Post-Concussion Assessment Research Articles

A-062 Cognitive Profiles in Athletes with Neurodevelopmental Disorders on Baseline Testing

Abstract Objective The Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) is a commonly utilized sport concussion assessment. Previous literature examined differences in concussion rates, symptom scores, and invalid baselines between healthy athletes and athletes with neurodevelopmental disorders. There are no current studies that investigate cognitive profiles of athletes with autism. The present study explores possible differences in ImPACT performance for these athletes. Method Participants included 31,368 high school athletes (mean age = 15.0, SD = 1.2; mean education = 9.0; SD = 1.4; 43.9% female) selected from a larger database who completed baseline ImPACT testing from 2008–2016. Self-reported neurodevelopmental history consisted of these distinct groups: attention-deficit/hyperactivity disorder (ADHD; 3.6%), learning disorders (LD; 1.3%), Autism (0.3%), ADHD/LD (0.6%). ImPACT Composite Scores were analyzed using Mixed-model ANCOVA (age and gender covariates)-Verbal Memory (VerbM), Visual Memory (VisM), Visual Motor Speed (VisMot), Reaction Time (RT), and Impulse Control (IC). Composites were standardized and RT was reverse coded. For comparison purposes, individuals from all neurodevelopmental groups were utilized. Results There was a main effect for Composites and neurodevelopmental history (p < .01). An interaction effect between Composites and neurodevelopmental history was found (p < .01). The Autism group scored significantly lower than healthy athletes on VerbM, VisM, VisMot, and RT. No difference was found for IC. Pattern differences between neurodevelopmental groups will also be reported. Discussion Results reveal cognitive profile differences for athletes with Autism and other neurodevelopmental disorders. The ImPACT provides normative data for LD and ADHD athletes; however, our results indicate similar pattern differences for Autism and ADHD/LD. Future research should investigate whether separate norms may be beneficial for these groups.

Impairments in Dynamic Postural Control across Concussion Clinical Milestones.

The aim of this study was to assess gait initiation (GI) performance longitudinally across clinical concussion recovery milestones through return to participation (RTP). We recruited 54 collegiate student-athletes, 27 with concussions and 27 matched controls (15 female and 12 male per group). Participants performed five trials of GI at baseline and again at five post-concussion clinical milestones: 1) Acute, the day clinical tests achieved baseline values on the 2) Balance Error Scoring System (BESS), 3) Immediate Post-Concussion Assessment and Cognitive Test ImPACT, 4) Asymptomatic, and 5) RTP Day. GI performance on six outcome measures (anterior/posterior and medial/lateral center of pressure displacements and velocities during the anticipatory postural adjustment [APA] phase and initial step length and velocity) with repeated-measures mixed model and pair-wise post hoc. A reliable change index (RCI) was calculated, and post-concussion participant's performance was compared to the RCI at milestones. There were significant interactions for APA posterior and lateral displacement, APA posterior velocity, step length, and step velocity. The post-hoc tests identified significant deficits across clinical milestones and at RTP for APA posterior and lateral displacement, step length, and step velocity. There were no post-hoc differences for any outcome measure in the control group. At RTP, 85.2-88.9% of concussion participants had at least one outcome measure which exceeded the 80% or 95% RCI. The primary finding of this study was persistent impairments in dynamic postural control, suggesting ongoing neurophysiological impairment despite clinical recovery. These results suggest that collegiate student-athletes may be RTP before neurophysiological recovery and potentially exposing themselves to elevated risk of recurrent concussion or subsequent musculoskeletal injury.

A Cohort Study of the Temporal Stability of ImPACT Scores Among NCAA Division I Collegiate Athletes: Clinical Implications of Test-Retest Reliability for Enhancing Student Athlete Safety.

In this study we examined the temporal stability of the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) within NCAA Division I athletes across various timepoints using an exhaustive series of statistical models. Within a cohort design, 48 athletes completed repeated baseline ImPACT assessments at various timepoints. Intraclass correlation coefficients (ICC) were calculated using a two-way mixed effects model with absolute agreement. Four ImPACT composite scores (Verbal Memory, Visual Memory, Visual Motor Speed, and Reaction Time) demonstrated moderate reliability (ICC=0.51-0.66) across the span of a typical Division I athlete's career, which is below previous reliability recommendations (0.90) for measures used in individual decision-making. No evidence of fixed bias was detected within Verbal Memory, Visual Motor Speed, or Reaction Time composite scores, and minimal detectable change values exceeded the limits of agreement. The demonstrated temporal stability of the ImPACT falls below the published recommendations, and as such, fails to provide robust support for the NCAA's recommendation to obtain a single preparticipation cognitive baseline for use in sports-related concussion management throughout an athlete's career. Clinical interpretation guidelines are provided for clinicians who utilize baseline ImPACT scores for later performance comparisons.

