Jonathan French, PsyD
Neuropsychology Fellow frenchje@upmc.edu
University of Pittsburgh Medical Center
Department of Orthopaedic Surgery
UPMC Sports Concussion Program

15 year old, Sophomore
Honors student, High Average standardized testing
No other medical history-no prior concussion
Strong migraine history in maternal family
In retrospect, difficulties with concussion started on September 11, 2009

Initial injury in video caused bilateral blurred vision, dizziness, photo/phonphobia, nausea, difficulty with play calls
No LOC, amnesia or mental status change
Never reported hit or symptoms to ATC, though told teammates
Second event in video worsened symptoms
That evening, told parents of symptoms (minimized difficulties)
No other medical intervention
Played remainder of season
Symptoms ebbed/flowed depending upon exertion and contact to head
Grades dropped during course of season (Straight A’s to C range)
Symptoms persistent throughout entire season
Sustained “another” concussion 10/30/09 (2 nd blow
Reported to ATC week after game/Referred to UPMC to last game)-posterior

November 16, 2009 Evaluation (2 Months after initial event)
Headaches daily in school (7/10-generalized pressure), moderate fatigue, “feeling slow”, fogginess, general dizziness, distractible, short term memory difficulty
Discussed inherent pressure of playing quarterback, team culture of playing through injury, pressure from coaches/family/friends
“Knew it was concussion, but nothing serious”
“Would be fine in long run”
“Good time to report injury given break from conditioning-no football responsibilities”
Father nonchalant, mother very concerned-discussed team/community culture of football
Physical evaluation indicated convergence insufficiency, provocative dizziness with horizontal/vertical saccades and gaze stability, balance WNL
ImPACT Testing

Recommended formal Vestibular Evaluation (UPMC-
Eye and Ear Institute/Center for Rehabilitation Services)
Patient strongly desired to remain in school
Allowed ½ days for 2 weeks
Provided full academic accommodations-including no tests for 3 weeks, ½ work assignments, books on tape if possible, extensions on all assignments, leaving class early, avoiding high stimulus areas, excused absences from school-recommended meeting with all teachers
Return evaluation in 2 weeks to monitor status

• In the early 2000’s, due to the increase of concussion, schools approached UPMC to help develop a plan for students with concussion
• UPMC’s sports concussion program wanted to collaborate with local schools to create an educational plan for individuals who are have a head injury
• This lead to a creation of an Academic
Accommodations form, which has been ever changing since it’s inception, and we continue to want to work with schools to improve it

Impact of School and Learning on mTBI
• Most educators, parents, and medical providers are aware of the deleterious impact of physical exertion on concussion symptoms and recovery, and are compliant with recommendations to reduce physical activity.
• Cognitive Exertion (Thinking) and the added stimulation of the school environment can significantly increase symptoms, even when the student has begun to recover
• Research has demonstrated generalized hyperactivation with concussion that is likely related to symptom increases when returning to school.
• Obvious Means: Testing, Group Work, Movies, Shop Class, Overhead lighting
• Subtle or Hidden Causes: Background noise (cafeteria, movement during and between classes), Taking notes (especially off of a projector), Sustained attention


Help to determine appropriate accommodations

HUGE individual differences

Can be Cognitive, Somatic, or Emotional

Can wax and wane throughout the day

1 st period “ok” by 8 th they are struggling

Student may not look or even act injured

Students are able to laugh when they are concussed

Some are able to continue to do well
 Don’t assume someone is “faking”; but we are aware this occurs

– Cognitive Difficulties
• Attention/Concentration
Problems
• Difficulty with memory
• Slowed processing
• Difficulty with Multitasking
– Physical Symptoms
• Difficulty to do well, if in significant pain
• Convergence Insufficiency
• Vestibular Dysfunction
– Sleep Disruptions
• Not sleeping at night it is difficult to perform well in school
• Fatigue throughout the day
– Emotional Instability
• Anxiety about catching up

• Communication problems: Staff are not aware of the injury or the severity of the problems (parents, guidance counselor, school nurse are key)
• Education problems: Staff shrug off injury because the student “looks fine,” “just had his/her bell rung,” or
“this is only their first concussion, I had 10 when I played football and it didn’t bother me” (individual differences)
• Resistance: Because of the extra time and effort involved in accommodations, staff are resistant to providing notes, checking off assignments, etc.

