gaylord center for concussion care: advanced concussion case studies
TRANSCRIPT
ADVANCED CASE STUDY #1
Sarah Bullard, Ph.D., ABPPAnne Pacileo PT
Clinical Presentations in Concussion
Concussion
Vestibular
Ocular
Cognitive/ Fatigue
Post Traumatic Migraine
Anxiety/Mood
Cervical
Based on model developed by UPMC Sports Concussion Program Presented on June 9, 2013 by Michael W. Collins, PhD
Clinical and Executive Director UPMC Sports Medicine Concussion Program
Gaylord Center for Concussion Care
Patient Calls
Physical Therapy Neuropsych
PTfollow- up
North Haven PT
OT
Speech
NP follow- up
Physiatry
Nutrition
Counseling
Cognitive Assessment
• Brief/focused• Neurocognitive Measures
– Sensitive/Specific to Concussion• Multiple, repeatable, equivalent forms• Validity/Effort Measures• Concussion Symptom Checklist
Pencil & Paper Concussion Assessment
Specific domains measured:
– Attention/Concentration• Auditory and Visual
Immediate and Sustained Working Memory
– Learning & Memory• Auditory and Visual
– Executive Functioning & Fluency
– Verbal and Visual
– Processing Speed/Reaction Time/Visual Scanning
– Concussion Symptom Checklist
• First developed by Dr. Jeff Barth at UVA: SLAM model
• PennState Sports Concussion Project– Designed to measure
specific areas sensitive to concussion
– Now used with NHL & NFL
– Designed to be administered in 30-45 minutes
– Designed for repeated administrations so should have multiple equivalent forms or know RCI (Reliable Change Index)
Computer Assessment (ImPact)
• Disadvantages– Hardware issues– Lack of human oversight– Limited domains of functioning
assessed– No validity/effort measures– Subject to “abuse” in clinical
and educational settings by users not familiar with limits of tests and measurement
– Research suggests both false positive and false negative errors
– Doesn’t take into account premorbid factors (learning problems, ADHD, mood disorders)
• Advantages– Can access large
numbers quickly– Standardized
administration of test stimuli
– Time & cost efficient– Doesn’t require
human administration
– Sensitivity—accuracy of reaction time measures
– Alternative forms or randomized stimuli
Impaired Performance by LD & ADHD*
ImPact Learning Disability ADHD
Verbal Memory Yes No
Visual Memory No Yes
Visual Motor Processing
Yes Yes
Reaction Time No No
Impulse Control No Yes
Symptom Checklist Yes Yes
*versus control group (p ≤ .05)
Why we chose the Paper & Pencil Route
• Referral population—the right tool for the job– Patients who are weeks if not months following the concussion– Patients who are not following the expected recovery curve (i.e.,
getting worse instead of better)– Patients with a history of LD and ADHD– Patients with a psychiatric overlay– Patients with a history of multiple concussions– Need to distinguish Psychiatric or Neurologic cause for symptoms
• Suspect secondary gain or malingering/poor effort• Suspect Somatoform Disorder
– Patients with positive CT or MRI scan– Patients with a need for a special education services (504 or IEP)
1. We start with a 20-30 minute interview2. Next we administer a neurocognitive battery of tests.
Approximate administration time is 30 to 45 minutes.– Attention/Concentration– Learning & Memory– Executive Functioning & Fluency– Verbal and Visual– Processing Speed/Reaction Time/Visual Scanning– Concussion Symptom Checklist– Mood screen
3. While the patient waits, the battery is scored.
Our Assessment
Care beyond the ordinary.
4. The patient and family, if applicable, are brought back in and given immediate feedback.
5. A plan is designed for school/work re-entry, any needed adjustments/accommodations, return to play decisions, mood follow-up and the need for medical follow-up.
6. A 2 to 3 page report is generated within 48 hours and faxed back to the referring provider and school, if needed.
Total Time with the patient: approximately 2 hours.
Our Assessment Continued
A concussion is not a structural injury; it is a functional injury…
A complex pathophysiological process affecting the brain, induced by traumatic biomechanic forces.
