STEP 2: Concussion Live Course - October 21-22, 2025, in Salt Lake City, UT-Case Discussion: Risk Factors of Special Populations

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This case involves a 50-year-old male forklift operator who sustained an unwitnessed fall at work two months ago, with coworkers noting confusion at the time. Initial emergency room evaluation and imaging were negative, and he was discharged. Occupational medicine referred him to physical therapy, and he was released to return to work after two weeks; however, he has been unable to resume his job due to ongoing symptoms. He was referred by Worker’s Compensation for further assessment.<br /><br />His past medical history is significant for diabetes, multiple emergency visits over four years for various issues, prior concussion, headache disorder, anxiety/depression, learning disabilities including ADD/ADHD, and sleep disorder. Socially, he is employed at a warehouse with commercial insurance and worker’s compensation coverage, has good family support, no known psychosocial issues, and has consulted an attorney but has not filed litigation.<br /><br />Symptom assessment demonstrates headache, dizziness, balance problems, sleep disturbances, light and sound sensitivity, sadness, numbness, mental fog, memory issues, and vision problems. Neurocognitive testing revealed the ability to spell “WORLD” backward and a delayed recall score of 2/3. Physical examination showed intolerance to vestibulo-ocular reflex (VOR) testing, decreased neck range of motion, cervical muscle tenderness, positive Romberg test, and inability to maintain tandem gait with eyes closed.<br /><br />The clinical assessment includes concussion, post-traumatic headaches, sleep impairment, vestibular dysfunction, and vision impairment related to the injury. Treatment plan includes starting amitriptyline 10 mg at bedtime, referral to physical therapy for cervical spine and vestibular rehabilitation, possible neuropsychology evaluation for cognition and mood, and potential neuro-optometry or vision therapy.<br /><br />Key teaching points emphasize the complexity of concussion presentations requiring thorough evaluation, consideration of employment factors, navigation challenges within workers' compensation systems, and state-specific regulations regarding medication availability and benefits. Terms like IME (Independent Medical Examination), MMI (Maximal Medical Improvement), and IR (Impairment Rating) are explained as relevant to occupational injury assessment.

Asset Subtitle

Lori M. Grafton, MD

Keywords

forklift operator injury

unwitnessed fall

concussion symptoms

post-traumatic headache

vestibular dysfunction

cervical spine rehabilitation

neurocognitive testing

workers compensation

occupational medicine

sleep disturbance