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22nd Annual Northeast Regional Nurse Practitioner Conference – May 6-8, 2015
Current Concepts of Concussion Evaluation and ManagementAlex M Taylor, PsyD
D I S C L O S U R E S
• There has been no commercial support or sponsorship for this program.
• The planners and presenters have declared that no conflicts of interest exist.
• The program co-sponsors do not endorse any products in conjunction with any educational activity.
A C C R E D I TAT I O N
Boston College Connell School of Nursing Continuing Education Program is accredited as a provider of continuing nursing education by the American Nurses Association Massachusetts, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
22nd Annual Northeast Regional Nurse Practitioner Conference – May 6-8, 2015
S E S S I O N O B J E C T I V E S
• Explain the need to identify and protect athletes with sports related concussion and establish return to play criteria.
• Identify indications for referral to a specialist, and considerations for treatment of patients with prolonged recovery.
Rationale
1. Concussion results in cognitive impairment 2. Impairment signifies increased vulnerability
to repeat injury 3. Measurement of cognitive function allows for
more reliable detection of cognitive impairment (sometimes in the absence of self-reported symptoms)
Assessment paradigms
Paper and pencil (traditional)
Excellent norms for peds
Limited access
Cost
Time / labor intensive
Computerized
Capacity to test large #s quickly (baseline)
Access
Alternate forms
Reaction Time
Automatized scoring
Language
Questionable norms for peds
Reliability / validity
Hybrid
Professional / college model
Paper/pencil & computerized
Include behavioral measures
What N-cognitive assessment does and doesn’t do
Does
Measure cognitive function
Identify the ‘not so forthcoming’ athlete
Help detect incomplete recovery
Assist return to play decision making
Does not do
Replace clinical judgment
Provide prognosis for future problems
Act as the sole determining factor for return to play
Prevent repeat concussion
Neurocognitive findings
• Areas that are particularly vulnerable – Attention / concentration – Working memory (online memory) – New learning & memory: storage / retrieval – Processing speed – Reaction time
• Typical recovery 10-14 days
Baseline model
Baseline Post - injury
Post - injury
Post - injury
Pre-injury Day 1 Day 3 Day 14 3 months
Neu
roco
gniti
ve F
unct
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ImPACT (Immediate postconcussion assessment and cognitive testing)
• Demographic/concussion history
• Postconcussion Symptom Scale • 22 Item Likert Scale (e.g. headache, dizziness, nausea, etc.)
• Neurocognitive Tasks • 6 subtests measuring memory, working memory, visual
attention/discrimination, inhibition, processing speed, reaction time • Provides Index Scores in areas of: Verbal Memory, Visual Memory,
Processing Speed & Reaction Time
• Detailed Clinical Report • Outlines demographic information, symptoms, neurocognitive data • Automatically computer scored
Test considerations
• Consider – Setting (e.g., group, office) – Distractions – Time of day
• Arousal / fatigue • Level of engagement / motivation • “Sandbagging” • Anxiety/depression
Additional interpretive considerations
• Learning Disability • Attention Deficit Hyperactivity Disorder • Emotional factors • Hx concussion • Age
Subtests: guidelines for interpretation
• High 80s WNL (total % correct) Word
Memory
• Mid-70s WNL (total % correct) Design
Memory
• 8-12 WNL X/O’s
• Total correct visible >25 • Avg correct RT visible <1.5 • Total correct hidden: 6-9
Symbol Match
• Total correct: ~13-15 3 Letters
Resources
• www.impacttest.com
• https://www.impacttestonline.com/customercenter/pdfs/ClinicalManual_2007-2012.pdf
Suggested Reading • Allen, B. J. and J. D. Gfeller (2011). "The Immediate Post-Concussion Assessment and Cognitive Testing battery and
traditional neuropsychological measures: a construct and concurrent validity study." Brain Inj 25(2): 179-191. • Duff, K. (2012). "Evidence-based indicators of neuropsychological change in the individual patient: relevant concepts
and methods." Arch Clin Neuropsychol 27(3): 248-261. • Fazio, V. C., M. R. Lovell, et al. (2007). "The relation between post concussion symptoms and neurocognitive
performance in concussed athletes." NeuroRehabilitation 22(3): 207-216. • Field, M., M. W. Collins, et al. (2003). "Does age play a role in recovery from sports-related concussion? A comparison
of high school and collegiate athletes." Journal of Pediatrics 142(5): 546-553. • Giza, C. C. and D. A. Hovda (2001). "The Neurometabolic Cascade of Concussion." J Athl Train 36(3): 228-235. • Iverson, G. L., M. R. Lovell, et al. (2003). "Interpreting change on ImPACT following sport concussion." Clin
Neuropsychol 17(4): 460-467. • Kirkwood, M. W., K. O. Yeates, et al. (2006). "Pediatric sport-related concussion: a review of the clinical management
of an oft-neglected population." Pediatrics 117(4): 1359-1371. • Meehan, W. P., 3rd, A. M. Taylor, et al. (2011). "The pediatric athlete: younger athletes with sport-related
concussion." Clin Sports Med 30(1): 133-144, x. • Schatz P, Glatts C. (2013). “Sandbagging" baseline test performance on ImPACT, without detection, is more difficult
than it appears. Arch Clin Neuropsychol. May;28(3):236-44 • Schatz, P., Pardini, J et al. (2006). "Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes."
Arch Clin Neuropsychol 21(1): 91-99.