Disparities on Baseline Performance Using Neurocognitive and Oculomotor Clinical Measures of Concussion

Background: Given the high participation of Black/African American individuals in high school sports, especially high-risk sports for concussion, it is important to note if racial and socioeconomic status (SES) differences exist in baseline performance on clinical measures of concussion. Purpose: To explore the association between race and SES on baseline concussion assessments of neurocognitive performance and oculomotor function in adolescent athletes. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: A total of 564 high school athletes (mean ± SD age, 15.33 ± 1.1 years) completed the baseline Immediate Post-Concussion Assessment and Cognitive Test and King-Devick (KD) battery before the start of their competitive season. Race was defined as either White/non-Hispanic or Black/African American. SES status was determined by whether the individual’s participating high school was a Title I or non–Title I school. A series of multivariable linear regression analyses were conducted to evaluate the association of computerized neurocognitive test scores (verbal memory, visual memory, motor processing speed, and reaction time), symptom severity scores, and KD scores by race and SES. Results: White/non-Hispanic individuals performed significantly better than Black/African American individuals on verbal memory (P < .01), visual memory (P < .01), visual motor processing speed (P < .01), and reaction time (P < .01) and had a lower symptom score (P < .01). Regarding SES, individuals from non–Title I schools performed better on visual memory (P = .05) and reaction time (P = .02) than individuals from Title I schools. Examination of cumulative KD test reading time revealed that there was no association between race on baseline reading times (P = .12). There was a significant association between cumulative reading time and SES (P = .02). Individuals from non–Title I schools performed significantly faster than individuals from Title I schools on KD test time. Conclusion: Overall, race and SES influence neurocognitive and oculomotor concussion baseline performance in high school athletes. These findings add to the growing literature on the influence of race and SES on neurocognitive and oculomotor function baseline concussion assessments; they highlight the necessity for individualized concussion baseline measurements or race-specific normative reference values.

Comparison of the PHQ9 and ImPACT symptom cluster scores in measuring depression among college athletes

Accurate identification of athletes in need of mental health services is essential. The clinical utility of the Patient Health Questionnaire − 9 (PHQ-9), a stand-alone measure of depression, was explored among Division II college athletes (n = 1,209) completing pre-participation concussion baseline assessments (mean age = 19.28), which also included Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). ImPACT’s symptom inventory can be divided into four clusters: affective, cognitive, physical/somatic, and sleep. Most athletes (81.9%) did not endorse any items on the affective symptom cluster; however, 90 athletes (7.4%) fell above the cutoff of 5 for depression on the PHQ-9, and approximately half of all athletes endorsed one or more PHQ-9 items. Simple linear regressions revealed ImPACT’s sleep symptom cluster as the best predictor of PHQ-9 total score; however, affective, cognitive, and physical symptom clusters significantly predicted PHQ-9 total score as well. Due to relative under-endorsement of items on ImPACT’s affective symptom cluster compared to the PHQ-9, the clinical utility of incorporating a stand-alone measure of depression such as the PHQ-9 during baseline testing is supported.

Cranial Strain Patterns Associated With Concussions.

