Managing Concussions, a partnership between the school and the primary care clinic
• Concussion basics – Ahrendt
• Concussion evaluation tools – Myhre
• Cognitive rest and Return to Learn – Ahrendt
• Breakout session
o Teach and practice BESS and VOMs
o Small group discussion of concussion cases
• Management of persistent symptoms- Smalley
• Wrap and questions
Workshop Breakout Session Cases
Case #1
A 15 year old male comes to see you on a Tuesday morning for an ER concussion visit follow-up. He reports he was hit during a football game Friday night. He didn’t say anything initially but after 2 more plays he started to feel dizzy and the trainer pulled him from the game. His parents took him to the ER. He was diagnosed with a concussion and told to follow-up with his primary care provider. He was restricted from sports until cleared. No imaging or lab studies were done.
Discussion:
1. Do you or your clinic currently use any specific processes or standardized forms for patients that come with concussions?
2. Which of the tools discussed today do you feel you would like to use?
3. Do you do primary management of post-concussion patients or do you refer?
Case #1 continued:
He reports that he had a “bad headache” Saturday and he mainly stayed in his room. His parents gave him some ibuprofen which helped the headache go from a 9/10 to a 3/10 on the pain scale. That night he watched a movie with his family which didn’t make his symptoms worse. Sunday he awoke feeling good but got a 5/10 headache in the afternoon that went away with rest and another dose of ibuprofen. He went to school yesterday and had another “bad headache” after his physics class and came home in the early afternoon. This morning he says he feels fine, and needs a note to return to school and football.
Discussion:
1. Prior to today, what type of evaluation or physical exam would you have done?
2. Are there any additional tools / exams you would use after todays workshop?
3. Would you manage this patient on your own or refer?
Case #1 continued:
On exam you find no evidence of trauma. Your “usual” neuro exam is normal. On VOMs screen he got dizzy while doing the Vestibular-Oculomotor Reflex and had a convergence to about 10cm. You have no baseline test, but with the BESS testing he scored: Firm 0/2/1 Foam 1/5/2
Discussion:
1. Do you clear him for return to football?
2. Do you clear him for return to school?
a. If so, any restrictions? Which ones?
3. When will you see him back for follow-up?
Case #2
A 17 year old female comes to see you for headaches that she has been getting daily for the last 2 weeks. She has a history of migraines but they were only happening about once a week before. Upon further questioning you discover the headaches got worse after a volleyball tournament she played in. She reports there was a collision with another player while they were both going for the ball at one point, but she doesn’t remember if she had a headache afterwards. She does remember getting a migraine on the drive back home. She has been going to volleyball practice but has had to stop early due to headaches a couple of times. She says she has been going to school and has had to go to the nurses office to take her headache meds almost every day. On exam she is light sensitive and keeps looking down and shading her eyes. She has symptoms on all of the VOM screen and is unable to do the BESS testing because she loses her balance as soon as she closes her eyes.
Discussion:
1. What type of restrictions would you give her?
2. Should she return to school today/tomorrow?
3. When she does return to school, what restrictions would you give her?
Case #2 continued:
When you see her on follow-up a week later she is able to attend school with the restrictions you put in place, but she develops worsening headaches after about 45 minutes of sitting in class and she is going to the nurses office frequently. Some of her teachers have been warning her that if she doesn’t get caught up on her homework she may fail their class. Your sheet with her school restrictions expires today and she needs updated instructions.
Discussion:
1. What school restrictions would you recommend at this point?
2. If you were to contact the school, what specific issues would you want to address with them? If this isn’t a school you have worked with in the past, who would you contact?
Case #3
The athletic trainer at your school contacts you because she heard you are an expert on managing mild traumatic brain injury and she wants to set up a protocol for managing these kids after concussion. She wants a comprehensive plan that can be used for everyone. (If you work in/with a school please discuss how you would do it in your situation. If not, in theory)
Discussion:
1. It’s time to have a meeting to discuss the plan, who should you invite to the meeting, and what roles would they have in the plan?
2. Would you manage middle school aged students differently from high school? 3. How do you define minimal vs moderate classroom participation?
Case #4
You are starting your new job as part of a university health care clinic. As you are known for the great work you have done with managing mild TBI in the past, they ask you to set up a program here as well.
1. What modifications would you have to make for a college aged patient to the discussed cognitive rehab plan? Is it usable at all?
2. How would you manage a student-athlete injured while playing at a game vs a student that was injured doing recreational activities (outside of the school environment)?