Paul D. Berkner

Factors Associated With Concussion-like Symptom Reporting in High School Athletes

IMPORTANCE Every state in the United States has passed legislation for sport-related concussion, making this health issue important for physicians and other health care professionals. Safely returning athletes to sport after concussion relies on accurately determining when their symptoms resolve. OBJECTIVE To evaluate baseline concussion-like symptom reporting in uninjured adolescent student athletes. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional, observational study, we studied 31 958 high school athletes from Maine with no concussion in the past 6 months who completed a preseason baseline testing program between 2009 and 2013. RESULTS Symptom reporting was more common in girls than boys. Most students with preexisting conditions reported one or more symptoms (60%-82% of boys and 73%-97% of girls). Nineteen percent of boys and 28% of girls reported having a symptom burden resembling an International Classification of Diseases, 10th Revision (ICD-10) diagnosis of postconcussional syndrome (PCS). Students with preexisting conditions were even more likely to endorse a symptom burden that resembled PCS (21%-47% for boys and 33%-72% for girls). Prior treatment of a psychiatric condition was the strongest independent predictor for symptom reporting in boys, followed by a history of migraines. For girls, the strongest independent predictors were prior treatment of a psychiatric condition or substance abuse and attention-deficit/hyperactivity disorder. The weakest independent predictor of symptoms for both sexes was history of prior concussions. CONCLUSIONS AND RELEVANCE In the absence of a recent concussion, symptom reporting is related to sex and preexisting conditions. Consideration of sex and preexisting health conditions can help prevent misinterpretation of symptoms in student athletes who sustain a concussion.

Multiple prior concussions are associated with symptoms in high school athletes

The purpose of this study was to evaluate the association of prior concussion on baseline computerized neurocognitive testing in a large cohort of high school athletes.

High School Athletes With ADHD and Learning Difficulties Have a Greater Lifetime Concussion History.

Objective: Examine lifetime history of concussions in adolescents who have developmental problems in comparison with those with no developmental problems. Method: Thirty-two thousand four hundred eighty-seven adolescent athletes completed baseline/pre-season evaluations. Based on self-reported histories, athletes were divided into four groups: ADHD only, ADHD and learning difficulties (LD), LD only, and controls. Results: Athletes with ADHD, LD, or ADHD plus LD reported a greater prevalence of prior concussions than athletes without these developmental conditions (ps < .05). When adjusting for sex differences in concussion prevalence rates (boys are greater than girls), there was an increase in prevalence of prior injuries in those with ADHD, and ADHD plus learning difficulties compared with those with LD only. This pattern was found for both girls and boys. There was no additive effect of having both conditions. Conclusion: Developmental conditions in adolescent athletes, such as ADHD and learning difficulties, are associated with a greater prevalence rate of prior concussion.

Relationship between short sleep duration and preseason concussion testing

Objective:Baseline, preseason assessment of cognition, symptoms, and balance has been recommended as part of a comprehensive sport concussion management program. We examined the relationship between sleep and baseline test results. We hypothesized that adolescents who slept fewer hours the night before would report more symptoms and perform more poorly on cognitive testing than students who had a full night sleep. Design:Cross-sectional observation study. Setting:Preseason concussion testing for high school athletes. Participants:A large sample (n = 2928) of student athletes from Maine, USA, between the ages of 13 and 18 years completed preseason testing. Participants with developmental problems, a history of treatment for neurological or psychiatric problems, recent concussion, or 3 or more prior concussions were excluded. Assessment of Risk Factors:Athletes were divided into 4 groups based on their sleep duration the night before testing. Main Outcome Measures:Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT; ImPACT Applications, Inc, Pittsburgh, PA) cognitive composite scores and the embedded Post-Concussion Symptom Scale. Results:Sleep was not related to any ImPACT cognitive composite score, after covarying for age and controlling for multiple comparisons. In contrast, there were sleep duration, sex, and sleep duration by sex effects on the Post-Concussion Symptom Scale. The effect of sleep duration on symptom reporting was more pronounced in girls. Supplementary analyses suggested that sleep insufficiency was associated with a diverse array of postconcussion-like symptoms. Conclusions:Poor sleep the night before baseline or postinjury testing may be an important confound when assessing postconcussion symptoms. Girls may be more vulnerable to experiencing and reporting symptoms following insufficient sleep. Clinical Relevance:Clinicians should routinely ask how the athlete slept the night before preseason baseline testing and consider deferring the symptom assessment or later retesting athletes who slept poorly.