Gaylord Center for Concussion Care
The Vestibular System
VisualVestibular
Proprioceptive
Primary Processor(Vestibular Nuclear
Complex)
AdaptiveProcessor
(Cerebellum)
Motor Neurons
Eye movements
Positional Movements
Typical symptoms present if the vestibular system is affected are:• Feeling of fogginess-”just not feeling right.”• Sensitivity to busy areas such as malls, crowded hallways• Dizziness• Nausea
– Eyes movements– Optokinetic sensitivity– Pursuit/Saccades– Near Point convergence– Near point of accommodation– Positional symptoms– Balance
• Static • Dynamic
Gaylord Center for Concussion Care
POST TRAUMATIC MIGRAINE AND CERVICAL SYMPTOMS
Typical symptoms present with Post Traumatic Migraine• Variable headache and intermittently severe• May present with vestibular migraine symptoms.• Nausea• Light and/or Noise sensitivity• Stress and Anxiety
Typical symptoms present if neck dysfunction is involved:• Neck Pain• Headache• Examination of neck• Range of Motion• Strength• Stability Screen
Gaylord Center for Concussion Care
TREATMENT
• Vestibular – Vestibular Therapy, Dynamic Physical Exertion
(as tolerated once vestibular therapy is complete)
• Vision – Vestibular Therapy with ocular motor focus, Vision
therapy, Dynamic physical exertion
• Cognitive – Physical/Cognitive Rest – Accommodations– Speech and Language Therapy
Gaylord Center for Concussion Care
• Anxiety/Mood– Treat vestibular signs if present– Supervised exertional therapy– Lifestyle regulation– Psychotherapy– Medication as appropriate
• Post Traumatic Migraine– Increased physical activity– Lifestyle regulation– Medication is often helpful
• Neck Pain– Therapy– Trigger Point therapy– Relaxation
Case Study
“Jane”
Jane: 14-yr-old female volleyball player
• Middle of three children; good health; A/B student
• 1st concussion in October of 2012– Recovered within a week
• 2nd concussion in September of 2013– No memory for getting hit, brief LOC,
immediately nauseous and tired– Persisting headaches, ringing in her ears,
sensitivity to light– Remained out of school for a few days
• Attended a volley ball practice and was struck on the head– Symptoms exacerbated
Jane: Initial visit
– Evaluated 6 weeks post concussion, complained of:
• Sensitive to light and sound• Occasional dizziness• Daily headaches that abated only somewhat on
weekends• Fatigue• Poor concentration• Difficulty recalling what she has read• Grades beginning to slip
– Was full time at school, no adjustments– Had pulled out of all extra-curricular activities
Jane: Initial Test Results
Impaired Borderline Low Avrg. Average High Avrg. Superior Very Sup.
Memory
Attention
Processingspeed
Executive Fx:hits a wall/lose track/
distracted Visual spatial
Language
Jane: Initial PT Findings
• Oculomotor signs: – smooth pursuit with symptoms, hypometric
corrections during seccades– Convergence 45cm (normal approx. 6cm)– Dynamic visual acuity 7 line difference– King Devick Score more than twice normal time
• Balance Assessment– Deteriorated balance with movement and with
eyes closed-Dynamic Gait Index 17/24- – Activities Balance confidence scale- 64.4/100– Poor ability to engage in simple cognitive tasks
during physical exertion.
Jane: Recommended Adjustments
• Half Days• Essential work• Extra time for tests/assignments• One test/day• Quiet room for tests• Note taker/iPad• No return to play• Nutritional recommendations• Follow up one month
Jane: One Month Follow-Up
• Improvement in headaches and fatigue– But headaches are still daily
• Improvement in light/sound sensitivity• Still difficult to concentrate in a noisy
environment• Overall described as “brighter” by mom• Described school as very supportive,
which helped relieve stress
Jane: One Month Follow-up
Impaired Borderline Low Avrg. Average High Avrg. Superior Very Sup.
Memory
Attention
Processingspeed
Executive Fx:hits a wall/lose track/
distracted Visual spatial
Language
Jane: One-Month Follow-Up PT
• Oculomotor signs: – smooth pursuit without symptoms, seccades
normal– Convergence 10 cm (normal approx. 6cm)– Dynamic visual acuity 3 line difference– King Devick Score significantly reduced
• Balance Assessment– Deteriorated balance with movement and with
eyes closed-Dynamic Gait Index 22/24- – Activities Balance confidence scale- 85/100– Able to walk at 3.5 miles per hour while moving
gaze to varied targets and engage in mild cognitive task.
Jane: Updated Adjustments for School
• Full days• Essential work• Extra time for tests/assignments• One test/day• Quiet room for tests• Use of iPAD to take notes• No return to play• Worried about rebound headaches: contact
pediatrician• Follow up one month: at which time most
adjustments are anticipated to be lifted
Jane: Two-Month Follow-Up
*Effort intact; Mood intact
Average High Average Superior Very SuperiorLow AverageBorderlineImpaired
Attention
Processingspeed
Executive fx(hits a wall)
Memory
Language
Visual spatial(Spatial judgment)
Jane: Final Result
• Cleared from PT to return to play/sport
• No ongoing adjustments needed at school
• Discussion with Jane and her father about the risks/benefits of contact sports and future concussions.
