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Estimated Duration of Continued Sport Participation Following Concussions and Its Association with Recovery Outcomes in Collegiate Athletes: Findings from the NCAA/DoD CARE Consortium

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Shawn Eagle at University of Pittsburgh
Shawn Eagle
Breton Asken at University of Florida
Breton Asken
Alicia Trbovich at University of Pittsburgh
Alicia Trbovich
Zac Houck at University of Florida
Zac Houck
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Background Continued participation after sport-related concussion (SRC) worsens outcomes, but it is unknown if duration of continued participation after SRC impacts recovery outcomes, and which athletes who continue to participate are at greatest risk for poor SRC outcomes. The purpose of this National Collegiate Athletic Association/Department of Defense (NCAA/DoD) Concussion Assessment, Research, and Education (CARE) Consortium study was to evaluate the association of estimated duration of continued participation after SRC with symptom severity and recovery time in collegiate athletes. Methods Clinicians estimated if/how long athletes continued participation after SRC. Collegiate athletes who continued participation after suspected SRC (n = 195/373, 52.3%) completed the Graded Symptom Checklist to evaluate the severity of total symptoms and migraine/fatigue, cognitive/ocular, and affective symptom clusters. Linear regression analyzed the associations between estimated duration of continued participation, symptom severity, and recovery time. Binary logistic regression examined the association of estimated duration of continued participation with the odds of recovery ≥ 14 and ≥ 21 days. Statistical significance was p < 0.05. Results Athletes who continued to participate did so for 27.9 ± 25.3 min (mean ± standard deviation; range 1–90 min). Longer estimated continued participation (1–90 min) was associated with greater symptom severity (β = 0.122, p = 0.02), affective (β = 0.171, p = 0.001) and migraine/fatigue symptoms (β = 0.104, p = 0.049), longer symptom duration (β = 0.193, p < 0.001), and longer time missed (β = 0.156, p = 0.003). Longer estimated continued participation positively interacted with female sex (cognitive/ocular: female R² = 0.03, male R² = 0.01, p = 0.02; affective: female R² = 0.06, male R² = 0.02, p = 0.006), migraine history (affective symptoms: no migraine R² = 0.02; migraine R² = 0.18; p = 0.04), and concussion history (affective: 2 + prior concussions [R² = 0.14] compared with those with 1 [R² = 0.07] or 0 [R² < 0.01] prior concussions [p = 0.003]). Conclusions Longer estimated duration of continued participation after SRC was associated with higher symptom severity, particularly affective and migraine/fatigue; longer symptom duration; and more time missed from sport. SRC outcomes in those who continue to play may be especially severe for female athletes, athletes with migraine history, and athletes with prior concussion(s). The findings can help clinicians and administrators to educate athletes on the importance of immediate removal following a suspected SRC.
Study cohort exclusion criteria and stepwise removal. SRC sport-related concussion
Study cohort exclusion criteria and stepwise removal. SRC sport-related concussion
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a–d Association between estimated duration of continued athletic participation after SRC and number of days with SRC symptoms and total number of days missed from unrestricted athletic activity. Associations with both SRC symptom duration (β = 0.193, 95% CI 0.083–0.303, p = 0.001) and total number of days missed from athletic activity (β = 0.156, 95% CI 0.053–0.258, p = 0.003) were statistically significant based on linear regression models covarying for sex, previous concussion, LD/ADHD history, migraine history, and psychiatric history. Scatterplots a and b display the bivariate, unadjusted association between estimated duration of continued athletic participation, and a SRC symptom duration (days) and b total number of days missed from sport after SRC. Scatterplots c and d show the association between duration of continued athletic participation and standardized regression model-predicted recovery outcomes (i.e., predicted number of days based on all regression model variables) for c SRC symptom duration and d total number of days missed from sport after SRC. SRC sport-related concussion, CI confidence interval, LD-ADHD learning disability or attention-deficit/hyperactivity disorder
a–d Association between estimated duration of continued athletic participation after SRC and number of days with SRC symptoms and total number of days missed from unrestricted athletic activity. Associations with both SRC symptom duration (β = 0.193, 95% CI 0.083–0.303, p = 0.001) and total number of days missed from athletic activity (β = 0.156, 95% CI 0.053–0.258, p = 0.003) were statistically significant based on linear regression models covarying for sex, previous concussion, LD/ADHD history, migraine history, and psychiatric history. Scatterplots a and b display the bivariate, unadjusted association between estimated duration of continued athletic participation, and a SRC symptom duration (days) and b total number of days missed from sport after SRC. Scatterplots c and d show the association between duration of continued athletic participation and standardized regression model-predicted recovery outcomes (i.e., predicted number of days based on all regression model variables) for c SRC symptom duration and d total number of days missed from sport after SRC. SRC sport-related concussion, CI confidence interval, LD-ADHD learning disability or attention-deficit/hyperactivity disorder