Concussions can cause cognitive impairment, somatic symptoms, and behavioral changes. Symptoms may vary in severity, depending on the degree of traumatic force. Due to the biomechanical nature of this trauma, cranial somatic dysfunctions may commonly be seen in patients with concussion. To determine whether patients were more likely to have nonphysiologic cranial somatic dysfunctions than physiologic cranial somatic dysfunctions after sustaining a concussion. College athletes who had a concussion based on the Immediate Post-Concussion Assessment and Cognitive test were evaluated by a physician within 1 week of the injury. Patients were evaluated for somatic dysfunctions of the cranium. Cranial somatic dysfunctions were documented; test scores and force vectors were compared with the type of strain pattern using SPSS, with P<.05 demonstrating statistical significance. Sixteen patients were included in the study: 10 with nonphysiologic cranial strain somatic dysfunctions and 6 with physiologic dysfunctions. Compared with lateral forces, forces of impact with anterioposterior vectors were associated 1.5 times more often with nonphysiologic rather than physiologic cranial somatic dysfunctions (P=.697). An analysis of specific cranial strain patterns and impact force vectors showed no statistical significance (P=.096). There was no statistically significant association showing that concussion patients were more likely to have nonphysiologic cranial somatic dysfunctions compared with physiological cranial somatic dysfunctions. However, nonphysiologic cranial somatic dysfunctions did show a trend toward association with concussion. Further studies are needed to better understand the potential association between concussion and cranial somatic dysfunctions.

Concussion Clinical Profiles Screening (CP Screen) Tool: Preliminary Evidence to Inform a Multidisciplinary Approach.

Current concussion symptom inventories emphasize total number or symptoms and severity and overlap with other conditions, such as mental health disorders, which may limit their specificity and clinical utility. To develop and test the reliability and validity of a new Concussion Clinical Profiles Screening tool (CP Screen) in both healthy controls and concussed. CP Screen is a 29-item self-report, clinical profile-based symptom inventory that measures the following 5 concussion clinical profiles: 1) anxiety/mood, 2) cognitive/fatigue, 3) migraine, 4) ocular, and 5) vestibular; and the following 2 modifying factors: 1) sleep and 2) neck. Post-Concussion Symptom Scale (PCSS), vestibular/ocular motor screening (VOMS) tool, and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) were conducted. CP Screen was administered in community a concussion surveillance program and 2 sports medicine concussion clinics. Responses include 248 athletes, 121 concussed, and 127 controls, enrolled between 2018 and 2019. Internal consistency of the CP Screen in the control (Cronbach's alpha=.87) and concussed (Cronbach's alpha=.93) samples was high. Moderate to high correlations among the CP Screen factors and PCSS factors and VOMS items, supporting concurrent validity. ROC curve analysis for identifying concussed from controls was significant (P<.001) for all CP Screen factor and modifier scores with excellent AUCs for migraine (.93), ocular (.88), vestibular (.85), and cognitive (.81) factors, demonstrating predictive validity. The CP Screen demonstrated strong reliability, concurrent validity with commonly used concussion assessment (ie, PCSS, VOMS, and ImPACT), and predictive validity for identifying concussion. The CP Screen extends current symptom inventories by evaluating more specific symptoms that may reflect clinical profiles and inform better clinical care.

The Rey Dot Counting Test as a Tool for Detecting Suboptimal Performance in Athlete Baseline Testing

The limitations of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)'s embedded validity measures (EVMs) are well-documented, as estimates suggest up to 35% of invalid baseline performances go undetected. Few studies have examined standalone performance validity tests (PVT) as a supplement to ImPACT's EVMs. College athletes (n=1,213) were administered a preseason baseline assessment that included ImPACT and the Rey Dot Counting Test (DCT), a standalone PVT, among other measures. Sixty-nine athletes (5.69%) met criteria for suboptimal effort on either ImPACT or the DCT. The DCT detected more cases of suboptimal effort (n=50) than ImPACT (n=21). A χ2 test of independence detected significant disagreement between the two measures, as only two individuals produced suboptimal effort on both (χ2(2)=1.568, p=.210). Despite this disagreement, there were significant differences between the suboptimal effort DCT group and the adequate effort DCT group across all four ImPACT neurocognitive domains (U=19,225.000, p<.001; U=17,859.000, p<.001; U=13,854.000, p<.001; U=17,850.500, p<.001). The DCT appears to detect suboptimal effort otherwise undetected by ImPACT's EVMs.

