1. Concussion in Sports Anna Linstedt, ATC/LAT, RMA
ThedaCare Orthopedic Care
Menasha High School

2. Financial Disclosures
I do not have any financial relationships or interests to disclose with relation to any information provided in this talk

3. Acknowledgments
Thank you to Dr. Doug Connor for his assistance with this presentation

4. Goals Definition Diagnosis / Assessment Management
Return to Learning / Play
Final Clearance

6. Definition Multiple position statements - definitions NATA AAN
‘‘trauma induced alteration in mental status that may or may not involve loss of consciousness.’’
AAN
“alteration of mental status due to a biomechanical forces affecting the brain.”
Does not require LOC
Merriam-Webster Dictionary
a stunning, damaging, or shattering effect from a hard blow; especially a jarring injury of the brain resulting in disturbance of cerebral function

8. Diagnosis & Assessment Tools
SCAT 2 *
SCAT 3
Childs test (5-12yo)
SAC
A, B, C versions
VOMS *
Vestibular oculomotor screening CN
SS *
* Tools that I utilize on my sideline and training room

9. Orientation
Immediate Memory
Concentration
Delayed Recall
Neurological exam
Symptom Score

11. Study Design Evaluate utility of SCAT-2 Division 1 University
Varsity athletes and Club rugby
Prospective cross sectional study
Concussed athletes
Controls
Comparison of baseline and post injury

12. Results
Symptoms are KEY!

13. Clinical Diagnosis History, History, History
Pull in the parents if need be
Diagnosis is made or not made over the next couple of days

14. WI Concussion Law 2011 WISCONSIN ACT 172
Applies to ALL youth sports
MUST provide educational information
Parent and athlete MUST read and sign
Immediate removal for SUSPECTED concussion
REQUIRES clearance to participate from a healthcare provider trained in concussion management

15. Initial Assessment History Review of medical history Physical exam
Neurologic exam
CN Testing
Balance assessment
BESS Testing
Vestibulo-ocular assessment

17. Cross-sectional study
Consistency and validity of VOMS
64 concussed patients (5 days p injury)
78 controls
Given PCSS and VOMS in clinic

18. Concussed patients Controls 61% noted symptoms with VOMS
Presence of +VOMS associated with higher PCSS
Controls
9% noted symptoms with VOMS

19. VOMS
Vestibular Ocular Movement Screen

21. VOMS Testing Smooth Pursuits (follow my finger, do not move your head)
Horizontal & Vertical
Saccadic Movement (look between my two fingers, do not move you head)
Near Point Convergence
See double: make notation
See blurry: make notation
Vestibular Ocular Reflex (VOR)
Arm out straight with thumb up
With just the head, look side to side
With just the head, look up and down
Visual Motion Sensitivity (VMS)
Rotating the whole upper body left to right, focusing on the thumb

22. Management Mental Rest Physical Rest Symptom Score follow up
Academic modifications if needed
Limited screen time
Physical Rest
Nothing to put them at risk of getting hit again
Out of gym class if strenuous exercise
Ok for walking, if no increase of symptoms
Symptom Score follow up
Every other day at school/home

23. Reassure them that they WILL GET BETTER

24. “Grandma Schedule” Get up at same time Eat consistent meals
Naps if necessary
Go to be at reasonable time
Key: Get back to normal ADL’s

25. Academic Modifications Return to Learning
Reduced coursework
No standardized test/quizes
May take frequent breaks
Extra time to complete homework
Possibility of ½ days of school
Decreased screen time for class
Limited physical activity
No contact type activities

26. Concussion Grading Scale
The post concussion Symptom Scale is essential a "state" measures of perceived symptoms associated
with concussion. That is, the athlete is asked to report his or her "current" experience of the symptoms.
This allows tracking of symptoms over very short intervals such as consecutive days or even few days.
Directions: after reading each symptom, please circle the number that best describes the way the
athlete has been feeling today. A rating of 0 means they have not experienced this symptom today.
A rating of 6 means they have experienced severe problems with this symptom today.
DOB:
Date Tested:
Date of Last Known Concussion (s)
SYMPTOM
None
Mild
Moderate
Severe
Headache 1 2 3 4 5 6
Nausea
Vomiting
Balance Problems
Dizziness
Fatigue
Trouble falling asleep
Sleeping more than usual
Sleeping less than usual
Drowsiness
Sensitivity to light
Sensitivity to noise
Irritability
Sadness
Nervousness
Feeling more emotional
Numbness or tingling
Feeling slowed down
Feeling mentally foggy
Difficulty concentrating
Difficulty remembering
Visual problems
Other
Total Symptom Score
Grand Total
ImPACT requires that the subject to rate the severity of 22 concussive symptoms (e.g. headache,
dizziness, sensitivity to light, etc.) via a 7 point Liker Scale.

27. Treatment
Is “complete” rest really the best option?

29. Design Prospective multi-center study
Follow-up of patients seen in the ER
Follow-up by phone or survey
Both 7 days and 28 days
Symptoms severity and physical activity
Early activity group (<7days)- 28% PCS
No activity group in <7 days- 40% PCS

30. What does this mean? Multiple flaws…
Get your concussion patients moving
Do not put them at risk for re-injury
Everyone should start stages 1 and 2 of RTP as soon as able
Clearance at stages 3 or 4
Emotional exertion occurs with removal of activity

31. Medications
Treat the symptoms

32. Vestibular Therapy
Neck pain / whiplash
Persistent dizziness

33. Return to Play 3 Criteria to return Asymptomatic at rest
Asymptomatic with exertion
RTP Guidelines
Return to baseline for neurocognitive testing

34. Neurocognitive Testing
ImPACT Test – another tool in the toolbox/piece of the pie
Used by the majority of HS in the Fox Valley
Need to be familiar with the testing before you interpret
Additional specific training through ImPACT
Refer to ImPACT Provider if un-sure how to interpret

35. Progressional Return to Play WIAA Guidelines
5 Stage Program
(24 hours between each stage)
Light aerobic
15 min light exercise (stationary bike or jogging)
Heavy aerobic
More strenuous running and sprinting in the gym or field
without equipment
Non-contact practice
Begin non-contact drills in full uniform
May also resume weight lifting
Full practice with contact
Full game clearance

36. Any increase of symptoms require repeat of that particular stage
Keep in mind games/competitions

37. Final Clearance Completed RTP progression Formal letter of clearance
School/PE Class
Sport Organization
Athletic Trainer

38. Prevention Culture of identification Rules Myths
Helmets, mouth guards, head-gear

39. Questions?

40. Contact Information
Anna Linstedt, LAT ThedaCare Orthopedic Care

41. Thank You