Case Study
“Kathy”Protracted Recovery
Kathy: Initial Appointment
• 16-year-old female• Whiplash injury in a motor vehicle accident
2 months previous• Remembers immediate neck pain and
headache• Did not strike head • History of migraines• Participated in varsity track as well as field
hockey• A student, Honors & AP classes• Missing school
Kathy: Initial complaints
• Light sensitivity- did not like wearing sunglasses because the pressure on her nose gave her a headache.
• Noise sensitivity• Fatigue/Poor sleep• Extremely Anxious and mildly depressed• Grades slipping • Hard to concentrate• Difficulty completing homework• Had been seen by chiropractor and but did not
get much relief from neck pain nor headaches
Kathy: Initial PT results (6 weeks)
• Had been adjusted by chiropractor by her visit to PT• Oculomotor signs:
smooth pursuit with symptoms Convergence Within normal limits but symptomatic with testing Dynamic visual acuity 3 line difference
• Balance Assessment Deteriorated balance with eyes closed in sharpened Romberg and standing on
foam. Dynamic Gait Index 17/24- Activities Balance confidence not administered SLS R= 3 seconds L= 4 seconds
• Other PT findings Rapid alternating movements UE delayed. Finger to Nose dysmetria Mild cervical ROM limitation into extension with some posterior cervical pain Muscle guarding in (B) SCM, Upper and middle traps, scalenes, lev scapulae,
spenius capiti. Unable to complete 10 minute exertion test due to headache, dizziness, mild
nausea- test stopped after 3 min 25 sec. Headaches daily
Kathy: Initial NP Results (2 months s/p Injury)
*Effort intact
Average High Average Superior Very SuperiorLow AverageBorderlineImpaired
Attention
Processingspeed
*strategizing &thinking quickly on your feet
Flexibility/Multi-tasking
Verbal Memory
Mood: Depressed &
Anxious
Kathy: Recommendations
• Half Days for two weeks• Extra time for assignments/tests• Note taking• Test format: multiple choice• Referred for psychotherapy• Refrain from driving until anxiety
improved• No sports• Nutritional recommendations
Kathy: 5 months later
• Complains of:– Fatigue (nap every afternoon)– Decreased attention/concentration– Forgetful– Daily headaches– Depression and anxiety
• School– Struggling to complete homework– Hard to start projects/hard to motivate– Not caught up in all classes
Kathy: Follow-up PT Findings
• Oculomotor signs: – smooth pursuit without symptoms– Convergence without symptoms– Dynamic visual acuity same line reading
• Balance Assessment– Balance with eyes closed in sharpened Romberg and standing on
foam Within normal parameters.– Dynamic Gait Index 23/24- – Single limb stance R= 12 seconds L= 15 seconds
• Other PT findings– Other findings- Rapid alternating movements UE normal. Finger to
Nose testing normal– Cervical symptoms absent– Days without headaches. – Able to tolerate up to 20 minutes of minimal to moderate exercise
walking in treadmill or stationary bike.– Core stabilization continued to be weak for dynamic activities
Kathy: 5 months post Injury
*Effort intact
Average High Average Superior Very SuperiorLow AverageBorderlineImpaired
Attention
Processingspeed
*Organization/Planning
when unstructured
Flexibility/Multi-tasking
Verbal Memory
With structure
Mood: Depressed &
Anxious
Kathy: Recommendations
• Test format: multiple choice• Extra time for assignments and tests
(headaches, fatigue, anxiety)• Separate room for tests• One test per day• Point person• No sports• Continued psychotherapy• Speech therapy
Kathy: 8 months later
• No more headaches• Breakthrough in psychotherapy: mood
dramatically improved• Fatigued somewhat more easily than in the
past, but able to manage without naps• Felt like herself
Kathy: Final PT visit
• Pt was referred to return to play protocol– Field Hockey
• Oculomotor signs: – smooth pursuit without symptoms– Convergence without symptoms– Dynamic visual acuity same line reading
• Balance Assessment– Balance with eyes closed in sharpened Romberg and standing on
foam Within normal parameters.– Dynamic Gait Index 24/24- – Single limb stance R= 30 seconds L= 30 seconds
• Other PT findings– Other findings- Rapid alternating movements UE normal. Finger to
Nose testing normal– Cervical symptoms absent– Headaches gone with physical activity. Pt did have headache after
riding in car to Boston for 2 ½ hours which recovered quickly.
Kathy: Final Eval 8 months post injury
*Effort intact; Mood intact
Average High Average Superior Very SuperiorLow AverageBorderlineImpaired
Attention
Processingspeed
Organization/Planning
when unstructured
Flexibility/Multi-tasking
Memory
Problem Solvingwith structure
Kathy: Recommendations
• Full time school schedule• No adjustments• Cleared to return to play______________________________________
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