51. He also complained of some persisting neck pain and stiffness. He was not taking anything for pain management. VOMS testing reproduced prominent symptoms of headache and dizziness. Neuro exam revealed balance difficulty with heel to shin and reverse tandem gait testing. ImPACT scores were globally decreased. Recommendations for continued relative rest with very light noncontact activity in the form of walking. Recommended trial of Aleve 2 tablets twice a day for 3-5 days headache and neck pain. The patient was removed from football for the remainder of the season.

62 Concussion Case #4- Recheck #1 Follow-up 09/24/15 (3 weeks postconcussion): The patient felt that his symptoms were only minimally (20%) improved. He was having difficulty tolerating a full day of school complaining of increased symptoms at the end of the school day. He was not taking any medication for pain management. His worst symptom was retroorbital headaches which were worse at the end of the school day. He complained of some problems with memory and ongoing dizziness. He complained of difficulty falling back asleep if he awakened at night. He was tolerating walking as a light physical activity. VOMS testing was improved, but still reproduced some headache and dizziness with smooth pursuits and rotational visual stimulation testing. ImPACT scores were improved, but still not back to baseline. Clinical trajectories were considered. There was concern for migraine component of the patient's symptoms. He was once again advised to try Aleve 2 tablets twice a day on a regular basis for a few days and then was given a prescription for Nortriptyline 10 mg at bedtime to see if this would help his headaches if the Aleve was not helpful. School note recommended continued part-time school as tolerated with academic assistance recommended. He could rest in the nurse's office at school if symptoms worsen at school.

63 Concussion Case #4- Postinjury ImPACT #1 and #2

64 Concussion Case #4- Symptom Scores 1 and 3 Weeks Postconcussion

65 Concussion Case #4- Recheck #2 The patient was seen in follow-up on 10/08/15 (5 weeks postconcussion). The patient had advanced to full day school attendance over the past week. He felt that he was catching up with his schoolwork and had done well on some recent tests. He was feeling 85-90% improved. He continued to complain of worsening retro-orbital headaches and fatigue at the end of the school day. He noted some dizziness if he moved quickly. He was also complaining of problems with falling asleep. He continued to complain of some ongoing mild neck pain. He was taking Aleve 1 tablet BID and did not start the nortriptyline. VOMS testing seemed improved overall but still reproduce some symptoms of headache and dizziness. Convergence testing remained mildly increased at 10 cm. ImPACT scores continued to show improvement, but were still not back to baseline. The patient was reassured that he was continuing to improve. Melatonin 1-3 mg was recommended for sleep. Continued recommendations for assistance at school and gradual increase of noncontact physical activity. There was still concerns for clinical trajectories of ocular motor, vestibular, cognitive, mood and cervical causing some of the patient's ongoing symptoms.

66 Concussion Case #4- Recheck #3 We received a call from the patient's guidance counselor on 10/26/15 because of concern for the patient's increased symptoms including headache and difficulty concentrating later in the school day that had been occurring over the past 2 weeks. The school nurse and guidance counselor had met and recommended alternating half day school attendance for the next 2 weeks. It was recommended that the patient drop his PE class. The patient was seen in follow-up on 10/29/15 (8 weeks postconcussion) stating that he had very few symptoms in the mornings, but by afternoon he became increasingly symptomatic. His main symptoms were headache, fatigue and some difficulty with concentration. The patient stated that the whole day of school is just alot. The melatonin was helping his sleep. He had discontinued Aleve because of concerns that it was causing headaches and elevated blood pressure. VOMS testing reproduced mild headache and dizziness symptoms. Convergence testing remained mild increased at 10 cm. ImPACT testing was performed. The patient's increased symptoms at the end of the school day were reviewed with clinical trajectories of cognitive fatigue, convergence insufficiency and the patient's persisting neck pain as possible causes. Return to school recommendations agreed with the above alternating half-day classes attendance for 2 weeks. The patient was being followed closely by the school nurse.

67 Concussion Case #4- Post-Injury ImPACT #3 and #4

68 Concussion Case #4 Phone call from school nurse 11/06/15 (9 weeks postconcussion): The patient had increased symptoms over the weekend. He was continuing to go to the nurse's office at school complaining of headache, fatigue, problems remembering what he had done in class, problems with the noise in the cafeteria and not tolerating the bus ride to school because it was too jarring. The nurse had noted a glazed over look. Convergence insufficiency causing the patient's symptoms was considered and referral to ophthalmology was arranged. Trial of amantadine was considered in spite of the strong ImPACT scores at the patient's last office visit.

69 Concussion Case #4- Recheck #4 The patient was seen in follow-up on 12/03/15 (3 months postconcussion): He had been evaluated in ophthalmology and the patient's current ocular condition was considered stable with no specific treatment offered. The patient downplayed his reports of afternoon headaches and memory issues stating that he was tolerating school quite well and was getting an A in Chemistry which was 1 of his hardest classes. He was still working to get caught up in Geometry and English and was receiving extra help in these classes. The patient described ongoing neck pain related to prolonged flexion of his neck at school when reading that seemed to aggravate his headache, memory problems and dizziness. The pain seemed to be in the bilateral occipital regions. The patient stated that he was eating well, sleeping well and tolerating light physical activity quite well. The patient's father voiced no concerns regarding the patient's ongoing concussion symptoms. Physical exam revealed some tenderness in the suboccipital region in the region of the occipital nerves. Clinical trajectories were once again reviewed considering a trial of Amantadine for the patient's afternoon memory issues versus Gabapentin for the patient's neck pain and apparent component of neck pain with occipital neuralgia. The patient was started on low-dose Gabapentin.

70 Concussion Case #4- Phone Update Phone call from the patient's mother on 12/14/15 (3.5 months postconcussion) stated that the patient seemed very fatigued and did not know the day of the week. He seemed to be tolerating the Gabapentin quite well which was helping his neck pain. Recommendations were to hold the Gabapentin until the start of Christmas break in 3-4 days. Anticipate that the 2 week break from school over Christmas break would help relieve any of the remaining symptoms. Recommendations were to call with a progress report in the next 1-2 weeks.