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a–d Demographic and medical history interactions with estimated duration of continued athletic participation on acute SRC symptom severity. Females, but not males, showed an association of longer estimated duration of continued athletic participation with a more severe cognitive/ocular symptoms (female R² = 0.03, male R² = 0.01, p = 0.02) and b more severe affective symptoms (female R² = 0.06, male R² = 0.02, p = 0.006). c Athletes with a history of migraine showed an association of longer estimated duration of continued athletic participation with more severe affective symptoms (no migraine history R² = 0.02, history of migraine R² = 0.18, p = 0.04). d We found a dose–response relationship with prior concussion such that the strongest association between longer estimated duration of continued athletic participation and more severe affective symptoms was seen in those with 2 + prior concussions (R² = 0.14) compared with those with 1 (R² = 0.06) or 0 (R² = 0.01) prior concussions (p = 0.003). SRC sport-related concussion, SCAT-3 Sport-Concussion Assessment Tool-Third Edition
a–d Demographic and medical history interactions with estimated duration of continued athletic participation on acute SRC symptom severity. Females, but not males, showed an association of longer estimated duration of continued athletic participation with a more severe cognitive/ocular symptoms (female R² = 0.03, male R² = 0.01, p = 0.02) and b more severe affective symptoms (female R² = 0.06, male R² = 0.02, p = 0.006). c Athletes with a history of migraine showed an association of longer estimated duration of continued athletic participation with more severe affective symptoms (no migraine history R² = 0.02, history of migraine R² = 0.18, p = 0.04). d We found a dose–response relationship with prior concussion such that the strongest association between longer estimated duration of continued athletic participation and more severe affective symptoms was seen in those with 2 + prior concussions (R² = 0.14) compared with those with 1 (R² = 0.06) or 0 (R² = 0.01) prior concussions (p = 0.003). SRC sport-related concussion, SCAT-3 Sport-Concussion Assessment Tool-Third Edition
… 
Interaction between estimated duration of continued athletic participation after SRC and prior concussion on length of SRC symptoms. Athletes reporting 2 + prior concussions showed an association of longer estimated duration of continued athletic participation with a longer period of being symptomatic after SRC (R² = 0.26). This association was not evident in athletes reporting 1 (R² = 0.01) or 0 (R² = 0.02) prior concussions (p = 0.02). SRC sport-related concussion
Interaction between estimated duration of continued athletic participation after SRC and prior concussion on length of SRC symptoms. Athletes reporting 2 + prior concussions showed an association of longer estimated duration of continued athletic participation with a longer period of being symptomatic after SRC (R² = 0.26). This association was not evident in athletes reporting 1 (R² = 0.01) or 0 (R² = 0.02) prior concussions (p = 0.02). SRC sport-related concussion
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Vol.:(0123456789)
Sports Medicine (2022) 52:1991–2001
https://doi.org/10.1007/s40279-022-01668-1
ORIGINAL RESEARCH ARTICLE
Estimated Duration ofContinued Sport Participation Following
Concussions andIts Association withRecovery Outcomes inCollegiate
Athletes: Findings fromtheNCAA/DoD CARE Consortium
ShawnR.Eagle1 · BretonAsken2· AliciaTrbovich1· ZacharyM.Houck3· RussellM.Bauer3· JamesR.Clugston3·
StevenP.Broglio4· ThomasW.McAllister5· MichaelA.McCrea6· PaulPasquina7· MichaelW.Collins1·
AnthonyP.Kontos1· CARE Consortium Investigators
Accepted: 21 February 2022 / Published online: 14 March 2022
© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022
Abstract
Background Continued participation after sport-related concussion (SRC) worsens outcomes, but it is unknown if dura-
tion of continued participation after SRC impacts recovery outcomes, and which athletes who continue to participate are at
greatest risk for poor SRC outcomes. The purpose of this National Collegiate Athletic Association/Department of Defense
(NCAA/DoD) Concussion Assessment, Research, and Education (CARE) Consortium study was to evaluate the association
of estimated duration of continued participation after SRC with symptom severity and recovery time in collegiate athletes.
Methods Clinicians estimated if/how long athletes continued participation after SRC. Collegiate athletes who continued
participation after suspected SRC (n = 195/373, 52.3%) completed the Graded Symptom Checklist to evaluate the severity
of total symptoms and migraine/fatigue, cognitive/ocular, and affective symptom clusters. Linear regression analyzed the
associations between estimated duration of continued participation, symptom severity, and recovery time. Binary logis-
tic regression examined the association of estimated duration of continued participation with the odds of recovery ≥ 14
and ≥ 21days. Statistical significance was p < 0.05.
Results Athletes who continued to participate did so for 27.9 ± 25.3min (mean ± standard deviation; range 1–90min). Longer
estimated continued participation (1–90min) was associated with greater symptom severity (β = 0.122, p = 0.02), affective
(β = 0.171, p = 0.001) and migraine/fatigue symptoms (β = 0.104, p = 0.049), longer symptom duration (β = 0.193, p < 0.001),
and longer time missed (β = 0.156, p = 0.003). Longer estimated continued participation positively interacted with female
sex (cognitive/ocular: female R2 = 0.03, male R2 = 0.01, p = 0.02; affective: female R2 = 0.06, male R2 = 0.02, p = 0.006),
migraine history (affective symptoms: no migraine R2 = 0.02; migraine R2 = 0.18; p = 0.04), and concussion history (affec-
tive: 2 + prior concussions [R2 = 0.14] compared with those with 1 [R2 = 0.07] or 0 [R2 < 0.01] prior concussions [p = 0.003]).
