Tracey Covassin

The Role of Age and Sex in Symptoms, Neurocognitive Performance, and Postural Stability in Athletes After Concussion

Background: Researchers have begun to focus on age and sex differences in concussion outcomes. Results suggest that younger athletes and female athletes may take longer to recover from a concussion. However, little is known about the interactive effects of age and sex on symptoms, neurocognitive testing (NCT), and postural stability. Hypothesis/Purpose: The purpose of the study was to examine sex and age differences in symptoms, NCT, and postural stability following concussion. We hypothesized that high school and female athletes would have worse symptoms, NCT, and postural stability than college and male athletes, respectively. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 296 concussed athletes from a multistate, 2-year study were enrolled in this study. Participants completed the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) and Post-Concussion Symptom Scale (PCSS) at baseline and again at 2, 7, and 14 days after concussion. Participants completed the Balance Error Scoring System (BESS) at 1, 2, and 3 days after concussion. Results: Female athletes performed worse than male athletes on visual memory (mean, 65.1% and 70.1%, respectively; P = .049) and reported more symptoms (mean, 14.4 and 10.1, respectively) after concussion (P = .035). High school athletes performed worse than college athletes on verbal (mean, 78.8% and 82.7%, respectively; P = .001) and visual (mean, 65.8% and 69.4%, respectively; P = .01) memory. High school athletes were still impaired on verbal memory 7 days after concussion compared with collegiate athletes (P = .001). High school male athletes scored worse on the BESS than college male athletes (mean, 18.8 and 13.0, respectively; P = .001). College female athletes scored worse on the BESS than high school female athletes (mean, 21.1 and 16.9, respectively; P = .001). Conclusion: The results of the current study supported age differences in memory and sex differences in memory and symptoms and an interaction between age and sex on postural stability after concussion that warrant consideration from clinicians and researchers when interpreting symptoms, specific components of NCT, and postural stability tests. Future research should develop and assess interventions tailored to age and sex differences and include younger (<14 years) participants.

Sex differences in baseline neuropsychological function and concussion symptoms of collegiate athletes

Objective: To investigate sex differences in baseline neuropsychological function and concussion symptoms between male and female collegiate athletes. Methods: A post-test only design was used to examine baseline neuropsychological test scores and concussion symptoms. A total of 1209 NCAA Division I collegiate athletes from five northeastern universities in the USA completed a baseline ImPACT test. ImPACT, a computerised neuropsychological test battery, was administered during an athlete’s pre-season. Results: Female athletes performed significantly better than male athletes on baseline verbal memory scores (p = 0.001), while male athletes performed significantly better than female athletes on baseline visual memory scores (p = 0.001). Female athletes endorsed a significant number of mild baseline symptoms as compared to male athletes. Conclusions: Male and female athletes exhibit differences on baseline neuropsychological test performance and concussion symptoms.

Epidemiological Considerations of Concussions Among Intercollegiate Athletes

The purpose of this study was to examine epidemiological trends of concussions among 15 different intercollegiate sports during the 1997-1998, 1998-1999, and 1999-2000 seasons. Data were collected using the National Collegiate Athletic Association (NCAA) Injury Surveillance System (ISS). For the 15 sports studied during the 3 academic years, the NCAA ISS documented 3,535 team-seasons, 40,547 reportable injuries, 5,566,924 practice athlete exposures (AEs), and 1,090,298 game AEs. Concussions accounted for 6.2% of all reported injuries during this 3-year study. Of all the reported injuries, women lacrosse players (13.9%) reported the highest percentage of suffering a concussion during a game followed by womens soccer (11.4%), mens ice hockey (10.3%), mens lacrosse (10.1%), football (8.8%), womens basketball, (8.5%), field hockey (7.2%), mens soccer (7.0%), wrestling (6.6%), mens basketball (5.0%), baseball (4.2%), and womens volleyball (4.1%). Female athletes from all 7 sports were found to be at a lower risk for suffering concussions during practice sessions than the 8 male sports. However, female athletes were found to be at a greater risk for suffering concussions during games compared to male athletes. Injury trends over the 3-year period indicate concussions continue to be on the rise for athletes participating in collegiate football, mens soccer, and womens and mens basketball.

