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 indire...
Goals Concussion Testing & Examination   History & Physical   Neurocognitive Testing Treatment   Pharmacologic   Non...
Concussion Evaluation Symptom History    Includes PMH (Migraines, ADHD, etc.) Physical Exam   Neurologic Neurocogniti...
Symptom History Onset & Duration Quality & Intensity Should Resolve Prior to RTP Some Predictive Value    Dizziness  ...
Physical Exam Nystagmus Saccades Gaze Stability Balance Testing Neurocognitive Testing
Neurocognitive Testing ImPACT   www.impacttest.com Headminder   www.cogstate.com/go/sport Cogstate   www.headminder....
Neurocognitive Testing Identify Occult Cognitive Impairment Attention to Several Domains   Attention & Memory   Cognit...
Neurocognitive Testing Results Can Assist   Severity   Prognosis   Status of the Recovery   Guide Treatment Considera...
Recommendations For Use Baseline Testing High-Risk Athletes with History Athletes who Deny Symptoms Assist in Accelera...
ImPACT Test: 6 PhasesWord Discrimination: 12 Word RecallDesign 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 Testing Not all Cases Require Testing Adjunctive Tool   Symptoms   Physical Exam NOT Sole Determinant ...
Additional Tools Imaging    CT    DTI    fMRI Biochemical Markers
Treatments Directed to Symptom Cluster(s)  Neuropsyche        Cognitive    Migraine /         Sleep     Physical       Di...
Symptom Domains Neuropsychiatric       Cognitive More emotional     Attention Problems Sadness            Memory Nerv...
Symptom Domains     Migraine /               Sleep      Physical             Disturbance Headaches             Falling A...
Pharmacologic Treatments Symptom Clusters   Amantadine, et al   Cognitive Set        Sleep & / or Mood                  ...
Cognitive Medications Amantadine   Dopaminergic / noradrenergic   Improves Symptoms & Scores Ritalin   Processing spe...
Non-Pharmacologic Academic / School Accommodations Athletic Accommodations Rehabilitative Needs   Vestibular Therapy  ...
Return to Activity Symptom Free No Medication or Rehab At Baseline RTP Protocol   Florida State Law
Graded RTP Protocol from 3rd ICCS   Consensus Statement, Zurich 2008Rehab Stage                      Fx Exercise at Each R...
References   Iverson G. Predicting slow recovery from sports-related concussion: the new simple-complex distinction. Clin...
Concussion Testing & Treatment
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Concussion Testing & Treatment

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Ted Farrar, M.D., presents "Concussion Testing & Treatment" at the 2013 9th Annual Cutting Edge Concepts in Orthopaedics & Sports Medicine Seminar presented by Orlando Orthopaedic Center Foundation.

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Concussion Testing & Treatment

  1. 1. Ted Farrar, MDFellowship Director, Primary Care Sports Medicine USF-MPM FM Residency
  2. 2. 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.
  3. 3. Goals Concussion Testing & Examination  History & Physical  Neurocognitive Testing Treatment  Pharmacologic  Non-Pharmacologic
  4. 4. Concussion Evaluation Symptom History  Includes PMH (Migraines, ADHD, etc.) Physical Exam  Neurologic Neurocognitive Testing  Adjunctive Tool
  5. 5. Symptom History Onset & Duration Quality & Intensity Should Resolve Prior to RTP Some Predictive Value  Dizziness  Headache  Fogginess
  6. 6. Physical Exam Nystagmus Saccades Gaze Stability Balance Testing Neurocognitive Testing
  7. 7. Neurocognitive Testing ImPACT  www.impacttest.com Headminder  www.cogstate.com/go/sport Cogstate  www.headminder.com Concussion Vital Signs  www.concussionvitalsigns.com
  8. 8. Neurocognitive Testing Identify Occult Cognitive Impairment Attention to Several Domains  Attention & Memory  Cognitive Processing Speed  Reaction Time Moderate Sensitivity  79%, PPV 90%, NPV 82%
  9. 9. Neurocognitive Testing Results Can Assist  Severity  Prognosis  Status of the Recovery  Guide Treatment Considerations  Helps Educate
  10. 10. Recommendations For Use Baseline Testing High-Risk Athletes with History Athletes who Deny Symptoms Assist in Accelerated Return Medicolegal Support
  11. 11. ImPACT Test: 6 PhasesWord Discrimination: 12 Word RecallDesign Memory: 12 Random Patterns
  12. 12. X’s & O’s: Match the Pattern / Speed Test
  13. 13. Symbol Matching Test: 27 Times
  14. 14. Color Match: Squares, then Boxes
  15. 15. 3 Letter Memory / Reverse CountdownRepeat Phase 1 & 2
  16. 16. Neurocognitive Testing Not all Cases Require Testing Adjunctive Tool  Symptoms  Physical Exam NOT Sole Determinant w/ RTP
  17. 17. Additional Tools Imaging  CT  DTI  fMRI Biochemical Markers
  18. 18. Treatments Directed to Symptom Cluster(s) Neuropsyche Cognitive Migraine / Sleep Physical Disturbance
  19. 19. Symptom Domains Neuropsychiatric Cognitive More emotional  Attention Problems Sadness  Memory Nervousness  Fogginess & Fatigue Irritability  Executive Slowing
  20. 20. Symptom Domains Migraine / Sleep Physical Disturbance Headaches  Falling Asleep Visual & Dizziness  Sleeping less Phono/Photophobia Nausea
  21. 21. Pharmacologic Treatments Symptom Clusters  Amantadine, et al Cognitive Set Sleep & / or Mood “Foggy” Falling asleep  Melatonin Memory Staying asleep Concentration Anxious  prn Imitrex Fatigue Irritability  Tylenol No FDA indications Somatic Set Headache Dizzy / Nausea Light / Sound
  22. 22. Cognitive Medications Amantadine  Dopaminergic / noradrenergic  Improves Symptoms & Scores Ritalin  Processing speed & General Function  Improved Recovery Rate
  23. 23. Non-Pharmacologic Academic / School Accommodations Athletic Accommodations Rehabilitative Needs  Vestibular Therapy  Ocular Therapy
  24. 24. Return to Activity Symptom Free No Medication or Rehab At Baseline RTP Protocol  Florida State Law
  25. 25. Graded RTP Protocol from 3rd ICCS Consensus Statement, Zurich 2008Rehab Stage Fx Exercise at Each Rehab Stage Objective of Each Stage1. No activity Complete rest (physical and Recovery cognitive)2. Light aerobic exercise Walk, swim or stationary bike Increase HR keeping intensity < 70% MPHR; no resistance training3. Sport-specific exercise Sport-specific drills with no head Add movement impact activities4. Non-contact training drills Progression to more complex drills; Exercise, coordination and may start progressive resistance cognitive load training5. Full contact practice After medical clearance; Restore confidence and assess participate in normal activities functional skills by coaching staff6. RTP Normal game play
  26. 26. 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 Standards Subcommittee. 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

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