Ted Farrar, MDFellowship Director, Primary Care Sports Medicine

USF-MPM FM Residency

Disclosure

Neither I nor any family member have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within this presentation.

GoalsConcussion Testing & Examination

History & Physical

Neurocognitive Testing

Treatment

Pharmacologic

Non-Pharmacologic

Concussion EvaluationSymptom History

Includes PMH (Migraines, ADHD, etc.)

Physical Exam

Neurologic

Neurocognitive Testing

Adjunctive Tool

Symptom HistoryOnset & Duration

Quality & Intensity

Should Resolve Prior to RTP

Some Predictive Value

Dizziness

Headache

Fogginess

Physical ExamNystagmus

Saccades

Gaze Stability

Balance Testing

Neurocognitive Testing

Neurocognitive Testing ImPACTwww.impacttest.com

Headminderwww.cogstate.com/go/sport

Cogstatewww.headminder.com

Concussion Vital Signswww.concussionvitalsigns.com

Neurocognitive TestingIdentify Occult Cognitive Impairment

Attention to Several Domains

Attention & Memory

Cognitive Processing Speed

Reaction Time

Moderate Sensitivity

79%, PPV 90%, NPV 82%

Neurocognitive TestingResults Can Assist

Severity

Prognosis

Status of the Recovery

Guide Treatment Considerations

Helps Educate

Recommendations For UseBaseline Testing

High-Risk Athletes with History

Athletes who Deny Symptoms

Assist in Accelerated Return

Medicolegal Support

ImPACT Test: 6 PhasesWord Discrimination: 12 Word Recall

Design Memory: 12 Random Patterns

X’s & O’s: Match the Pattern / Speed Test

Symbol Matching Test: 27 Times

Color Match: Squares, then Boxes

3 Letter Memory / Reverse CountdownRepeat Phase 1 & 2

Neurocognitive TestingNot all Cases Require Testing

Adjunctive Tool

Symptoms

Physical Exam

NOT Sole Determinant w/ RTP

Additional ToolsImaging

CT

DTI

fMRI

Biochemical Markers

TreatmentsDirected to Symptom Cluster(s)

Neuropsyche Cognitive

Migraine / Physical

Sleep Disturbance

Symptom Domains

More emotional

Sadness

Nervousness

Irritability

Attention Problems

Memory

Fogginess & Fatigue

Executive Slowing

Neuropsychiatric Cognitive

Symptom Domains

Headaches

Visual & Dizziness

Phono/Photophobia

Nausea

Falling Asleep

Sleeping less

Migraine / Physical

Sleep Disturbance

Pharmacologic TreatmentsSymptom Clusters

Amantadine, et al

Melatonin

prn Imitrex

Tylenol

No FDA indications

Cognitive Set“Foggy”MemoryConcentrationFatigue

Sleep & / or MoodFalling asleepStaying asleepAnxiousIrritability

Somatic SetHeadacheDizzy / NauseaLight / Sound

Cognitive MedicationsAmantadine

Dopaminergic / noradrenergic

Improves Symptoms & Scores

Ritalin

Processing speed & General Function

Improved Recovery Rate

Non-PharmacologicAcademic / School Accommodations

Athletic Accommodations

Rehabilitative Needs

Vestibular Therapy

Ocular Therapy

Return to ActivitySymptom Free

No Medication or Rehab

At Baseline

RTP Protocol

Florida State Law

Rehab Stage Fx Exercise at Each Rehab Stage Objective of Each Stage

1. No activity Complete rest (physical and cognitive)

Recovery

2. Light aerobic exercise Walk, swim or stationary bike keeping intensity < 70% MPHR; no resistance training

Increase HR

3. Sport-specific exercise Sport-specific drills with no head impact activities

Add movement

4. Non-contact training drills Progression to more complex drills; may start progressive resistance training

Exercise, coordination and cognitive load

5. Full contact practice After medical clearance;participate in normal activities

Restore confidence and assess functional skills by coaching staff

6. RTP Normal game play

Graded RTP Protocol from 3rd ICCS Consensus Statement, Zurich 2008

References Iverson G. Predicting slow recovery from sports-related concussion: the new simple-complex distinction. Clinical Journal of Sport Medicine.

2007: 17(1), 1731-Pardini D, Stump J, Lovell MR, Collins MW, Moritz K, Fu F. The post-concussion symptoms scale (PCSS): A factor analysis. British Journal of Sports Medicine, 2004: 38, 661.

Collins MW, Iverson GL, Lovell MR, McKeag DB, Norwig J, Maroon J. On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clinical Journal of Sport Medicine, 2003: 13(4), 222-229.

Lau BC, Lovell MR, Collins MW, Pardini JE. Neurocognitive and symptom predictors of recovery in high school athletes. Clinical Journal of Sports Medicine, 2009: 19(3), 216-221.

Peer reviewed Practice parameter: the management of concussion in sports (summary statement). Report of the Quality StandardsSubcommittee. Neurology 1997 Mar;48(3):581-5.

Lovell MR, Collins MW, Iverson GL, Johnston KM, Bradley JP. Grade 1 or "ding" concussions in high school athletes. Am J Sports Med 2004 Jan-Feb;32(1):47-54.

Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Johnston K, Kelly J, Lovell M, McCrory P, Meeuwisse W, Schamasch P; Concussion in Sport Group. Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med 2002 Feb;36(1):6-10.

McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Kelly J, Lovell M, Schamasch P; International Symposium on Concussion in Sport. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med 2005 Mar;15(2):48-55.

Concussion (mild traumatic brain injury) and the team physician: a consensus statement. Med Sci Sports Exerc 2006 Feb;38(2):395-9.

McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, Cantu R. Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med 2009 May;43 Suppl 1:i76-90.

AAN Position Statement on Sports Concussion October 2010 available at http://www.aan.com/globals/axon/assets/7913.pdf

Guskiewicz KM, Marshall SW, Bailes J, McCrea M, Harding HP Jr, Matthews A, Mihalik JR, Cantu RC. Recurrent concussion and risk of depression in retired professional football players. Med Sci Sports Exerc 2007 Jun;39(6):903-09.

McKee AC, Cantu RC, et al. Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy following Repetitive Head Injury. J Neuropathol Exp Neurol 2009 July; 68(7): 709–735..

Neal MT, Wilson JL, Hsu W, Powers AK. Concussions: What a neurosurgeon should kow about current scientific evidence and management strategies. Surg Neurol Int 2012;3:1`6

Johnson EW, Kegel NE, Collins MW. Neuropsychological Assessment of Sport-Related Concussion. Clin Sports Med 2011:30, 73-88

Reference Bibliography not otherwise specifically mentioned as of November 2011: http://impacttest.com/uploads/resources/Updated_References11_11.pdf