One-Year Test-Retest Reliability of the Online Version of ImPACT in High School Athletes

Background: The ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) neurocognitive testing battery is a popular assessment tool used for concussion management. The stability of the baseline neurocognitive assessment is important for accurate comparisons between postconcussion and baseline neurocognitive performance. Psychometric properties of the recently released online version of ImPACT have yet to be established; therefore, research evaluating the reliability of this measure is warranted. Purpose: The authors investigated the 1-year test-retest reliability of the ImPACT online version in a sample of high school athletes. Study Design: Case series; Level of evidence, 4 Methods: A total of 369 varsity high school athletes completed 2 mandatory preseason baseline cognitive assessments approximately 1 year apart as required by their respective athletics program. No diagnosed concussion occurred between assessments. Results: Intraclass correlation coefficients (ICCs) for ImPACT online indicated that motor processing speed (.85) was the most stable composite score, followed by reaction time (.76), visual memory (.70), and verbal memory (.62). Unbiased estimates of reliability were consistent with ICCs: motor processing speed (.85), reaction time (.76), visual memory (.71), and verbal memory (.62). Conclusion: The online ImPACT baseline is a stable measure of neurocognitive performance across a 1-year time period for high school athletes. These reliability data for online ImPACT are higher than the 2-year ICCs previously reported from the desktop version. Clinical Relevance: It is recommended that the ImPACT baseline assessment (both desktop and online) continue to be updated every 2 years. The online version of ImPACT appears to be a stable measure of neurocognitive performance over a 1-year period, and systematic evaluation of its stability over a 2-year period is warranted.

A Revised Factor Structure for the Post-Concussion Symptom Scale Baseline and Postconcussion Factors

Background: Symptom reports play a critical role in the assessment and management of concussions. Symptoms are often conceptualized as factors comprising several related symptoms (eg, somatic factor = headache, nausea, vomiting). Previous research examining the factor structure of the 22-item Post-Concussion Symptom Scale (PCSS) has been limited to small samples and has not adequately evaluated factor loadings at both baseline and postconcussion for male and female athletes at the high school and collegiate levels. Purpose: To examine the factor structure of the 22-item PCSS in independent samples of high school and collegiate athletes reported at baseline and postconcussion, and to evaluate sex and age differences in the resulting baseline and postconcussion symptom factor scores. Study Design: Case series; Level of evidence, 4. Methods: Exploratory factor analytic (EFA) methods were applied to 2 separate samples of athletes who completed the PCSS at baseline (n = 30,455) and 1 to 7 days after a sport-related concussion (n = 1438). The baseline sample (mean ± standard deviation) was 15.74 ± 1.78 years, with a range of 13 to 22 years, and the postconcussion sample was 17.14 ± 2.25 years, with a range of 13 to 24 years. Results: A 4-factor solution accounting for 49.1% of the variance at baseline included a cognitive-sensory, sleep-arousal, vestibular-somatic, and affective factor structure. A 4-factor solution that included cognitive-fatigue-migraine, affective, somatic, and sleep was revealed for the postconcussion EFA. High school athletes reported higher baseline levels of the cognitive-sensory and vestibular-somatic symptom factors and lower levels of the sleep-arousal factor than college athletes. Female participants reported higher symptoms on all postconcussion factors than male participants. Conclusion: The current findings reveal different symptom factors at baseline and postinjury and several age and sex differences on the symptom factors. At postconcussion, symptoms aggregated into a global concussion factor including cognitive, fatigue, and migraine symptoms. Symptoms reported at baseline are not the same as those reported after injury. The presence of a global postconcussion symptom comprising the fatigue factor highlights the importance of physical and cognitive rest during the first week after a concussion. Although headache was the most commonly reported symptom, it was not the greatest contributor to the global postconcussion symptom factor.

Epidemiology of Sports-Related Concussion in NCAA Athletes From 2009-2010 to 2013-2014 Incidence, Recurrence, and Mechanisms

