concussion testing & treatment
DESCRIPTION
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.TRANSCRIPT
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