Conclusions Longer estimated duration of continued participation after SRC was associated with higher symptom severity,
particularly affective and migraine/fatigue; longer symptom duration; and more time missed from sport. SRC outcomes in
those who continue to play may be especially severe for female athletes, athletes with migraine history, and athletes with
prior concussion(s). The findings can help clinicians and administrators to educate athletes on the importance of immediate
removal following a suspected SRC.
The members of CARE Consortium Investigators are listed in
Acknowledgements.
* Shawn R. Eagle
eaglesr2@upmc.edu
Extended author information available on the last page of the article
Key Points
Estimated duration of continued participation after sport-
related concussion was significantly associated with
increased odds for prolonged recovery.
Athletes who continued participation had worse symp-
tom severities, longer symptom duration, and longer time
missed from sport.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Multiple factors contribute to concussion recovery time, acute symptom presentation, the risk for prolonged symptoms, and general performance on concussion assessments [4,5]. Immediate removal from play [6][7][8] and sex [9][10][11][12][13][14][15][16][17][18], for example, influence recovery and acute symptom presentation. Some additional factors that may The Members of the CARE Consortium Investigators are Mentioned in Acknowledgments section. ...
... First, linear regressions were used to determine univariate associations before progressing to final, multiple regression models. Sex [9][10][11][12][13][14][15][16][17][18], immediate removal from play/competition, and injury reported immediately [6][7][8][34][35][36][37] have strong evidence showing their influence on recovery and concussion outcomes and were included in all final, multiple regression models as covariates. Univariate associations between other potential covariates (age at injury, concussion history, delayed symptom onset, attentiondeficit hyperactivity disorder, learning disability, loss of consciousness, retrograde amnesia, anterograde amnesia, psychiatric disorder, depression [diagnosed], migraine Consort diagram procedures for cleaning data. ...
... Although not a primary or secondary outcome in our study, it is important to briefly discuss the results of three of the covariates: sex, immediate removal play/competition, and injury reported immediately. Sex [9][10][11][12][13][14][15][16][17][18], immediate removal from play/competition, and injury reported immediately [6][7][8][34][35][36][37] influence both concussion battery outcomes and time to asymptomatic and return to play. However, our results showed these covariates did not always significantly contribute to our final, multiple regression models or ANCOVA results. ...
The Interval Between Concussions Does Not Influence Time to Asymptomatic or Return to Play: A CARE Consortium Study
Article
  • Apr 2024
The purpose of this study was to determine if the time interval between two concussive events influences the number of days to asymptomatic status, days to return to play, or performance on common post-concussion assessments following the second concussion. Data from 448 collegiate athletes and service academy cadets with two concussions (time between concussions: median 295.0 days [interquartile range: 125.0–438.2]), 40.0% female) were analyzed from Concussion Assessment Research and Education (CARE) Consortium institutions between 2014 and 2020. Days between concussions was the primary predictor variable. Primary outcome measures included time to asymptomatic and time to return to play following the second concussion. Secondary outcome measures included total number of symptoms, total symptom severity, Balance Error Scoring System total score, and Standardized Assessment of Concussion total score within 48 h of their second concussion. Time between concussions did not significantly contribute to the multivariate time to asymptomatic (p = 0.390), time to return to play (p = 0.859), or the secondary outcomes (p-range = 0.165–0.477) models. Time to asymptomatic (p = 0.619) or return to play (p = 0.524) did not differ between same-season and different-season concussions. Sex significantly contributed to the return to play (p = 0.005) multivariate model. Delayed symptom onset and immediate removal from play/competition significantly contributed to the total number of symptoms (p = 0.001, p = 0.014) and symptom severity (p = 0.011, p = 0.022) multivariate models. These results suggest that in a population with a large period between injuries, the time between concussions may not be relevant to clinical recovery.
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... In a study of athletes >18 years old, longer estimated duration of continued athletic participation after SRC was associated with greater acute symptom severity, longer days until symptom free and more time missed from sport. 95 In another study evaluating athletes 12-19 years old, those who continued to play with signs and symptoms of SRC took longer to recover than those who were immediately removed and were 8.8 times more likely to demonstrate delayed recovery (≥21 days). 96 In another study of athletes >18 years old, those with delayed removal had significantly longer symptom duration and approximately three additional days missed from sport after controlling for other SRC recovery modifiers. ...
... 83 100 In addition, delayed athlete removal from sport participation, as well as the time interval until evaluated by a medical provider, have been associated with prolonged recovery and greater days until RTS. 95 Importantly, several studies have demonstrated that, while female sex is associated with greater baseline symptoms, the days until RTS are comparable with male athletes. 43 79 83 101 102 This may reflect the impact of policies/legislation, especially at the collegiate level in the USA, where equal access to medical care for female and male athletes is mandated. ...