• Goals: A collaborative effort
– Create a way for educators to know that the student is injured and based on the evaluation, understand that certain tasks would provoke symptoms and prolong recovery
– To help students learn the core information needed to move on, without effecting their recovery
– Do not want students grades to suffer because of the injury
– Balance between recovery, academics, and normal activities
– Provide the right environment for recovery, as quick as possible
• It is NOT:
– UPMC telling you how to educate these students
• You are the educational professionals
• We want to collaborate with schools
– A “pass”
– Dismiss them from work/learning

• The recommendations were made based on the assessment at the time of the visit
• Recommendations part of treatment for this medical condition
• Formalize a 504 plan if necassary

• No school
• Initiate Homebound education
• Half days
– Modified days – core classes, extra study periods
• Full Days

• Students will not be as effective in testing situations, and they most likely will exacerbate symptoms
• Modifying test schedules, length, format, etc. is beneficial

• Reduce the amount of total work
• Modify the work by shortening assignments
• Changing modalities
• Auditory learning
• Audit Classes

• Note taking can be extremely provocative of symptoms
• Have the student listening to lectures having preprinted notes, scribes, etc.
• Allow the students to take breaks throughout the day
• Allow students extra time to complete assignments

• Allow students the opportunity for food and water if needed to help with symptoms
• Due to light sensitivity, allow sunglasses
• Modify computer screens
• Modify busy/disturbing environments
• No gym class

– Communication at all levels is key
• Both educators and treatment providers should work together
– Give the student the right environment to recover
– Recovery is quicker and safer when students receive a consistent message from all involved in their care
– Discussing options with injured student can be empowering
– Ideally, injured students’ grades should not suffer due to this temporary disability
– “Healthy” appearance of student is usually a difficulty
– Utilize available references, and encourage students/parents/administration to do the same

November 30 Evaluation
Vestibular evaluation indicated convergence insufficiency, difficulties with dynamic visual acuity, VOR exercises provocative for dizziness, posturography WNL
Home-Based PT outlined, Patient compliant
Symptoms not improved and persistent
Patient vocalized concerns over injury, response from coaching staff, etc.
“Play through pain culture”
Both parents understanding and concerned
Teachers helpful at providing accommodations
Father trying to “educate” others regarding injury
Vestibular screening improved, but remained abnormal
ImPACT Testing

Continued Vestibular Therapy-no exertion until WNL
Recommended homebound instruction
Recommended medication referral
Dr. Camiolo-Medical Advisor-UPMC Sports
Concussion Program
Amantadine 200mg
Follow up in 2-3 weeks

Factor Analysis,
Post-Concussion
Symptom Scale
(Pardini, Lovell, Collins et al. 2004)
•
More emotional
•
Sadness
•
Nervousness
•
Irritability
•
Headaches
•
Visual Problems
•
Dizziness
•
Noise/Light Sensitivity
•
Nausea
N=327, High School
•
Difficulty falling asleep and University
•
Sleeping less than usual
Athletes Within
7 Days of Concussion
•
Attention Problems
•
Memory dysfunction
• “Fogginess”
•
Fatigue
•
Cognitive slowing

Somatic
Symptoms
Headaches Prophylaxis

Propranolol*

Verapamil*

Amitriptyline*

Escitalopram (Lexapro)

Sertraline (Zoloft)
Vestibular Therapy
Emotionality
SSRIs

Escitalopram (Lexapro)

Sertraline (Zoloft)
Therapy
Cognitive Symptoms
Neurostimulants

Amantadine*

Methylphenidate*

Atomoxetine (Strattera)* Sleep
Disturbance
Melatonin
Trazodone
NOTE:
*Off-label use

December 18, 2009 (3 months post-injury)
Headaches 1/7 days (1/10, 20 minute duration), mild perceived difficulty with short-term memory
No other symptoms reported
Discharged from Vestibular therapy-all WNL
Started Exertional Physical Therapy
Sean Learish,PT-Center for Rehab Services-Director of
Exertional PT- UPMC Sports Concussion Program
ImPACT Testing

December 18 recommendations
Return to full school, minimal accommodations
(breaks from class if needed, tutoring in difficult classes, extensions all assignments)
Progress with exertional therapy to Stage 3-4
No contact sports
Continue Amantadine
Follow up 1 month

January 11, 2010 (4 months post-injury)
Off Amantadine
Reported circumscribed short term memory difficulties
Doing well in school-full curriculum
No other symptoms reported
Stage 4 Physical Exertion-no difficulties
Vestibular screening WNL
ImPACT Testing

January 11, 2010 Recommendations
Continue Exertion as tolerated
Follow up in February for monitoring of status

February 22, 2010 Evaluation
100% asymptomatic-no difficulties reported
Full physical and cognitive exertion
Grades returned completely to normal

February 22, 2010 Recommendations
Full clearance back to all sports, including football
Quotes from Family:
Both “Felt educated about injury”
Strong desire to “educate others”
Reported misperceptions of others
Concussion is always repetitive and cumulative
Son has “permanent damage”
Son would “never” return to football
Son would “never be the same cognitively or physically”
Son should “never play football again” (from same people who questioned veracity of injury to begin with)
“Poor education throughout community-from coaches to clinicians”
Without academic accommodations probably would have taken even longer to recover

Jonathan French, PsyD
Neuropsychology Fellow
UPMC Sports Concussion Program frenchje@upmc.edu