1. Mark Lovell PhD, FACPN, D.Sci Chairman and CEO Software Developer ImPACT Applications, Inc. Management of Sports Concussion and The ImPACT® Program

2. Sports Concussions in the News

3. Introduction to ImPACT

4. 4 1994 NFL Establishes mTBI Program Injury to well-known players Concern regarding long-term functioning of athletes Resulted in programs throughout sports

5. ImPACT: Design and Structure ► Based on early work with Pittsburgh Steelers ► Designed to evaluate multiple aspects of cognitive functioning in brief time period ► Harnesses the power of the computer ► Subtests measure multiple cognitive processes Verbal and Visual Memory Cognitive Speed Interaction of Memory and Speed (Cognitive Efficiency) © Self-report of symptoms

6. ImPACT: Design and Structure ► Brain function is affected following concussion ► Athlete’s cannot be trusted to accurately report ► Baseline testing provides the basis for comparison

7. ImPACT: Design and Structure ► Levels of interpretation:  Composite Scores: summary scores of performance in specific areas (verbal memory, visual memory, reaction time, processing speed)  Test scores: Provides more specific information on performance  Symptom scores (what the athlete is telling us about how they feel)

8. What ImPACT Is and Isn’t:

9. Testing reveals cognitive deficits in asymptomatic athletes within 4 days post- concussion N=215, MANOVA p<.000000 Unique Contributions of Neurocognitive Assessment to Concussion Management Fazio, Lovell, Collins et al., Neurorehabilitaiton, 2007)

10. Implementing the ImPACT Program

11. Group Baseline Testing Recommendations The Pre-Injury Phase

12. Return to Play Supervised at School Or clinic Remove From Play Evaluation Pre-season 1-3 Days

13. Why Bother with Baseline Testing? ► Athletes vary tremendously in how they perform on testing ► The best comparison of the athlete is to his or herself (when uninjured) ► Is a valuable educational tool

14. What Sports? WhichAthletes? ► High School ► Collegiate ► Middle School ► Club Teams ► Ages 10-60

15. Computer Lab Baseline Testing What is Required for Baseline Testing? ►Baseline testing link ►Name / Date of birth (no SS# required) ►Every 2 years age 13- 19  Younger = yearly  1 time during college, once during pros Who can Supervise/Proctor the Exam? ►Taken test twice themselves ►Understand the basic process ►Interpretation is done by MD or PhD

16. ►Test Lab before going live ►EXTERNAL MOUSE (invalid without) ►Control the testing environment  Empty terminal between athletes  10-15 athletes per administrator  Lower the lights ►Use the baseline testing link Computer Lab Baseline Testing

17. Explain the Test…  Not an intelligence test.  Want to complete as fast and accurately as possible.  Difficult - not going to get everything right  Read directions twice before starting each subtest – raise hand with questions.  Take questions in a quiet place so no others are disturbed during testing. Computer Lab Baseline Testing

18. Review Athletes’ Baselines to Determine Validity ► Check validity index ► Compare to expectations/academic status Discuss Invalid Tests with Athlete Explain Test/Clear Up Confusion ► Repeat invalid baseline tests ► If invalid test is missed, simply use normative data during post-concussion evaluation Baseline Interpretation Guidelines

19. Screen for invalid tests

20. “Horseplay” Failure to Understand Directions “Sandbagging” or Faking Not Using Mouse/Malfunctioning Mouse Incentive different at baseline/post-injury

21. Pressure to Play in Sports: Can we trust what the athlete is telling us? ► We can’t trust a concussed athlete to diagnose their own injury ► Athletes are notorious for hiding symptoms ► Studies suggest that up to 50% of athletes experience concussion symptoms per year, but only 10 percent report having an injury

22. Correlation of estimate of “back to normal” (0- 100%) with post-injury ImPACT Scores. (N=87). Sandel, Lovell, Collins et al., 2011. Neurocognitive DomainPatient Verbal Memory.45 Visual Memory.48 Processing Speed.45 Reaction Time-.53 Symptom Score-.70 How well can young athletes estimate their level of cognitive functioning? (not very well)

23. Post-Injury Phase: Concussion Management Basics

24. The UPMC Sports Concussion Program Department of Orthopaedic Surgery

25. Return to Play Criteria According to the Vienna Conference and CIS guidelines, the athlete has to meet three criteria for return to play: ►Symptom Free at Rest ►Symptom Free with Exertion ►Normal Neurocognitive Functioning