Clinical recovery from concussion–return to school and sport: a systematic review and meta-analysis
Article
  • Jun 2023
Objective To define the time frames, measures used and modifying factors influencing recovery, return to school/learn (RTL) and return to sport (RTS) after sport-related concussion (SRC). Design Systematic review and meta-analysis. Data sources 8 databases searched through 22 March 2022. Eligibility criteria Studies with diagnosed/suspected SRC and interventions facilitating RTL/RTS or investigating the time and modifying factors for clinical recovery. Outcomes included days until symptom free, days until RTL and days until RTS. We documented study design, population, methodology and results. Risk of bias was evaluated using a modified Scottish Intercollegiate Guidelines Network tool. Results 278 studies were included (80.6% cohort studies and 92.8% from North America). 7.9% were considered high-quality studies, while 23.0% were considered high risk of bias and inadmissible. The mean days until symptom free was 14.0 days (95% CI: 12.7, 15.4; I ² =98.0%). The mean days until RTL was 8.3 (95% CI: 5.6, 11.1; I ² =99.3%), with 93% of athletes having a full RTL by 10 days without new academic support. The mean days until RTS was 19.8 days (95% CI: 18.8, 20.7; I ² =99.3%), with high heterogeneity between studies. Several measures define and track recovery, with initial symptom burden remaining the strongest predictor of longer days until RTS. Continuing to play and delayed access to healthcare providers were associated with longer recovery. Premorbid and postmorbid factors (eg, depression/anxiety, migraine history) may modify recovery time frames. Though point estimates suggest that female sex or younger age cohorts take longer to recover, the heterogeneity of study designs, outcomes and overlap in CIs with male sex or older age cohorts suggests that all have similar recovery patterns. Conclusion Most athletes have full RTL by 10 days but take twice as long for an RTS. PROSPERO registration number CRD42020159928.
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... 5,6 Prior research has shown that cognition, balance, and mobility all suffer after sustaining concussion injuries and do so at varying rates. 7,8 Three distinct sensory systems-somatosensory, visual, and vestibular-are integrated to maintain balance, which is a complex task. Normal balancing can be preserved even when one sensory system is disabled. ...
Characteristics of the Functional Gait Assessment in adolescents with concussion
Article
Full-text available
  • Jul 2023
Objectives: To assesse the characteristics and validity of the Functional Gait Assessment (FGA). Concussion is a frequent brain injury that affect cognition, balance, and mobility. Prediction of the course of recovery after concussion could be achieved using a multidimensional examination. The FGA has been used to assess balance of individuals with concussion. Methods: A prospective cross-sectional study was commenced between 2015-2020 in Pittsburgh, PA, USA, including 27 high schoolers with current complaints of concussion and 86 healthy controls. Participants in both groups provided demographics and completed FGA, Gait Disorientation Test (GDT), and Gait Speed (GS) tests. Results: The FGA test correlated significantly with the GS and GDT. The FGA score in adolescents with concussion was significantly lower than healthy controls (U=1574.5, p=0.004). An FGA score less than 27 indicated a positive concussion injury with a sensitivity of 0.33 and a specificity of 0.92. The FGA showed a diagnostic odds ratio of 5.64. The positive and the negative likelihood ratios were of 3.03 and 0.54, respectively. For adolescents with concussion, the FGA showed no floor effect; however, a small ceiling effect (11.1%) was observed. Conclusion: The FGA was valid and feasible to assess concussion injuries. It should be noted that a full score on the FGA should not be interpreted as full recovery from a concussion injury.
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... 29,38 It is crucial that coaches and health care providers remain highly vigilant for concussive symptoms, as gymnasts may play through pain, worsening their symptoms and ultimately prolonging their recovery time. 2,9 All concussions resulted in missed time, but in 73.9% of concussions, the athlete was able to return the same season. Return to sport after concussion for gymnasts may be particularly challenging, as the athlete must return to not only high-impact activities, but also activities that involve positions of inversion, twisting, and air awareness, all of which can worsen postconcussive symptoms. ...
Multicenter Analysis of the Epidemiology of Injury Patterns and Return to Sport in Collegiate Gymnasts
Article
Full-text available
  • Feb 2023
Background Gymnastics requires intense year-round upper and lower extremity strength training typically starting from an early age. As such, the injury patterns observed in these athletes may be unique. Purpose To characterize the types of injuries and provide return-to-sport data in male and female collegiate gymnasts. Study Design Descriptive epidemiology study. Methods A conference-specific injury database was utilized to perform a retrospective review of injuries for male and female National Collegiate Athletic Association (NCAA) Division I gymnasts within the Pacific Coast Conference between 2017 and 2020 (N = 673 gymnasts). Injuries were stratified by anatomic location, sex, time missed, and injury diagnoses. Relative risk (RR) was used to compare results between sexes. Results Of the 673 gymnasts, 183 (27.2%) experienced 1093 injuries during the study period. Injuries were sustained in 35 of 145 male athletes (24.1%) as compared with 148 of 528 female athletes (28.0%; RR, 0.86 [95% CI, 0.63-1.19]; P = .390). Approximately 66.1% (723/1093) of injuries occurred in a practice setting, compared with 84 of 1093 injuries (7.7%) occurring during competition. Overall, 417 of 1093 injuries (38.2%) resulted in no missed time. Shoulder injuries and elbow/arm injuries were significantly more common in male versus female athletes (RR, 1.99 [95% CI, 1.32-3.01], P = .001; and RR, 2.08 [95% CI, 1.05-4.13], P = .036, respectively). In total, 23 concussions affected 21 of 673 athletes (3.1%); 6 concussions (26.1%) resulted in the inability to return to sport during the same season. Conclusion For the majority of musculoskeletal injuries, the gymnasts were able to return to sport during the same season. Male athletes were more likely to experience shoulder and elbow/arm injuries, likely because of sex-specific events. Concussions occurred in 3.1% of the gymnasts, highlighting the need for vigilant monitoring. This analysis of the incidence and outcomes of injuries observed in NCAA Division I gymnasts may guide injury prevention protocols as well as provide important prognostic information.
