1 Concussion in Sports Anna Linstedt, ATC/LAT, RMAThedaCare Orthopedic Care Menasha High School

2 Financial DisclosuresI 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 ManagementReturn to Learning / Play Final Clearance

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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

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8 Diagnosis & Assessment ToolsSCAT 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

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11 Study Design Evaluate utility of SCAT-2 Division 1 UniversityVarsity 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, HistoryPull 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 172Applies 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 examNeurologic exam CN Testing Balance assessment BESS Testing Vestibulo-ocular assessment

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17 Cross-sectional studyConsistency 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 VOMSPresence of +VOMS associated with higher PCSS Controls 9% noted symptoms with VOMS

19 VOMS Vestibular Ocular Movement Screen

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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 upAcademic 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 mealsNaps if necessary Go to be at reasonable time Key: Get back to normal ADL’s

25 Academic Modifications Return to LearningReduced 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 ScaleThe 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?

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29 Design Prospective multi-center studyFollow-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 restAsymptomatic with exertion RTP Guidelines Return to baseline for neurocognitive testing

34 Neurocognitive TestingImPACT 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 Guidelines5 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 stageKeep in mind games/competitions

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

38 Prevention Culture of identification Rules MythsHelmets, mouth guards, head-gear

39 Questions?

40 Contact Information Anna Linstedt, LAT ThedaCare Orthopedic Care

41 Thank You