26. Return to Play Protocol On-field Assessment (Usually ATC) ► Signs/Symptoms Evaluation ► Neurologic Examination ► Mental Status Testing  Orientation, Concentration, Anterograde / Retrograde Amnesia Serial Evaluation Necessary Possible Exertional Testing Any Positive Findings Preclude Return to Play Stage ONE: Sideline Testing

27. 1.ImPACT Assessment ►Evaluation should occur in first few days after concussion ►Clinical Interview, ImPACT ►Referral (as needed) to other specialists ►Recommendations Regarding Cognitive & Physical Activity  School Attendance  Gym Class Attendance  Academic Accommodations  Athletic Participation 2.Future Evaluations as Recommended 3.Return to Baseline (or estimated pre-injury status) ►Symptom data AND Cognitive data 4.Progress through Exertion/Practice 5.Return to Competition

28. UPMC Typical Evaluation Detailed Clinical Interview Vestibular Screening Computerized Neurocognitive Testing Same day patient feedback  Severity of Injury?  Prognosis for Recovery?  Neuroimaging indicated?  Level of Physical Exertion Allowed?  Level of Cognitive Exertion Allowed?  Academic Accommodations?  Return to Play? Communication to ATC, Team Physician, Referring Physician, etc.

29. CLINICAL EVALUATION  Clinical Interview  Vestibular Screening  ImPACT Testing

30. Symptom Evaluation/Clinical Interview: What is Asymptomatic? IS NOT “How are you feeling?” or “Do You Have a Headache?” IS a series of questions inquiring about subtleties of injury “Do you have a pressure in your head that increases as day progresses?” “Are you more sensitive to lights and noises than normal?” “Do you become dizzy when looking up/down, turning head, standing quickly?” “Do you feel more fatigued than normal at the end of the day?” “Do you have blurred or fuzzy vision while reading or difficulty reading?” “Do you feel more distractible in school than normal?” “Do you feel a sense of fogginess during the day?” “Do you have difficulty falling/staying asleep?” “Have you or your parents noticed that you are more irritable than normal?”

31.  Clinical Interview  Vestibular Screening  ImPACT Testing CLINICAL EVALUATION

32. Ocular-Motor: – Smooth Pursuits (“H-Test”) – Saccades (Vertical/Horizontal) Any dizziness, blurriness, over/under shoots? Vestibular-Ocular: – Gaze Stability (focus on stationary object while moving head side to side/up and down) Vertical/Horizontal – Any observable nystagmus, provocative dizziness/bluriness, slowed movements? – Convergence In high school/college aged athletes, near point < 6-8 cm Balance Examination Romberg, Compliant Foam-eyes open/eyes closed Vestibular Screening : Physical Examination

33. UPMC Sports Concussion Program-Vestibular Screening Examination Mucha A, Collins MW, Furman J

34. Physical Exam – Balance Screen Tandem Stance ► Eyes Open/Arms Crossed  Abnormal if <30 sec or unsteady ► Eyes Closed/Arms Crossed  Abnormal if <20 sec (unless 50+ years old) Tandem Walk  Abnormal if unsteady or unable

35. CLINICAL EVALUATION  Clinical Interview  Vestibular Screening  Computerized Neurocognitive Testing - ImPACT

36. Concussion Resources: CDC Tool Kit ►Three kits with information for physicians, parents, and coaches ►Information on High School and Youth Management of Concussion ►Link to order tool kit: http://wwwn.cdc.gov/pubs/ncipc.aspx

37. ImPACT Demonstration

38. Focused Case Presentation (If Time Permits)

39. Female High School Player without Baseline

41. ► 18 year old Female-Senior in HS – Excellent student – No concussion history ► Injured and removed from game ► Evaluated in ER ► Told she could play when headaches went away Entering playoffs Female High School Soccer Player

42. ► Was absent when team was baselined ► Father noticed she was “not herself” ► Called for appointment with clinic ► Seen 6 days after injury ► Very reluctant to admit to symptoms Female High School Soccer Player

48. Thank you For additional information please contact the ImPACT Team 877-646-7991 or visit our website at: www.impacttest.com