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... This is critical as concussion non-disclosure persists [31] and delayed reporting is associated with longer recovery times. [32,33] Previously, larger staffs and the medical model of athletic health care were associated with improved health outcomes following athletic injury, [34] however, immediate availability at the practice, as mandated by Requirement #5, site may be independent of overall outcomes. ...
National Collegiate Athletic Association Athletic Trainers’ Response to the Arrington Settlement: Management, Compliance, and Practice Patterns: AT’s Arrington Settlement Compliance
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  • Aug 2022
Objectives : The primary purpose of this study was to assess Athletic Trainers (ATs) report of NCAA member institutions compliance with the Arrington settlement, the concussion lawsuit vs the NCAA, and to elucidate compliance predictors. A secondary purpose was to provide a contemporary concussion management clinical practice patterns description amongst NCAA collegiate athletic trainers. Methods Head Athletic Trainers from NCAA Division I, II, and III completed an electronic questionnaire in August 2020 regarding their institution’s response to the Arrington Settlement and their current concussion management clinical practice patterns. The 37-item questionnaire included AT and institution demographics, current concussion management policies, and response to the Arrington settlement with specific focus on the five settlement requirements. An overall compliance score on the five requirements, compliance on the individual requirements, and concussion management practices are reported with descriptives. Regression was used to identify specific predictors of both overall and individual settlement requirements. An ANOVA compared compliance by NCAA division level. Being pressured to be non-compliant was assessed between sexes by a chi-square. Results There were 223 respondents (21.8%) and overall compliance was high (4.1 ± 0.7) with the five required Arrington Settlement components. Settlement requirement 1, pre-season baseline testing, and requirement 5, presence of trained personnel at all contact sport practices, had the lowest compliance rates at 44.8% and 73.3% respectively. The number of sports the institution offered was the only significant predictor each requirement. There was no difference in compliance between NCAA divisions. Although the overall rate of being non-compliant pressure was low (13.8%), females were 3.28x more likely report being pressured than males. Conclusions NCAA institutions are generally compliant with the Arrington settlement; however, lack of clarity in the requirements, particularly requirement 1, raises potential concerns. Concussion management practices continue to incorporate multifaceted approaches and are largely consistent with current best practices.
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Physical activity and recovery following concussion in collegiate athletes: a LIMBIC MATARS Consortium Investigation
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Access to athletic trainers and sex as modifiers of time to reach clinical milestones after sport-related concussion in collegiate athletes
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  • Feb 2024
  • BRAIN INJURY
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Full-text available
  • Jun 2023
Introduction This systematic review examined whether race or ethnicity are associated with clinical outcomes (e.g., time to return to school/sports, symptom duration, vestibular deficits, and neurocognitive functioning) following sport-related concussion among child, adolescent, or college-aged student athletes. Additionally, this review assessed whether the existing literature on this topic incorporated or included broader coverage of social determinants of health. Methods The online databases PubMed, MEDLINE®, PsycINFO®, CINAHL, Cochrane Library, EMBASE, SPORTDiscus, Scopus, and Web of Science were searched. Results A total of 5,118 abstracts were screened and 12 studies met inclusion criteria, including 2,887 youth and young adults. Among the included articles, only 3 studies (25%) examined whether race and ethnicity were associated with outcomes following concussion as a primary objective. None of the studies assessed the association between social determinants of health and outcomes following concussion as a primary objective, although 5 studies (41.7%) addressed a social determinant of health or closely related topic as a secondary objective. Discussion Overall, the literature to date is extremely limited and insufficient for drawing conclusions about whether race or ethnicity are categorically associated with outcomes from sport-related concussion, or more specifically, whether there are socioeconomic, structural, or cultural differences or disparities that might be associated with clinical outcome. Systematic review registration identifier: PROSPERO, CRD42016041479, CRD42019128300.
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  • Curr Psychiatr Rep
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Article
  • Oct 2020
Context Previous researchers have examined factor structures for common concussion symptom inventories. However, they failed to discriminate between the acute (<72 hours) and subacute (3 days–3 months) periods after concussion. The Sport Concussion Assessment Tool (SCAT) is an acute assessment that, when compared with other concussion symptom inventories, includes or excludes symptoms that may result in different symptom factors. Objective The primary purpose was to investigate the symptom factor structure of the 22-item SCAT symptom inventory in healthy, uninjured and acutely concussed high school and collegiate athletes. The secondary purpose was to document the frequency of the unique SCAT symptom inventory items. Design Case series. Setting High school and college. Patients or Other Participants A total of 1334 healthy, uninjured and 200 acutely concussed high school and collegiate athletes. Main Outcome Measure(s) Healthy, uninjured participants completed the SCAT symptom inventory at a single assessment. Participants in the acutely concussed sample completed the SCAT symptom inventory within 72 hours after concussion. Two separate exploratory factor analyses (EFAs) using a principal component analysis and varimax extraction method were conducted. Results A 3-factor solution accounted for 48.1% of the total variance for the healthy, uninjured sample: cognitive-fatigue (eg, feeling “in a fog” and “don't feel right”), migraine (eg, neck pain and headache), and affective (eg, more emotional and sadness) symptom factors. A 3-factor solution accounted for 55.0% of the variance for the acutely concussed sample: migraine-fatigue (eg, headache and “pressure in the head”), affective (eg, sadness and more emotional), and cognitive-ocular (eg, difficulty remembering and balance problems) symptom factors. Conclusions The inclusion of unique SCAT symptom inventory items did not alter the symptom factor structure for the healthy, uninjured sample. For the acutely concussed sample, all but 1 unique SCAT symptom inventory item (neck pain) loaded onto a factor.