Background: The epidemiology of sports-related concussion (SRC) among student-athletes has been extensively researched. However, recent data at the collegiate level are limited. Purpose: To describe the epidemiology of SRC in 25 National Collegiate Athletic Association (NCAA) sports. Study Design: Descriptive epidemiology study. Methods: SRC data from the NCAA Injury Surveillance Program during the 2009-2010 to 2013-2014 academic years were analyzed. Concussion injury rates, rate ratios (RRs), and injury proportion ratios were reported with 95% CIs. National estimates were also calculated to examine linear trends across time. Results: During the study period, 1670 SRCs were reported, representing a national estimate of 10,560 SRCs reported annually. Among the 25 sports, the overall concussion rate was 4.47 per 10,000 athlete-exposures (AEs) (95% CI, 4.25-4.68). Overall, more SRCs occurred in competitions (53.2%). The competition rate (12.81 per 10,000 AEs) was larger than the practice rate (2.57 per 10,000 AEs) (competition vs practice, RR = 4.99; 95% CI, 4.53-5.49). Of all SRCs, 9.0% were recurrent. Most SRCs occurred from player contact (68.0%). The largest concussion rates were in men’s wrestling (10.92 per 10,000 AEs; 95% CI, 8.62-13.23), men’s ice hockey (7.91 per 10,000 AEs; 95% CI, 6.87-8.95), women’s ice hockey (7.50 per 10,000 AEs; 95% CI, 5.91-9.10), and men’s football (6.71 per 10,000 AEs; 95% CI, 6.17-7.24). However, men’s football had the largest annual estimate of reported SRCs (n = 3417), followed by women’s soccer (n = 1113) and women’s basketball (n = 998). Among all SRCs, a linear trend did not exist in national estimates across time (P = .17). However, increases were found within specific sports, such as men’s football, women’s ice hockey, and men’s lacrosse. Conclusion: The estimated number of nationally reported SRCs has increased within specific sports. However, it is unknown whether these increases are attributable to increased reporting or frequency of concussions. Many sports report more SRCs in practice than in competition, although competition rates are higher. Men’s wrestling and men’s and women’s ice hockey have the highest reported concussion rates. Men’s football had the highest annual national estimate of reported SRCs, although the annual participation count was also the highest. Future research should continue to longitudinally examine SRC incidence while considering differences by sex, division, and level of competition.

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) Practices of Sports Medicine Professionals

CONTEXT Computerized neurocognitive testing is becoming popular among clinicians evaluating sport-related concussions across all levels of sport. Baseline neurocognitive testing has been recommended to provide more accurate representation of the preconcussion cognitive status of individual athletes. However, little is known about the use of baseline neurocognitive testing in concussion assessment and management. OBJECTIVE To examine implementation and practice trends of sports medicine professionals using baseline neurocognitive testing at the high school and collegiate levels. DESIGN Quantitative survey research. SETTING Online survey. PATIENTS OR OTHER PARTICIPANTS Certified athletic trainers (ATs) from approximately 1209 US institutions listed on the ImPACT Web site were recruited. A total of 399 ATs completed the survey, for a response return rate of 32.7%. MAIN OUTCOME MEASURE(S) Survey questions addressed educational level, years of certification, employment setting, percentage of athletes baseline tested, and accuracy of baseline tests. Other items addressed postconcussive neurocognitive testing protocols and scenarios for return-to-play decisions based on neurocognitive testing. RESULTS Nearly all ATs (94.7%) administered baseline computerized neurocognitive testing to their athletes. However, only 51.9% examined these baseline tests for validity. The majority of ATs indicated that they administer baseline neurocognitive tests most frequently to football players (88.4%), followed by womens soccer players (78.8%) and mens soccer players (71.2%). Nearly all respondents (95.5%) stated that they would not return a symptomatic athlete to play if the athletes neurocognitive scores were back to baseline. However, when asked if they would return an athlete who is symptom free but who scores below his or her baseline, 86.5% responded no, 9.8% responded yes, and 3.8% indicated that it depended on the importance of the competition. CONCLUSIONS The use of baseline testing, baseline testing readministration, and postconcussion protocols among ATs is increasing. However, the ATs in this study reported that they relied more on symptoms than on neurocognitive test scores when making return-to-play decisions.

Depression and Neurocognitive Performance After Concussion Among Male and Female High School and Collegiate Athletes

