Outline Cases in Sport Related Concussion Management The Team Approach. Initial Findings. Case 1: Initial Findings, recommendations: Referral

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1 Outline Cases in Sport Related Concussion Management The Team Approach Panel: - Aimee Custer, PsyD - Amy Hamilton, ATC - Carly Mattson, DPT - Alex Noll, DO 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 - Justin Tatman, ATC; Moderator Case 1: Patient Demographics: 16 year old, male 11 th grade Football, outside linebacker History of two previously diagnosed concussions Injury occurred Friday 8/31/18, during 3 rd quarter of varsity game MOI: While attempting to make a tackle, opposing player ducked causing own teammate to hit him helmet-tohelmet Unanticipated rotational force 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, recommendations: Referral 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 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) 1

2 Patient History from Clinical Interview 9/13/18: Clinic Presentation 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 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 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 : 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 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) on 10/1/18. If remains asymptomatic, cleared to play in game on Friday 10/5/18 (5 weeks since DOI) 2

3 Case 2: Patient demographics 17 year old, female 12 th 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 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 or pathology; Chiari 1 malformation (pre-morbid) Released same day; told to follow up with PCP or TBI clinic 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 OCULAR Referrals ANXIETY/ MOOD 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 3

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 weeks Initiate therapy, attend weekly, complete HEP daily 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 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 Clinic Impression 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 Patient referred to specialty clinic after 4 weeks due to lack of improvement, worsening HA, and inability to perform occupational tasks POST- TRAUMATIC MIGRAINE CERVICAL VESTIBULAR COGNITIVE/ FATIGUE 4

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 Cleared for full return to work without restrictions 16 week after DOI Migraine management plan Follow up as needed Specialty Clinics Internal & External Internal (contract sites) & External Athletic Training, Sports Medicine Team Exertion Physical Vestibular Oculomotor Rehab Behavioral Neuro Optometry Vision Neurology Psychiatry, Psychology, Behavioral Health Speech, Occupational Thank You! 5