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Sport Concussion Assessment Tool Symptom Inventory: Healthy and Acute Postconcussion Symptom Factor Structures
Article
  • Sep 2020
  • J ATHL TRAINING
Context: Previous researchers have examined factor structures for common concussion symptom inventories. However, they failed to discriminate between the acute (<72 hours) and subacute (3 days-3 months) periods after concussion. The Sport Concussion Assessment Tool (SCAT) is an acute assessment that, when compared with other concussion symptom inventories, includes or excludes symptoms that may result in different symptom factors. Objective: The primary purpose was to investigate the symptom factor structure of the 22-item SCAT symptom inventory in healthy, uninjured and acutely concussed high school and collegiate athletes. The secondary purpose was to document the frequency of the unique SCAT symptom inventory items. Design: Case series. Setting: High school and college. Patients or other participants: A total of 1334 healthy, uninjured and 200 acutely concussed high school and collegiate athletes. Main outcome measure(s): Healthy, uninjured participants completed the SCAT symptom inventory at a single assessment. Participants in the acutely concussed sample completed the SCAT symptom inventory within 72 hours after concussion. Two separate exploratory factor analyses (EFAs) using a principal component analysis and varimax extraction method were conducted. Results: A 3-factor solution accounted for 48.1% of the total variance for the healthy, uninjured sample: cognitive fatigue (eg, feeling "in a fog" and "don't feel right"), migraine (eg, neck pain and headache), and affective (eg, more emotional and sadness) symptom factors. A 3-factor solution accounted for 55.0% of the variance for the acutely concussed sample: migraine fatigue (eg, headache and "pressure in the head"), affective (eg, sadness and more emotional), and cognitive ocular (eg, difficulty remembering and balance problems) symptom factors. Conclusions: The inclusion of unique SCAT symptom inventory items did not alter the symptom factor structure for the healthy, uninjured sample. For the acute concussed sample, all but 1 unique SCAT symptom inventory item (neck pain) loaded onto a factor.
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Concussion Symptom Cut-offs for Identification and Prognosis of Sport-Related Concussion: The Role of Time Since Injury
Article
  • May 2020
  • AM J SPORT MED
Background: Symptom reporting is one of the most sensitive markers of concussed status and/or recovery time, using scales such as the Post-Concussion Symptom Scale (PCSS). It is known that time from injury until initial clinic visit impacts symptom presentation and recovery outcomes, but no study to date has evaluated changes in clinical cut-off scores for the PCSS based on earlier versus later clinical presentation post-concussion. Purpose: To evaluate if time since injury following sport-related concussion (SRC) affected clinical cutoff scores for total PCSS and PCSS factors in differentiating athletes with SRC from healthy controls and predicting prolonged recovery (>30 days) following SRC. Study Design: Case-control study. Methods: A chart review of clinical data from patients with SRC (age: 13-25 years; n=588; females: n=319) who presented to concussion-specialty clinics was conducted. Participants were categorized based on time from injury: EARLY (≤7 days; n=348) and LATE (8-21 days; n=240). Outcomes were total symptom severity (i.e., total PCSS score), and total score for each of 4 symptom factors (cognitive/migraine/fatigue [CMF], affective, sleep, and somatic). Area under the curve analyses (AUC) were conducted with Youden’s index to optimize sensitivity/specificity cut-offs. Results: In EARLY, CMF (cut-off: ≥7; AUC: 0.944) Affective (cut-off: ≥1; AUC=0.614), and total PCSS (cut-off: ≥7; AUC=0.889) differentiated SRC from controls. In LATE, CMF cut-off was reduced (cut-off: ≥4; AUC=0.935) while total PCSS score (cut-off: ≥7; AUC=0.877), Affective (cut-off: ≥1; AUC=0.603) and Sleep factors (cut-off: ≥1; AUC=0.609) remained the same. In EARLY, CMF was the strongest predictor of protracted recovery (cut-off: ≥23; AUC=0.717) followed by total PCSS (cut-off: ≥39; AUC=0.695) and Affective (cut-off: ≥2; AUC=0.614). Affective (cut-off: ≥1; AUC=0.642) and total PCSS (cut-off: ≥35; AUC=0.592) were significant predictors in LATE, but the cut-off threshold was reduced. Conclusion: The findings indicate that PCSS symptom clinical cut-offs for identifying injury and recovery prognosis change based on time since injury. Specifically, the combination of CMF, Affective, and Sleep factors is the best differentiator of SRC from controls regardless of time since injury. Further, CMF is the most robust predictor of prolonged recovery if the patient is within 1 week of SRC, whereas the Affective factor is the most robust predictor of prolonged recovery if the patient is within 2-3 weeks of SRC. Clinical Relevance: Clinicians should adjust diagnostic and prognostic models based on time from injury. PCSS is among the most commonly used symptom reporting tools, and the cut-offs reported in this study can provide useful information to clinicians for the diagnosis and prognosis of SRC. What is known about the subject: Symptom reporting is one of the most sensitive markers of concussed status and/or recovery time, using scales such as the PCSS. It is known that time from injury until initial clinic visit impacts symptom presentation and recovery outcomes, but no study to date has evaluated changes in clinical cut-off scores for the PCSS based on earlier versus later clinical presentation post-concussion. What this study adds to existing knowledge: The results of this study indicate that the value of PCSS symptom clinical cut-offs changes based on whether the athlete presents to the clinic within 1 week or 2-3 weeks post-SRC. This study is the first to report the effect of time since injury on cut-off values for total PCSS scores and symptom factors, both to identify SRC and predict recovery time. The information from the present study can inform clinical awareness that different types of symptoms may be more or less apparent/useful depending on the number of days from injury.
