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.

1. Ted Farrar, MD
Fellowship Director, Primary Care Sports Medicine
USF-MPM FM Residency

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. Goals
 Concussion Testing & Examination
 History & Physical
 Neurocognitive Testing
 Treatment
 Pharmacologic
 Non-Pharmacologic

4. Concussion Evaluation
 Symptom History
 Includes PMH (Migraines, ADHD, etc.)
 Physical Exam
 Neurologic
 Neurocognitive Testing
 Adjunctive Tool

5. Symptom History
 Onset & Duration
 Quality & Intensity
 Should Resolve Prior to RTP
 Some Predictive Value
 Dizziness
 Headache
 Fogginess

6. Physical Exam
 Nystagmus
 Saccades
 Gaze Stability
 Balance Testing
 Neurocognitive Testing

7. Neurocognitive Testing
 ImPACT
 www.impacttest.com
 Headminder
 www.cogstate.com/go/sport
 Cogstate
 www.headminder.com
 Concussion Vital Signs
 www.concussionvitalsigns.com

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. Neurocognitive Testing
 Results Can Assist
 Severity
 Prognosis
 Status of the Recovery
 Guide Treatment Considerations
 Helps Educate

10. Recommendations For Use
 Baseline Testing
 High-Risk Athletes with History
 Athletes who Deny Symptoms
 Assist in Accelerated Return
 Medicolegal Support

11. ImPACT Test: 6 Phases
Word Discrimination: 12 Word Recall
Design Memory: 12 Random Patterns

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

13. Symbol Matching Test: 27 Times

14. Color Match: Squares, then Boxes

15. 3 Letter Memory / Reverse Countdown
Repeat Phase 1 & 2

16. Neurocognitive Testing
 Not all Cases Require Testing
 Adjunctive Tool
 Symptoms
 Physical Exam
 NOT Sole Determinant w/ RTP

17. Additional Tools
 Imaging
 CT
 DTI
 fMRI
 Biochemical Markers

18. Treatments
 Directed to Symptom Cluster(s)
Neuropsyche Cognitive
Migraine / Sleep
Physical Disturbance

19. Symptom Domains
Neuropsychiatric Cognitive
 More emotional  Attention Problems
 Sadness  Memory
 Nervousness  Fogginess & Fatigue
 Irritability  Executive Slowing

20. Symptom Domains
Migraine / Sleep
Physical Disturbance
 Headaches  Falling Asleep
 Visual & Dizziness  Sleeping less
 Phono/Photophobia
 Nausea

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. Cognitive Medications
 Amantadine
 Dopaminergic / noradrenergic
 Improves Symptoms & Scores
 Ritalin
 Processing speed & General Function
 Improved Recovery Rate

23. Non-Pharmacologic
 Academic / School Accommodations
 Athletic Accommodations
 Rehabilitative Needs
 Vestibular Therapy
 Ocular Therapy

24. Return to Activity
 Symptom Free
 No Medication or Rehab
 At Baseline
 RTP Protocol
 Florida State Law

25. Graded RTP Protocol from 3rd ICCS
Consensus Statement, Zurich 2008
Rehab Stage Fx Exercise at Each Rehab Stage Objective of Each Stage
1. 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 training
3. Sport-specific exercise Sport-specific drills with no head Add movement
impact activities
4. Non-contact training drills Progression to more complex drills; Exercise, coordination and
may start progressive resistance cognitive load
training
5. Full contact practice After medical clearance; Restore confidence and assess
participate in normal activities functional skills by coaching staff
6. RTP Normal game play

27. References
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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
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 Lovell MR, Collins MW, Iverson GL, Johnston KM, Bradley JP. Grade 1 or "ding" concussions in high school athletes. Am J Sports Med 2004
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 Reference Bibliography not otherwise specifically mentioned as of November 2011:
http://impacttest.com/uploads/resources/Updated_References11_11.pdf