Cross-cultural exploration of baseline ImPACT Quick Test performance among football athletes in Zambia

ABSTRACT Objective Concussion is a global sport injury; however, this public health issue has yet to be studied across Africa. It is unknown if tests such as the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) Quick Test (QT) are culturally appropriate for implementation as part of a concussion screening protocol in Zambia or other African nations. Study objectives included: 1) establish that Zambian athletes are able to complete the iPad-based ImPACT QT with respect to language or cultural barriers that may exist, and 2) document baseline neurocognitive percentile ranks among Zambian football athletes on the ImPACT QT. Methods This study was completed with adult premiere league football athletes in Zambia (n = 125) aged 24.48 ± 5.41. Participants completed the ImPACT QT neurocognitive assessment prior to a preseason practice. Outcome measures were average performance on 3 factor scores: Motor Speed, Memory, and Attention Tracker, presented as percentile ranks using normative data built-into the ImPACT QT. Results Zambian athletes scored nearly two standard deviations below the mean on Motor Speed (7th percentile), using North American normative data. However, performance on Attention Tracker (44th percentile) and Memory (56th percentile) was within the average range. Conclusion Results of the current study show that Zambian athletes are able to complete the ImPACT QT, despite any language or cultural differences that may exist. In addition, preliminary percentile ranks suggest Zambian football athletes have average scores on Attention and Memory and below average scores on Motor Speed. These data are the first to explore Zambian athletes’ performance on a cognitive concussion measure.

Documenting The Prevalence Of Symptom Exacerbation Following The Completion Of A Computerized Neurocognitive Testing Battery In Athletes With Concussion

Symptom exacerbation following computerized neurocognitive testing (CNT) has been documented at the acute and subacute time points after concussion; however, the prevalence and indications of clinically significant symptom exacerbation following CNT is currently unknown. PURPOSE: 1) To document the prevalence of symptom exacerbation following CNT in concussed athletes and 2) explore factors that may predict symptom increases associated with the completion of CNT. METHODS: Two hundred and five concussed athletes (M = 16.48 ± 1.97 yrs; 47% female) completed a standard clinical visit that included a health and injury history, CNT (The Immediate Post-concussion Assessment and Cognitive Testing: ImPACT), Post-Concussion Symptom Scale (PCSS), and the Vestibular and Ocular-motor Screen (VOMS) within 30 days of injury (M = 7.73 ± 5.54 days). The PCSS was administered immediately before and after CNT, and changes on symptom total were used as outcome scores. To account for normal variation in symptom reporting, minimal clinically important differences (MCID) were calculated from the current sample. Two logistic regressions (LR) were used to explore the association between demographic (age, sex, history of SRC, migraine, anxiety, LD, ADHD) and injury-related factors that included vestibular/ocular motor impairment, symptom burden, time until first clinical visit, and removal from play status on post-CNT symptom exacerbation. Statistical significance was set at p < .05. RESULTS: Approximately 33% (68/205) of concussed athletes exhibited clinically significant increases in total PCSS symptoms after CNT. The LR examining demographic variables and post-CNT symptom exacerbation was not significant (χ2(7, 203) = 2.62, p = .92), however the LR using injury-related predictors was significant (χ2(7, 195) = 17.29, p = .02). More specifically, a significant relationship between the ocular component of the VOMS and symptom exacerbation was revealed (adjusted OR= 0.43, p= .04). CONCLUSIONS: The majority of the sample did not exhibit increased symptoms following CNT; however, the participants that do experience increases in post-concussion symptoms after completing CNT are more likely to have a co-morbid ocular impairment associated with their concussion. Clinicians should examine pre and post CNT symptom scores.

Randomized Controlled Trial (RCT) Of A Precision Vestibular Treatment In Adolescent Athletes Following Sport-related Concussion

Concussion care continues to evolve to incorporate more active treatments such as prescribed exercise (Leddy et al., 2019) and vestibular therapy (Broglio et al., 2015). Consensus statements advocate for randomized controlled trials (RCT) to determine the effectiveness of treatments. To date, there has not been an RCT of precision vestibular treatment in athletes following sport-related concussion (SRC) with vestibular symptoms/impairment. PURPOSE: To determine using an RCT the effectiveness of precision, vestibular treatment compared to standard of care for reducing recovery time, symptoms, and impairment in adolescent athletes with vestibular symptoms/impairment following SRC. METHODS: This study involved an RCT in 50 adolescent athletes with a diagnosed SRC with vestibular symptoms/impairment within 10 days of injury. Participants were randomized to vestibular treatment (i.e., gaze stability, visual motion habituation, dynamic balance, gait) (VEST) or control (i.e., behavioral management) (CTRL), and completed the Dizziness Handicap Inventory (DHI), Modified Balance Error Scoring System (mBESS), Vestibular/Ocular Motor Screening (VOMS), Post-concussion Symptom Scale (PCSS), Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) at enrollment and 2- and 4-weeks post-enrollment. Recovery time was recorded using time of medical clearance for full return to activity. Compliance was monitored using daily text messaging. RESULTS: Groups were similar on demographics, initial injury characteristics/severity, and risk factors (all p> .05). mBESS total scores for VESTIB (-1.5) improved more from enrollment to 2-weeks than CONTROLS (-0.3) (p=.04). VESTIB was 8.6x (95% CI= 1.2 - 20.2) more likely to be recovered by 4-weeks than CONTROLS (p=.01). Survival analysis indicated that recovery for VESTIB (45 days) was significantly (p=.04) faster than CONTROLS (57 days). CONCLUSION: The current study provides the first RCT empirical evidence to support the effectiveness of a precision vestibular treatment in adolescent athletes following SRC. Future research should focus on determining the most effective frequency, intensity, and timing for vestibular precision treatments following SRC. Supported by a grant from the Chuck Noll Foundation.

