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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