"Traumatic Brain Injury in a Collegiate Football Player: A Case Report" by Camille Bordelon

For the 26th Annual SEATA Student Symposium on February 3-5, 2011, nine 2nd year Athletic Training Students submitted Case Study Abstracts. All nine students were chosen to present either orally or a poster presentation at the Symposium. Camille Bordelon, a 2nd year Athletic Training Student with Football wrote her Case Study Abstract on "Traumatic Brain Injury in a Collegiate Football Player". This case study is of significant relevance to Sports Medicine today, with the increasing concern over head injuries and long-term complications in professional football. Below is Camille's abstract that covers Personal Data, Past and Present Medical History, Signs and Symptoms, Differential Diagnosis, Diagnostic Testing, Final Diagnosis, Treatment and Outcome, and Deviation from the Expected in a severe head injury of a collegiate football player.

TRAUMATIC BRAIN INJURY IN A COLLEGIATE FOOTBALL PLAYER:

AUTHORS AND AFFILIATION:
Camille Bordelon, ATS, Louisiana State University, Baton Rouge, Louisiana
Jack Marucci, MS, ATC, LAT, Louisiana State University, Baton Rouge, Louisiana

Personal Data
The patient is a 20 year old African American male collegiate football wide receiver.

Past Personal Medical History
The patient has no past medical history of a traumatic brain injury.

Current Medical History
After jumping to receive a pass on the turf, the patient's legs were undercut, causing him to land directly on the back of his head. There was no loss of consciousness, but the patient was extremely disoriented and could not keep his balance without assistance.

Physical Signs and Symptoms
The patient had no loss of consciousness, but his mental status deteriorated quickly. He exhibited symptoms of profound confusion, headache, dizziness, and slurred speech. He was extremely groggy, falling asleep every few seconds and had to be held upright while seated to keep him from falling. In addition to showing symptoms of brain injury, he also reported facial pain and was noted to have constant blood-tinged clear drainage from his right nostril. In the ER, he was noted to show focal findings of a right pronator drift and right-sided finger-to-nose abnormalities.

Differential Diagnosis
Grade One Concussion, Grade Two Concussion, Grade Three Concussion, Intracerebral hemorrhage facial contusion, facial fracture

Results of Diagnostic Imaging/Laboratory Tests
A CT of the head done in the ER was WNL. A CT of the C-spine was also ordered and was WNL. Additionally, an MRI of the brain and a CT scan of the facial bones were ordered. The MRI of the brain was WNL. The CT Scan of the facial bones showed non-displaced right infraorbital and nasal fractures. Follow-up MRI of the brain on Day 4 was also WNL. The symptom score for his Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) was a 44 whereas his baseline score was a 3.

Final Diagnosis
The patient was diagnosed with a Grade Three Concussion by the Cantu Scale, as well as nasal and infraorbital fractures.

Treatment and Outcome
The patient was hospitalized for 4 days due to the severity of his concussion and balance problems and was discharged when he was able to walk without assistance. His facial fractures were treated non-operatively. Soon after discharge, the symptom score for his Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) was a 44 whereas his baseline score was a 3. After a consultation with a neurologist, the patient was instructed to rest for 4 weeks before participating in full activity. After this rest period, patient's ImPACT test was back to baseline. His symptoms resolved and he then participated in light contact and running drills for ten days before his symptoms returned. Prior to a game, he reported dizziness with contact warm-up drills. He then reported the dizziness had been occuring since the plane ride the day before. He also reported a mild presistant neck ache, blurred vision, and difficulty focusing in the classroom. He was held from the game and reevaluated. At that time, his ImPACT test symptom score was higher than his baseline at a score of 22. He underwent another MRI and CT Scan with unchanged results from the previous tests. The neurologist felt most of his signs and symptoms were post-concussive. However, he also thought there was a possibility of vestibular signs and symptoms as well, which would explain the patient's focal findings on exam in the hispital despite normal imaging studies. The patient began vestibular rehabilitation with a specialized physical therapist. The rehabilitation program was initially based off of the University of Pittsburgh Medical Center Concussion Rehabilitation Protocol. The initial focus was remedial therapy of the Posterior Cervical Spine muscles. Prior to onset of therapy, the patient was still reporting blurred vision, stiff neck, discomfort with head rotation, balance difficulty with eyes open and closed, and tenderness on C4-C5 with increasing pain and decreased ROM with rotation. The treatment also included cold laser therapy to help reduce pain and inflammation, manipulation of the cervical spine joints, and stretching. The next step was vestibular ocular reflex therapy and cervical ocular reflex therapy. With vestibular ocular reflex therapy, the patient looks at a target and shakes his head in a yes and no movement while walking forwards and backwards. With the cervical ocular reflex therapy, the patient keeps his head fixed on a target while walking forwards and backwards with torso twisting. After two to three weeks of vestibular therapy, the patient's symptoms had resolved and he began participating in individual drills and was slowly worked back into the rotation. He is now playing without limitations and reports his movement and hand-eye coordination to be better then before.

Deviation from the Expected
This patient's case had several unique features. First, his post-concussive symptoms were two-fold. He showed symptoms of the typical diffuse injury seen in a concussion but he also had symptoms of a focal vestibular injury. The impact of the fall caused brain trauma, but it also harmed the vestibular system, causing the patient's eye movement, proprioception, and inner ear to not function properly. This in turn affected his vision, balance, and concentration ability even after the concussion was resolved. Another unique feature is that the patient sustained facial fractures even though the blow to the head was on the posterior aspect. This is a true "contra-coup" injury, which is defined as an injury that occurs when the maximal area of injury is on the opposite side of the skill where the impact occurred due to the transmission of forces. Additionally, the nasal drainage, which was initially concerning for a spinal fluid leak from a basilar skull fracture, was in retrospect a mix of blood from the trauma of the nasal fracture as well as mucous that was jarred loose from his sinuses as a result of the impact. Due to the unique aspects of this patient's case, his treatment was tailored specifically to his needs, which ultimately provided him with a good outcome and a full recovery.