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Preliminary Evidence of a Dose-Response for Continuing to Play on Recovery Time After Concussion
Article
  • Apr 2019
  • J HEAD TRAUMA REHAB
Objective: To investigate a dose-response relationship between continuing to play following concussion and outcomes. Participants: A total of 130 athletes (age 11-19 years). Design: Repeated-measures design comparing symptoms, neurocognitive performance, and recovery time between 52 athletes immediately removed from play (Removed), 24 who continued to play for 15 minutes or less (Short-Play), and 32 who continued to play for more than 15 minutes (Long-Play). Main measures: Recovery was the number of days from injury to clearance. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) measured neurocognitive outcomes and the Post-Concussion Symptom Scale (PCSS) measured symptom severity. Results: Long-Play (44.09 ± 27.01 days) took longer to recover than Short-Play (28.42±12.74 days) and Removed (18.98 ± 13.76 days). Short-Play was 5.43 times more likely, and Long-Play 11.76 times more likely, to experience protracted recovery relative to Removed. Both Play groups had worse neurocognitive performance and higher symptom scores than Removed at days 1 to 7, with Long-Play demonstrating worse reaction time than Short-Play. At days 8 to 30, both Play groups performed worse than Removed on visual memory and visual motor speed, while only Long-Play performed worse on verbal memory and reaction time. Conclusions: Results provide initial evidence of a dose-response effect for continuing to play on recovery from concussion, highlighting the importance of removal from play.
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Determinants of Intention to Disclose Concussion Symptoms in a Population of U.S. Military Cadets
Article
  • Nov 2018
  • J SCI MED SPORT
Objectives: Non-disclosure of concussion complicates concussion management, but almost nothing is known about non-disclosure in military settings. This study describes concussion disclosure-related knowledge, attitudes, perceived social norms, perceived control, and intention. Additionally, the study identifies determinants of high intention to disclose concussion symptoms. Design: Cross sectional survey. Methods: First-year service academy cadets completed a cross-sectional survey to assess perceptions of concussion disclosure. Independent variables included: gender, race, ethnicity, high school athlete status, NCAA athlete status, previous concussion history, previous concussion education, socioeconomic proxy, concussion-related knowledge, attitudes about concussion, perceived social norms (perceived peer/organizational support and actions), and perceived control over disclosure. Log-binomial regression was used to identify determinants of high intention to disclose concussion symptoms. Results: A total of 972 first-year military service academy cadets completed the survey [85% response; age = 18.4 ± 0.9 y]. In the simple models, previous concussion history was associated with lower intention to disclose concussion symptoms. High perceived control over disclosure, higher concussion knowledge, more favorable attitudes and social norms about concussion were associated with high intention to disclose. In the multivariable model, a 10% shift towards more favorable perceived social norms (PR = 1.28; p < 0.001) and attitudes (PR = 1.07; p = 0.05) about concussion were associated with high intention to disclose concussion symptoms. High perceived control over disclosure was associated with high intention to disclose concussion symptoms (PR = 1.39; p = 0.08). Conclusions: Concussion-related perceived social norms, attitudes, and perceived control are associated with intention to disclose. Organizationally appropriate intervention strategies can be developed from these data.
