1. Concussion Cases Kellie Bartlow, DO UMKC Sports Medicine Fellow

2. 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

3. 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

4. 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)

5. JF: History Denies diagnosis of ADD/ADHD Denies diagnosis of autism Denies diagnosis of dyslexia

6. JF: SCAT3 ✓ ✓ ✓ ✓ ✓ ✓

7. Ο Ο Ο 15

8. JF: SCAT3 Ο Ο Ο 5 Ο Ο

9. FB 17 ✓ ✓ 0 N/A ✓ ✓ ✓ ✓ ✓ ✓ 12

10. JF: SCAT3 Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο 37 13 ✓

11. JF: SCAT3 Ο Ο Ο Ο Ο ΟΟΟ Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο Ο 5 15 555 2 3

12. JF: SCAT3 Normal ROM, no tenderness, normal sensation/strength Football cleats ✓ Rubber track 7 4 0

13. JF: SCAT3 ✓ 1 5

14. 13 37 5 15 3 5 28/30 11/30 N/A 1

15. 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

16. JF: Follow Up Post-injury computerized neurocognitive testing completed day after injury

17. 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

18. JF: Follow Up Symptoms resolved completely 6 days following initial injury Computerized neurocognitive testing repeated 24 hours later

19. 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)

20. 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

21. 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

22. GW: Post-Injury Neurocognitive Testing

23. 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

24. GW: Physical Examination Examination at 5 days post-injury was unremarkable

25. 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

26. 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

27. 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

28. 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

29. 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

30. GW: Take Home Message Symptoms can become prolonged with early return to activities

31. Case 3: MS 16 year old running back Seen on the sideline with headache, dizziness and feeling “out of it” near end of 4 th quarter of varsity football game

32. 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

33. 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

34. 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

35. 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

36. MS: Follow Up Computerized neurocognitive testing completed 3 days after injury

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. MS: Follow Up

45. 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

46. 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

47. 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

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

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