Clinical Predictors Of Prolonged Recovery From Sport-related Concussion: Importance Of Early Clinical Care

Initiation of clinical care may play a critical role in promoting recovery following sport-related concussion (SRC). There has been no research on the role of time to first clinic visit on recovery following SRC in pediatric athletes. Rapid recovery may be especially important in pediatric populations, as prolonged recovery may lead to developmental challenges and/or impact schoolwork and learning capacity. PURPOSE: To investigate the association of time to first clinic visit (≤7 days compared to 8-20 days from injury) in relation to other pre- (e.g., sex; concussion, migraine history) and post-injury (e.g., symptoms, impairment) predictors to prolonged recovery (>30 days) in pediatric athletes with SRC. METHODS: This study was a retrospective review of medical records from a concussion-specialty clinic representing 164 pediatric athletes (aged 12-17) with diagnosed SRC between April 2016-January 2019. Participants were separated into EARLY (≤7 days) and LATE (8-20 days) time to first clinic visit cohorts. Participants completed the Post-concussion Symptom Scale (PCSS), Immediate Post-concussion Assessment and Cognitive Testing (ImPACT), Vestibular/Ocular Motor Screening (VOMS), and demographics/medical history. Adjusted odds ratios (OR) were derived from a backwards stepwise logistic regression (LR) with normal (≤30 days) or prolonged (>30 days) recovery as the outcome. Time to first clinic visit, pre-injury factors, and post-injury clinical assessments were included as predictors. RESULTS: There were no differences in age or cognitive performance between EARLY and LATE. EARLY had a higher PCSS score (29.4±19.6) than LATE (22.2±18.3; p=0.018). LATE had a higher proportion of females (55%) than EARLY (28%; p<0.001). The LR (R2=0.14, p<0.001) identified days to first clinic visit (OR=2.9; p=0.007), as the strongest predictor of recovery >30 days. Vestibular dysfunction (OR=1.1; p=0.040) and PCSS score (OR=1.04; p=0.004) were also predictors of recovery >30 days. CONCLUSIONS: Among all pre- and post-injury predictors, days to first clinic visit was the most robust predictor of prolonged recovery. Vestibular dysfunction and PCSS score also predicted prolonged recovery. The findings highlight the importance of early intervention and care following SRC in pediatric populations.

Assessing The Relationship Between Depression-related Symptoms And Post-concussion Clinical Outcomes

