Concussion Cases

Kellie Bartlow, DOUMKC Sports Medicine Fellow

Case 1: JF

• JF is a 17 year old wide receiver • During a Friday night game, JF

complains to the ATC of headache and sensitivity to stadium lights after being tackled

JF: History

• Currently complains of headache, nausea, dizziness, fatigue, sensitivity to light and feeling mentally foggy

• Is able to describe the play in which he was hit in full detail

• No loss of consciousness• Denies history of past concussion

JF: History

• Denies past treatment of headaches or migraines

• Denies history of epilepsy/seizures, meningitis or brain surgery

• Denies past treatment of substance/alcohol abuse

• Denies past treatment of psychiatric conditions (depression, anxiety)

JF: History

• Denies diagnosis of ADD/ADHD• Denies diagnosis of autism• Denies diagnosis of dyslexia

JF: SCAT3

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JF: SCAT3

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JF: SCAT3

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JF: SCAT3

Normal ROM, no tenderness, normal sensation/strength

Football cleats

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JF: Assessment & Plan• Diagnosed with concussion• JF and his father advised of diagnosis and

that JF would not be allowed to return to game

• ATC notified coaching staff and took possession of JF’s helmet

• JF and his father instructed on cognitive and physical rest

• JF was reevaluated several times during remainder of game; when light sensitivity became too difficult, JF was sent home with his father after discussing precautions

JF: Follow Up

• Post-injury computerized neurocognitive testing completed day after injury

JF: Follow Up• Seen again by physician 4 days after

initial injury• Continued to have headache, fatigue

and difficulty with concentration but symptom score improved to 3

• Exam unremarkable• Advised continued cognitive and

physical rest until symptoms 0 for 24 hours, at which point he would be allowed to begin RTP protocol with ATC

JF: Follow Up

• Symptoms resolved completely 6 days following initial injury

• Computerized neurocognitive testing repeated 24 hours later

JF: Follow Up• As previously recommended, JF

began graded RTP program, directed by ATC

• At follow up with physician 11 days after initial injury, had completed graded RTP protocol with the exception of full practice (which he was to complete later that day)

• Cleared to return without restriction following day with condition that he did not develop symptoms during practice (which he did not)

Case 2: GW

• 14 year old linebacker• Head injury during freshman football

game• Had neurocognitive testing with ATC

day after injury• Presents for evaluation by physician

5 days after injury

GW: History

• No history of prior concussion• Denies treatment in past of

headache/migraine• Denies history of epilepsy, seizure,

brain surgery, meningitis• Denies current or past treatment of

alcohol/substance abuse or psychiatric conditions

• Denies diagnosis of ADD/ADHD, dyslexia, autism

GW: Post-Injury Neurocognitive Testing

GW: History

• Symptom score at 1 day post-injury: 58– Headache, nausea, balance problems,

dizziness, fatigue, sleeping more than usual, drowsiness, sensitivity to light and noise, irritability, sadness, nervousness, emotional, feeling mentally foggy, difficulty with memory and concentration

• Symptom score at 5 days post-injury: 30– No longer dizzy or with balance

problems– Other symptoms improved in severity

GW: Physical Examination

• Examination at 5 days post-injury was unremarkable

GW: Assessment/Plan

• Diagnosed with concussion• Advised continued cognitive and

physical rest as initiated by ATC until symptoms 0 for 24 hours

• Follow up with physician in 1 week; if symptoms returned to 0 for 24 hours prior to reevaluation by physician he would be allowed to begin RTP protocol with ATC

GW: Follow Up• At 1 week follow up (12 days after

initial injury), GW continued to have symptoms lingering in low teens for several days

• GW reported going to school for full days without worsening of symptoms

• He then admitted to going for a run with his friends and playing Frisbee over the past several days

• Examination remained unremarkable

GW: Follow Up

• Discussed prolonged symptoms with returning to activities prior to symptom resolution

• Reiterated recommendation for cognitive AND physical rest until symptoms 0 for 24 hours

• Planned for follow up with physician in 1 week with instruction to begin graded RTP protocol with ATC once symptom-free for 24 hours

GW: Follow Up

• On next follow up visit, GW reported avoiding physical activities until his symptoms resolved

• Symptoms had resolved 3 days prior to second follow up and GW had begun graded RTP protocol 1 day prior to follow up (not earlier due to symptom resolution during the weekend)

• Plan: progress through protocol, follow up in 1 week for full release

GW: Follow Up

• On third follow up, GW had progressed through each step of graded RTP protocol without symptoms