Sex differences and self-reported attention problems during baseline concussion testing

Amateur athletic programs often use computerized cognitive testing as part of their concussion management programs. There is evidence that athletes with preexisting attention problems will have worse cognitive performance and more symptoms at baseline testing. The purpose of this study was to examine whether attention problems affect assessments differently for male and female athletes. Participants were drawn from a database that included 6,840 adolescents from Maine who completed Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) at baseline (primary outcome measure). The final sample included 249 boys and 100 girls with self-reported attention problems. Each participant was individually matched for sex, age, number of past concussions, and sport to a control participant (249 boys, 100 girls). Boys with attention problems had worse reaction time than boys without attention problems. Girls with attention problems had worse visual-motor speed than girls without attention problems. Boys with attention problems reported more total symptoms, including more cognitive-sensory and sleep-arousal symptoms, compared with boys without attention problems. Girls with attention problems reported more cognitive-sensory, sleep-arousal, and affective symptoms than girls without attention problems. When considering the assessment, management, and outcome from concussions in adolescent athletes, it is important to consider both sex and preinjury attention problems regarding cognitive test results and symptom reporting.

Consistency of Self-reported Concussion History in Adolescent Athletes.

Relying on self-reported concussion injury history is common in both clinical care and research. However, young athletes may not provide consistent medical information. To date, little is known about the reliability of self-reported concussion history in high school students. This study examined whether student athletes reported their lifetime history of concussions consistently over time. Self-reported concussion history was examined in 4792 student athletes (ages 13-18) from Maine who completed a preseason health survey on two occasions (median re-test interval = 23.7 months; standard deviation = 7.3; interquartile range = 12.4-24.5). Consistency of self-reported concussion history was determined by differences in the number of concussions reported during the second survey. Inconsistent concussion history was defined primarily by a decrease in the number of lifetime concussions reported at the second testing, compared with at the first testing. The majority of the sample (80.3%) reported no change in the number of concussions between the two baseline assessments. A minority (15.9%; n = 763) reported more concussions during the second assessment. Only 3.8% (n = 181) of student athletes provided inconsistent concussion histories, defined as fewer concussions at the second assessment. Boys provided inconsistent concussion histories a little more frequently, compared with girls (5.3% and 2.0%, respectively; p < 0.001). Similarly, athletes with self-reported attention-deficit hyperactivity disorder (ADHD) provided inconsistent concussion histories somewhat more frequently, compared with those without ADHD (7.8% and 3.5%, respectively; p < 0.001). Of the athletes with inconsistent concussion histories, greater degree of inconsistency was associated with a greater number of concussions initially reported at baseline (rs = 0.54; p < 0.001). Only a small proportion of student athletes provided inconsistent concussion histories. Male gender, ADHD, and greater number of baseline concussions were significantly associated with inconsistency in reporting. Overall, these findings suggest that student athletes are quite consistent when reporting their concussion history when surveyed twice during high school.

Multiple Past Concussions in High School Football Players: Are There Differences in Cognitive Functioning and Symptom Reporting?

Background: There is increasing concern about the possible long-term effects of multiple concussions, particularly on the developing adolescent brain. Whether the effect of multiple concussions is detectable in high school football players has not been well studied, although the public health implications are great in this population. Purpose: To determine if there are measureable differences in cognitive functioning or symptom reporting in high school football players with a history of multiple concussions. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Participants included 5232 male adolescent football players (mean [±SD] age, 15.5 ± 1.2 years) who completed baseline testing between 2009 and 2014. On the basis of injury history, athletes were grouped into 0 (n = 4183), 1 (n = 733), 2 (n = 216), 3 (n = 67), or ≥4 (n = 33) prior concussions. Cognitive functioning was measured by the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery, and symptom ratings were obtained from the Post-Concussion Symptom Scale. Results: There were no statistically significant differences between groups (based on the number of reported concussions) regarding cognitive functioning. Athletes with ≥3 prior concussions reported more symptoms than did athletes with 0 or 1 prior injury. In multivariate analyses, concussion history was independently related to symptom reporting but less so than developmental problems (eg, attention or learning problems) or other health problems (eg, past treatment for psychiatric problems, headaches, or migraines). Conclusion: In the largest study to date, high school football players with multiple past concussions performed the same on cognitive testing as those with no prior concussions. Concussion history was one of several factors that were independently related to symptom reporting.

Factor Structure of ImPACT® in Adolescent Student Athletes

Objective ImPACT® (Immediate Post-Concussion Assessment and Cognitive Testing) is a computerized neuropsychological screening battery, which is widely used to measure the acute effects of sport-related concussion and to monitor recovery from injury. This study examined the factor structure of ImPACT® in several samples of high school student athletes. We hypothesized that a 2-factor structure would be present in all samples. Method A sample of 4,809 adolescent student athletes was included, and subgroups with a history of treatment for headaches or a self-reported history of learning problems or attention-deficit hyperactivity disorder were analyzed separately. Exploratory principal axis factor analyses with Promax rotations were used. Results As hypothesized, both the combination of Verbal Memory and Visual Memory Composite scores loaded on one (Memory) factor, while Visual Motor Speed and Reaction Time loaded on a different (Speed) factor, in the total sample and in all subgroups. Conclusion These results provide reasonably compelling evidence, across multiple samples, which ImPACT® measures 2 distinct factors: memory and speed.