Concussive injury and depression affect millions of individuals each year and are connected through common overlapping symptoms. PURPOSE: Aim 1 was to establish an association between post-concussion depression-related symptoms and post-concussion symptoms, balance performance, vestibular function, and executive function. Aim 2 was to further establish the relationship between concussion history and post-concussion depression-related symptoms, concussion symptoms, and mood disturbance. METHODS: 164 concussed individuals (mean age=14.52±3.51 years, 50.61% male, mean time from injury=18.24±13.60) were included in this analysis. Depression-related symptoms were quantified using the Beck Depression Inventory (BDI-II) and post-concussion symptoms using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). Clinical post-concussion assessments utilized were the modified Balance Error Scoring System (mBESS), Vestibular/Ocular-Motor Screening (VOMS), and, for adolescent patients, the Behavior Rating Inventory of Executive Function (BRIEF). Mood disturbance was quantified using the Profile of Mood States (POMS). mBESS, VOMS, RPQ, and BRIEF were measured against BDI-II scores using Pearson Correlation and Linear Regression analyses. BDI-II, POMS, and RPQ scores were analyzed based on concussion history using Wilcoxon Rank-Sum Tests. RESULTS: As depression-related symptoms increased, post-concussion symptoms (p<0.001, r=0.68) and VOMS scores measuring changes in headache and dizziness (p<0.001, r=0.34; p=0.01, r=0.20 respectively) significantly increased. There was no significant correlation between depression-related symptoms and balance performance (p=0.093, r=0.13). In adolescents, as depression-related symptoms increased parent reported executive function decreased (p<0.001, r=0.46). Those who reported a concussion history reported significantly more depressive-related symptoms (p=0.004), concussion symptoms (p=0.004), and mood disturbance (p=0.002). CONCLUSION: This study adds to the current literature surrounding the relationship between concussion and depression by identifying a relationship between depression related symptoms, post-concussion symptoms, and post-concussion clinical assessments.

Baseline Concussion Symptom Reporting As A Possible Screening Method For Generalized Anxiety Disorder

Athletes with previous diagnosis of a psychiatric condition, such as depression or anxiety, have been shown to experience a larger overall concussion symptom score compared to those without a previous psychiatric treatment. Anxiety rates in college students is high (42%) with student-athletes only slightly lower (37%) compared to the general the population (18%). PURPOSE: The purpose of this study was to compare concussion-related anxiety symptoms and validated anxiety disorder screeners to see if baseline concussion symptoms could be used as a screening tool for follow-up mental health assessments. METHODS: 254 club level collegiate student-athletes (18.2±1.4yrs, 150 female, 104 male) completed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) including the 22-item Post-Concussion Symptom Scale (PCSS), the Patient Reported Outcome Measurement Information System (PROMIS-29), and the Depression Anxiety Stress Scales (DASS-21). DSM-5 Anxiety symptoms were compared to the PCSS symptoms and an anxiety-related concussion symptom score was calculated. These along with the anxiety sub-scales for both the DASS-21 and PROMIS-29 were used for analysis. RESULTS: Participants were divided into 4 anxiety level groups based on norms from the DASS-21 (normal=36; mild=76; moderate=87; severe=28). There was a significant correlation (p<0.001) between Anxiety Cluster PCSS symptom score and DASS-21 anxiety subscale (r=.41) and PROMIS-29 Anxiety Sub-score (r=.44). The DASS-21 and PROMIS-29 were also significantly correlated (r=.64, p<0.001). There were significant group differences across the 4 DASS-21 anxiety levels for Anxiety Symptom Cluster (F(4, 226)=9.27, p<0.001) and the PROMIS-29 Anxiety subscale (F(4,223)=31.01, p<0.001). CONCLUSIONS: The significance from this data shows that the proposed symptom clusters that potentially pertain to anxiety symptoms are meaningfully related to higher scores on the DASS-21 and the PROMIS-29 anxiety related questions. Participants that demonstrated a higher overall concussion-related anxiety symptom score were more likely to exhibit more severe levels of anxiety suggesting that this cluster score could potentially screen individuals at risk for anxiety disorders thus providing a pathway to refer and provide resources and support.

Upping The Ante: Can Agility Performance Differentiate Previously Concussed From Healthy Controls?

Returning to sport or active duty has the potential to put athletes or service members at risk. Yet, post-concussion assessments primarily rely on subjective reporting or simple clinical tests - tasks that lack ecologic validity in comparison with sport or combat environments. Both environments may require fast-paced movements such as turning, which involves the integration of oculomotor and vestibular information, as well as cognitive control for execution. Testing anticipated and unanticipated turns during agility tasks performed at high speeds may provide a more valid test setting, and help to quantify differences between previously concussed and healthy persons performing more complex movement tasks. PURPOSE: To compare performance on unanticipated and anticipated agility tasks between previously concussed and healthy controls. METHODS: We tested agility performance, defined by peak turning velocity (yaw, °/s), in previously concussed and healthy controls in two participant samples: athletes (concussed n=5, control n=5) and a general population (concussed n=8, controls n=10). Athletes completed unanticipated turns cued by a light stimulus, and the general population completed anticipated turns using a modified Illinois Agility task (IAT). Peak turning velocity was extracted from a waist worn inertial sensor. Athlete and general population data were compared separately. Cohen’s d effect size was used to evaluate between-group differences due to small sample sizes. RESULTS: The concussed athletes (mean(SD); 239(46) °/s) turned slower than the control athletes (300(37) °/s; d = -1.45, large effect) completing unanticipated turns. In the general population performing anticipated turns, the concussed group (220(23) °/s) turned slower than the healthy controls (237(33) °/s; d = -0.57, medium effect). CONCLUSION: Findings suggest differences between groups in both samples, despite using different agility tasks. Moving forward, we plan to evaluate anticipated turns performance in an active military duty population. However, unanticipated turn tasks, which require a movement coupled in response to stimulus are an interesting area for future exploration. Supported by the Assistant Secretary of Defense for Health Affairs (#W81XWH-18-2-0049) and the Medical Research Foundation of Oregon.