• Examination remained unremarkable• GW was returned to full activity

without restriction

GW: Take Home Message

• Symptoms can become prolonged with early return to activities

Case 3: MS

• 16 year old running back• Seen on the sideline with headache,

dizziness and feeling “out of it” near end of 4th quarter of varsity football game

MS: History• Reports being hit several times in the

game, most notably just before coming to the sidelines with symptoms

• Denies any past concussions• Denies past treatment of

headaches/migraines• Denies history of brain surgery,

meningitis, ADD/ADHD, dyslexia, autism

• Denies current/past treatment of alcohol/substance abuse or psychiatric conditions

MS: Physical Examination

• Cognitive Assessment– Modified Maddocks Questions: is able to

state which venue he is playing in, which half it is, who scored last, what team was last played and if his team won the last game

– Correctly states the month, date, day of the week, year and time within 1 hour

– Immediate and short-term memory intact

– Concentration intact

MS: Physical Examination

• Balance Examination– Modified BESS of 15/30 (9 errors with

single leg stance and 6 errors with tandem stance)

• Coordination intact• Sensation intact• Motor intact• Cranial nerves II-XII GIB• EOM intact without nystagmus

MS: Assessment & Plan

• Diagnosed with concussion• MS and his parents advised of

diagnosis; game had ended by this time so no need to keep from playing

• MS and his parents instructed on cognitive and physical rest as well as return precautions

• Father was very concerned that further evaluation needed; reassured father that no imaging recommended at current time given symptoms and examination but reiterated return precautions

MS: Follow Up

• Computerized neurocognitive testing completed 3 days after injury

MS: Follow Up

• MS returned for reevaluation 4 days following injury

• Reported continued symptom score in mid to upper 60’s

• Father present for visit and relayed that he had taken MS to ER on night of injury for further evaluation and MS had been admitted

MS: Follow Up• Stated that a neurologist had been

consulted while inpatient and reportedly said MS could not have a concussion as he was able to walk to the sideline without difficulty

• Was diagnosed with atypical migraine with vertigo as MS’s mother and grandmother have history of migraines

• MS cleared by neurologist to return to unrestricted play 5 days following injury

MS: Follow Up

• Father stated he does not know which diagnosis to believe but wishes to be cautious with returning MS to play

• MS confided that he may have given incorrect information to the neurologist as he could not accurately remember when he was hit during the game but was able to remember more clearly as the weekend progressed

MS: Follow Up• Physical examination unremarkable with

the exception of positive Romberg testing and abnormally slow and unsteady tandem gait

• Discussed with MS and his father that concussion still remained the working diagnosis as MS only developed symptoms AFTER sustaining a head injury

• Reviewed computerized testing and showed multiple areas of change from baseline

• Again recommended cognitive and physical rest with plan to follow up in 1 week

MS: Follow Up• MS returned 11 days post-injury• Reported that he had been to see

another physician; most recently seeing a primary care sports medicine physician

• Stated the same evaluation was completed as on sideline and in training room

• Reported being diagnosed with concussion and instructed in cognitive and physical rest

• Had been advised of possibility of vestibular rehab but was not prescribed

MS: Follow Up

• Symptom score in 40’s (improved from 60’s previous week)

• Examination unremarkable; gait abnormalities resolved

• Recommended continued cognitive and physical rest

• Discussed vestibular rehab but MS declined; planned to pursue through outside physician

MS: Follow Up

• MS returned for reevaluation 18 days post-injury

• Reported once again seeing his outside physician who had scheduled vestibular rehab to begin in following week

• Outside physician had requested computerized neurocognitive testing be repeated

MS: Follow Up

MS: Follow Up

• Further reported symptom score had been improving to mid 30’s at end of prior week but on day of evaluation score was again in upper 40’s

• Had been completing full days of school at end of prior week

• Over weekend went on a 4+ hour walk with family for Tour of Homes

MS: Follow Up

• Recommended increasing rest with bump in symptom score

• Clarified physical rest recommendations

• MS continues to be treated for his concussion symptoms but is not yet back to baseline as of today

MS: Take Home Messages

• Not all physicians, even those specializing in neurology or neurosurgery, are trained in concussion diagnosis and management

• As with prior case, increasing physical and cognitive activities too quickly can prolong symptoms and recovery

References

• SCAT3 forms downloaded from http://links.lww.com/JSM/A30

Questions?

http://www.businessweek.com/articles/2013-03-06/new-research-points-to-brain-injuries-in-college-football