OBJECTIVES To prospectively examine the relationship of sport-related concussion with depression and neurocognitive performance and symptoms among male and female high school and college athletes. A secondary objective was to explore age and sex differences. DESIGN Pretest, multiple posttest, repeated-measures design. SETTING Laboratory. PARTICIPANTS High school and collegiate athletes (N=75) with a diagnosed concussion. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Beck Depression Inventory-II and computerized neurocognitive test battery (Immediate Post-concussion Assessment and Cognitive Test), which includes concussion symptoms (Post-concussion Symptom Scale) at baseline and at 2, 7, and 14 days postinjury. RESULTS Concussed athletes exhibited significantly higher levels of depression from baseline at 2 days (P≤.001), 7 days (P=.006), and 14 days postconcussion (P=.04). Collegiate athletes demonstrated a significant increase in depression at 14 days postconcussion than did high school athletes (P=.03). There were no sex differences in depression levels. Neurocognitive decrements at 14 days were supported for reaction time (P=.001) and visual memory (P=.001). Somatic depression at 7 days postconcussion was related to slower reaction time at 7 days postconcussion. Somatic depression at 14 days postinjury was related to lower visual memory scores at 14 days postinjury. CONCLUSIONS Although not clinically significant, athletes experienced increased depression scores up to 14 days after concussion that coincided with neurocognitive decrements in reaction time and visual memory. Somatic depression appears to be most salient with regard to lower neurocognitive performance. Mood assessments after concussion are warranted to help monitor and enhance recovery.

Sex and Age Differences in Depression and Baseline Sport-Related Concussion Neurocognitive Performance and Symptoms

Objective To examine depression and baseline neurocognitive function and concussion symptoms in male and female high school and college athletes. Design Cross sectional. Setting Athletes completed testing at a designated computer laboratory at high schools and colleges. Participants Participants included 1616 collegiate (n = 837) and high school (n = 779) athletes from 3 states participating in a variety of competitive sports. Interventions Participants completed the baseline Immediate Postconcussion Assessment and Cognitive Test (ImPACT), symptom inventory, and Beck Depression Inventory II (BDI-II). Main Outcome Measures Between-group comparisons for depression groups on ImPACT composite scores (verbal and visual memory, reaction time, motor processing speed), total symptoms, and symptom cluster (sleep, cognitive, emotional, somatic/migraine) scores. Between-group comparisons for age and sex on BDI-II, ImPACT, total symptoms, and symptom cluster scores. Results The severe depression group scored worse on visual memory and reported more total, somatic/migraine, cognitive, emotional, and sleep symptoms than less depressed groups. High school athletes reported more somatic/migraine symptoms than collegiate athletes, whereas collegiate athletes reported more emotional and sleep symptoms than high school athletes. Women had higher verbal memory and reported more cognitive, emotional, and sleep symptom clusters compared with men. Women outperformed men on verbal memory, whereas collegiate athletes outperformed high school athletes on processing speed. Conclusions Athletes with severe depression scored lower on visual memory than those with minimal depression. Athletes with severe depression report more concussion symptoms than athletes with minimal and moderate depression scores. Symptoms of depression should be included in baseline assessments to help disentangle depression from concussion symptoms.

Concussion History and Postconcussion Neurocognitive Performance and Symptoms in Collegiate Athletes

CONTEXT Athletes are at an inherent risk for sustaining concussions. Research examining the long-term consequences of sport-related concussion has been inconsistent in demonstrating lingering neurocognitive decrements that may be associated with a previous history of concussion. OBJECTIVE To determine the relationship between concussion history and postconcussion neurocognitive performance and symptoms in collegiate athletes. DESIGN Repeated-measures design. SETTING Multi-center analysis of collegiate athletes. PATIENTS OR OTHER PARTICIPANTS Fifty-seven concussed collegiate athletes (36 without concussion history, 21 with a history of 2 or more concussions). INTERVENTION(S) All subjects were administered an Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) neurocognitive test battery, which measures verbal memory, visual memory, reaction time, and visual processing speed and 22 concussion symptoms. MAIN OUTCOME MEASURE(S) Subjects who sustained a concussion were administered 2 follow-up tests at days 1 and 5 postinjury. Independent variables were history of concussion (no history of concussion, 2 or more concussions) and time (baseline, day 1 postconcussion, or day 5 postconcussion). RESULTS A within-subjects effect (time) on ImPACT performance (P < .001), a between-subjects multivariate effect of group (P < .001), and a group-by-time interaction (P = .034) were noted. Athletes with a concussion history performed significantly worse on verbal memory (P = .01) and reaction time (P = .023) at day 5 postconcussion compared with athletes who did not report a previous concussion. No significant group differences were seen at day 5 postinjury on visual memory (P = .167), processing speed (P = .179), or total concussion symptoms (P = .87). CONCLUSIONS Concussed collegiate athletes with a history of 2 or more concussions took longer to recover verbal memory and reaction time than athletes without a history of concussion.