Exploring Baseline Concussion-Assessment Performance in Adapted Wheelchair Sport Athletes.

With growing awareness of and advocacy for including individuals with disabilities in sport, implementation of concussion-assessment and -management strategies is warranted. Limited research is available on concussion assessment in adapted wheelchair sport athletes. To examine baseline symptom reporting, computerized neurocognitive testing, and a modified balance scoring system in adapted athletes. A secondary objective was to provide preliminary normative data for this population. Cross-sectional study. University athletic training room and computer laboratory. Twenty-one athletes (age = 22.1 ± 3.0 years) from 1 institution's collegiate adapted athletics program. Athletes completed baseline Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and the Wheelchair Error Scoring System (WESS) before the start of their respective seasons. Symptom reporting variables consisted of total symptoms, symptom severity scores, and baseline symptom factors (eg, vestibular-somatic, sleep arousal, cognitive-sensory, and affective). We analyzed ImPACT composite scores of verbal memory, visual memory, visual motor processing speed, and reaction time and impulse control to determine neurocognitive function. Balance performance was quantified using the WESS condition and overall errors. Compared with normative reference values, 17 (81%) of adapted athletes reported greater symptoms and 20 (95%) performed at or below average on at least 1 neurocognitive composite score. Mean errors on the WESS were 3.14 ± 2.9, with 81% committing ≥1 error. Sex differences were not present for symptoms, neurocognitive testing, or balance measures. Our findings provide context for baseline performance in adapted athletes and help to further develop the WESS as an assessment of balance in these athletes.

Return to Sport Following Adolescent Concussion: Epidemiologic Findings From a High School Population.

High school athletes sustaining a concussion require careful attention when determining return-to-sport (RTS) readiness. The purpose of this study was to determine epidemiological and RTS data of a large cohort of high school athletes who sustained 1 or more concussions. Records of 357 consecutive youth patients who sustained concussions and presented to a single health care system between September 2013 and December 2016 were reviewed. Demographic data, RTS, and concussion-related variables were obtained via chart review. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores at baseline and following concussions were performed by neuropsychologists. The average age at injury was 15.5 years (range, 14-18 years), 61.9% of patients were male, 6.7% reported a loss of consciousness, and 14.3% reported amnesia, requiring 30.4±23.3 days of recovery prior to RTS. The most common sport of injury was football (27.7%). There was a high incidence of previous concussion (33.1%), and 32 athletes sustained a recurrent concussion. A multivariate model demonstrated that females, players with a history of concussion, and those diagnosed in-clinic rather than in-game required increased time to RTS. Memory ImPACT scores were found to increase as players had recurrent concussions. Visual motor speed and reaction time scores decreased with recurrent concussions. [Orthopedics. 2020;43(4):e306-e310.].

Assessing the predictive value of primary evaluation with the Immediate Post-Concussion Assessment and Cognitive Test following head injury.