Concussion-Like Symptom Reporting in High School Student Athletes with ADHD.

Disclosures: Nathan Cook: I Have No Relevant Financial Relationships To Disclose Objective: Symptom reporting in student athletes with attentiondeficit hyperactivity disorder (ADHD) who are slow-to-recover from a sport-related concussion can be difficult to interpret; it can be challenging to differentiate pre-existing symptoms from concussionrelated symptoms. This study documents preseason symptom reporting in athletes with and without ADHD. Design: Cross-sectional, case-control, cohort survey study. Setting: High schools from the state of Maine, USA. Participants: Participants were 37,510 high school athletes who completed a baseline preseason health survey and symptom questionnaire between 2009 and 2014. None reported suffering a concussion within the past 6 months. A total of 2,409 (6.4%) self-reported having ADHD, and 786 (32.6%) reported taking medication to treat ADHD. Three groups included: (1) controls, (2) ADHD with medication use (Medication), and (3) ADHD but no medication use (No Medication). Interventions: None. Main Outcome Measures: The Post-Concussion Scale includes 22 symptoms such as headache, dizziness, concentration problems, and forgetfulness. Students rate the severity of each symptom from 0 to 6. Results: Groups differed significantly on the Post-Concussion Scale [girls: X(2)1⁄422.6.29, P <.001; boys: X(2)1⁄4267.15, P <.001]. Pairwise comparisons revealed similar results for both sexes; namely, the Medication group (boys: Md1⁄44; girls: Md1⁄49) and No Medication group (boys: Md1⁄43.5; girls: Md1⁄47) did not differ from one another. Both the No Medication group (girls: Mann-Whitney U1⁄42,881,457, P <.001; boys: U1⁄48,170,938, P <.001) and the Medication group differed significantly from Controls (girls: Md1⁄42; U1⁄41,187,040.5, P <.001; boys: Md1⁄41; U1⁄43,836,183.5, P <.001). Girls with ADHD, regardless of medication status, had greater total symptom scores compared to boys with ADHD. Frequencies of endorsing specific symptoms (ie, item score > 1), stratified by group and gender, are presented. Conclusions: Better understanding of symptom reporting in uninjured student athletes with ADHD can facilitate the clinical interpretation of symptoms in those who are slow to recover following a concussion. Level of Evidence: Level III

Investigating Effects of Sex Differences and Prior Concussions on Symptom Reporting and Cognition Among Adolescent Soccer Players

Background: There has been increasing concern regarding the possible effect of multiple concussions on the developing brain, especially for adolescent females. Hypothesis/Purpose: The objectives were to determine if there are differences in cognitive functioning, symptom reporting, and/or sex effects from prior concussions. In a very large sample of youth soccer players, it was hypothesized that (1) there would be no differences in cognitive test performance between those with and without prior concussions, (2) baseline preseason symptoms would be better predicted by noninjury factors than concussion history, and (3) males and females with prior concussions would not have differences in cognition or symptoms. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Participants included 9314 youth soccer players (mean = 14.8 years, SD = 1.2) who completed preseason baseline cognitive testing, symptom reporting, and a health/injury history questionnaire from the ImPACT battery (Immediate Post-concussion Assessment and Cognitive Testing). On the basis of injury history, athletes were grouped by number of prior concussions: 0 (boys, n = 4012; girls, n = 3963), 1 (boys, n = 527; girls, n = 457), 2 (boys, n = 130; girls, n = 97), or ≥3 (boys, n = 73; girls, n = 55). The primary measures were the 4 primary cognitive scores and the total symptom ratings from ImPACT. Primary outcomes were assessed across injury groups, controlling for age, sex, learning disability, attention-deficit/hyperactivity disorder (ADHD), treatment for headaches/migraines, substance abuse, and mental health problems. Results: Cognitive test performance was not associated with concussion history but was associated with sex, age, learning disability, ADHD, and prior mental health problems. Greater symptom reporting was more strongly associated with psychiatric problems, older age, learning disability, substance abuse, headaches, being female, and ADHD than with a history of multiple concussions. Boys and girls did not differ on cognitive scores or symptom reporting based on a history of concussion. Conclusion: In this very large sample of youth soccer players with prior concussion, there was no evidence of negative effects on cognition, very weak evidence of negative effects on symptom reporting, and no evidence of sex × concussion differences in cognition or symptom reporting.