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Pre-Injury Migraine History as a Risk Factor for Prolonged Return to School and Sports Following Concussion
Article
  • May 2018
Having a pre-existing migraine disorder might be a risk factor for a prolonged recovery following a sport-related concussion. We examined whether having a migraine history was associated with a prolonged return to academics and athletics following a concussion. High school and collegiate athletes (N=1,265; 42% female) who sustained a sport-related concussion were monitored by athletic trainers using a web-based surveillance system that collects information about concussion recovery. Nonparametric Kolmogorov-Smirnov tests (KS) were used to compare days to return to academics/athletics across groups due to non-normally distributed outcome variables and unequal distributions of scores between groups. Chi-square tests were used to examine the proportion of players who had not returned to academics/athletics at 7, 14, and 21 days post-injury stratified by self-reported migraine history. There were 117 athletes (9.2%) who reported a pre-injury migraine history. Athletes with a history of migraine took a median of 6 days to return to academics (M=10.6, SD=14.2) and 15.5 days to return to athletics (M=23.8, SD=30.8), while those with no migraine history took a median of 5 days to return to academics (M=7.5, SD=10.9) and 14 days to return to athletics (M=19.4, SD=19.4). There were no statistically significant differences in days to return to school or athletics between the groups (KS ps>.05). However, a lower percentage of athletes with a history of migraine had returned to school after 7 days (57% vs. 68%, χ2=5.53, p=.02), 14 days (75% vs. 88%, χ2=14.21, p<.001), and 21 days post-injury (89% vs. 94%, χ2=4.90, p=.03). Stratifying the analyses by sex showed that this effect was significant in girls and women with pre-existing migraines, but not boys and men with pre-existing migraines. There were no group differences in recovery rates when examining return to athletics. Athletes with a pre-injury migraine history may be at an elevated risk for a protracted return to school after concussion, especially girls and women.
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Immediate Removal From Activity After Sport-Related Concussion Is Associated With Shorter Clinical Recovery and Less Severe Symptoms in Collegiate Student-Athletes
Article
  • Mar 2018
  • AM J SPORT MED
Background: Timely removal from activity after concussion symptoms remains problematic despite heightened awareness. Previous studies indicated potential adverse effects of continuing to participate in physical activity immediately after sustaining a concussion. Hypothesis/Purpose: The purpose was to determine the effect of timing of removal from play after concussion on clinical outcomes. It was hypothesized that immediate removal from activity after sport-related concussion (SRC) would be associated with less time missed from sport, a shorter symptomatic period, and better outcomes on acute clinical measures. Study design: Cohort study; Level of evidence, 3. Methods: Data were reported from the National Collegiate Athletic Association and Department of Defense Grand Alliance: Concussion Awareness, Research, and Education (CARE) Consortium. Participants with 506 diagnosed SRCs from 18 sports and 25 institutions and military service academies were analyzed and classified as either immediate removal from activity (I-RFA) or delayed removal from activity (D-RFA). Outcomes of interest included time missed from sport attributed to their SRC, symptom duration, and clinical assessment scores. Results: There were 322 participants (63.6%) characterized as D-RFA. I-RFA status was associated with significantly less time missed from sport ( R2change = .022-.024, P < .001 to P = .001) and shorter symptom duration ( R2change = .044-.046, P < .001 [all imputations]) while controlling for other SRC recovery modifiers. These athletes missed approximately 3 fewer days from sport participation. I-RFA athletes had significantly less severe acute SRC symptoms and were at lower risk of recovery taking ≥14 days (relative risk = .614, P < .001, small-medium effect size) and ≥21 days (relative risk = .534, P = .010, small effect size). Conclusion: I-RFA is a protective factor associated with less severe acute symptoms and shorter recovery after SRC. Conveying this message to athletes, coaches, and others involved in the care of athletes may promote timely injury reporting.
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Concussion Nondisclosure During Professional Career Among a Cohort of Former National Football League Athletes
Article
  • Sep 2017
  • AM J SPORT MED
Background: Despite a focus on the incidence and effects of concussion, nondisclosure of sports-related concussions among retired players from the National Football League (NFL) has yet to be examined. Purpose: Examine the prevalence of and factors associated with nondisclosure of sports-related concussions in former NFL athletes. Study design: Cross-sectional study; Level of evidence, 3. Methods: A sample of 829 former NFL players completed a general health survey. This historical cohort included players who had played before World War II to 2001. Respondents retrospectively recalled sports-related concussions that they sustained during their professional careers and whether at least one of these sports-related concussions was not reported to medical staff. We computed the prevalence of nondisclosure among those recalling sport-related concussions during their professional careers. Multivariable binomial regression estimated adjusted prevalence ratios (PR) with 95% confidence intervals (CIs) controlling for race/ethnicity, number of years played, primary position played, professional career concussion history, and playing era. Playing era was categorized by whether the majority of a player's career was before or after a 1976 rule change to limit contact ("spearing"). Results: Overall, 417 (50.3%) respondents reported they had sustained a concussion and did not inform medical staff at least once during their professional playing career. Nonwhite respondents had a higher prevalence of nondisclosure than white/non-Hispanic respondents (adjusted PR = 1.19; 95% CI, 1.02-1.38). An interaction between professional career concussion history and playing era was also found ( P = .08). Compared with those in the pre-spearing rule change group with 1 or 2 concussions, all other groups had larger prevalences of nondisclosure (increases ranging from 41% to 153% in multivariable models). Across concussion strata, nondisclosure prevalence was generally higher in the post-spearing rule change group than the pre-spearing rule change group, with the largest differences found among those with 1 or 2 concussions or those with 3 or 4 concussions. Conclusion: A large proportion of former NFL players in this historical cohort reported at least one instance of not disclosing sports-related concussions to medical staff. Future research on concussion nondisclosure needs to identify mechanisms to improve football players' intentions to disclose concussion-related symptoms to health care providers and to equip health care providers with more effective strategies for timely identification of concussion.
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