Concussions are a major public health concern, especially for high school and college student athletes. However, there are few prognostic metrics that can accurately quantify concussion severity in order to anticipate recovery time and symptom regression. The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) is a widely used neurocognitive assessment that can diagnose and track recovery from concussions. This study assesses whether initial ImPACT scores, collected within 48 hours of the injury, can predict persistence of concussion at follow-up. Results from 6912 ImPACT tests were compiled in 2161 unique student athletes, ages 12-22 years. The authors defined a novel metric, the Severity Index (SI), which is a summation of the number of standard deviations from baseline at the 80% CI for each of the 5 composite scores reported by ImPACT. Patients were binned into groups based on SI (0-3.99, 4-7.99, 8-11.99, 12+) and the relationships between SI groups, composite scores, symptom profiles, and recovery time were characterized using 1-way and 2-way ANOVAs and Kaplan-Meier plots. A logistic regression assessed the value of SI for predicting concussion at follow-up. Patients with a higher SI at diagnosis were more likely to still be concussed at their first follow-up (F3,2300 = 93.06; p < 0.0001). Groups with a higher SI also displayed consistently slower recovery over a 42-day period and were more likely to report symptoms in all 4 symptom clusters (Migraine, Cognition, Sleep, and Neuropsychiatric). When controlling for sex, age, number of previous concussions, days between assessments, and location, SI significantly increased the odds of being concussed at follow-up (OR 1.122, 95% CI 1.088-1.142; p < 0.001). This model showed good discrimination with an area under the curve of 0.74. SI is a useful prognostic tool for assessing head injury severity. Concussions with higher initial SI tend to last longer and have broader symptomatic profiles. These findings can help patients and providers estimate recovery based on similar ImPACT score profiles.

Association of time to initial clinic visit with prolonged recovery in pediatric patients with concussion.

No studies to date have investigated the role of early clinical care in time to recovery from concussion in a pediatric population. The purpose of this study was to investigate the role of clinic presentation timing (≤ 7 days [early] compared to 8-20 days [late] from injury) in concussion assessment performance and risk for prolonged recovery (> 30 days) in pediatric concussion. This study is a retrospective cross-sectional study from a concussion clinic between April 2016 and January 2019, including 218 children and adolescents with diagnosed concussion, separated based on clinic presentation timing following injury: early (≤ 7 days) and late (8-20 days). Outcomes were recovery time, Postconcussion Symptom Scale (PCSS), Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), Vestibular/Ocular Motor Screen (VOMS), and demographics, medical history, and injury information. A general linear model and chi-square analyses were used to assess differences between early and late presentation, along with logistic regression, to predict prolonged recovery (> 30 days). Those with early presentation reported higher symptoms on VOMS subtests (79%-85%) compared to those with late presentation (61%-78%), with the exception of near-point of convergence distance and visual motion sensitivity (VMS). The strongest predictor of prolonged recovery was number of days to first clinic visit (OR 9.8). Positive VMS (OR 5.18), history of headache/migraine (OR 4.02), and PCSS score (OR 1.04) were also predictive of prolonged recovery. Despite patients in the early presentation group presenting with more positive VOMS scores, the early presentation group recovered sooner than patients in the late presentation group. Even after controlling for vestibular dysfunction, history of headache or migraine, and total symptom severity, days to first visit remained the most robust predictor of recovery > 30 days. These findings suggest that early, specialized medical care and intervention for children and adolescents with recent concussion is associated with normal recovery time. Clinicians should educate children and parents on the potential importance of early treatment to improve the odds of positive outcomes following concussion.

Self-reported prior night’s sleep quantity on baseline symptom factors and computerized neurocognitive testing in high school athletes

Little is known regarding sleep and baseline concussion performance and symptoms in athletes. We explored the effects of self-reported prior night’s sleep quantity on baseline symptoms and computerized neurocognitive testing in high school athletes. A retrospective analysis of 958 high school athletes between the ages of 13–19 years was completed on Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) performance. Participants were categorized into two groups based on self-reported prior night’s sleep quantity: <8 h (n = 524; 55%) and ≥8 h (n = 434; 45%). Measures consisted of baseline total symptom score, symptom factors (vestibular-somatic, sleep-arousal, affective, and cognitive-sensory), and ImPACT composite scores (verbal and visual memory, visual-motor speed, reaction time, and impulse control). Significant differences were found on all baseline symptom factors (ps < .02) and total symptom scores (p < .001) with greater symptom reporting in the <8 h prior night’s sleep group. No group differences were observed between duration and composite scores of verbal memory (p = .49), visual memory (p = .94), visual-motor speed (p = .38), reaction time (p = .50), or impulse control (p = .81). High school athletes who report <8 h of sleep the night prior to baseline concussion testing reported greater symptoms across all symptom factors. Clinicians should consider inadequate sleep the night prior to concussion testing to ensure accurate, valid assessments, especially on symptom reporting scales.