Post-Concussion Symptom Scale Research Articles

Return-to-learn after sport-related concussion: does school level matter?

Return-to-learn (RTL) after sport-related concussion (SRC) is an important yet understudied topic. The authors sought to do the following: 1) describe patterns of RTL among athletes by school level (i.e., middle school, high school, college); and 2) evaluate the predictive value of school level on RTL duration. A retrospective, single-institution cohort study of adolescent and young adult athletes 12-23 years old who sustained an SRC between November 2017 and April 2022 and who presented to a multidisciplinary specialty concussion clinic was conducted. The independent variable was school level, trichotomized into middle school, high school, and college. Time to RTL was the primary outcome and was defined as days from SRC to return to any academic activities. ANOVA was used to compare RTL duration across school levels. A multivariable linear regression was performed to evaluate for predictive value of school level on RTL duration. Covariates included the following: sex, race/ethnicity, learning disorder, psychiatric conditions, migraines, family history of psychiatric conditions/migraines, initial Post-Concussion Symptom Scale score, and number of prior concussions. Of 1007 total athletes, 116 (11.5%) were in middle school, 835 (83.0%) were in high school, and 56 (5.6%) were in college. The mean RTL times (in days) were as follows: 8.0 ± 13.1 (middle school), 8.5 ± 13.7 (high school), and 15.6 ± 22.3 (college). One-way ANOVA showed a statistically significant difference between groups (F[2, 1007] = 6.93, p = 0.001). A Tukey post hoc test revealed a longer RTL duration in collegiate athletes when compared to middle school (p = 0.003) and high school (p < 0.001) athletes. Collegiate athletes had longer RTL duration compared to other school levels (β = 0.14, p < 0.001). There was no difference between middle school and high school athletes (p = 0.935). The subanalysis revealed a longer RTL duration in high school freshmen/sophomores (9.5 ± 14.9 days) when compared to juniors/seniors (7.6 ± 12.6 days; t = 2.05, p = 0.041), and being an older (junior/senior) high school athlete was predictive of shorter RTL duration (β = -0.11, p = 0.011). When examining patients who presented to a multidisciplinary sport concussion center, RTL duration was longer in collegiate athletes when compared to middle and high school athletes. Younger high school athletes had longer time to RTL compared to their older counterparts. This study provides insight into how varying scholastic environments may contribute to RTL.

329 Acute Cognitive Symptom Cluster Predicts Return-to-Learn Duration Following a Sport-Related Concussion

INTRODUCTION: Adolescents sustaining sport-related concussion (SRC) often experience difficulties with the return-to-learn (RTL) process. While initial symptom burden has predicted prolonged RTL, no studies have established a relationship between acute cognitive symptoms and RTL duration. METHODS: A retrospective single-institution cohort study of adolescent athletes 12-23-years-old evaluated within 5 days of a diagnosed SRC from 11/2017-10/2020 was conducted. Athletes missing cognitive symptom ratings and RTL data were excluded. The primary exposure variable was cognitive symptom score, consisting of 4 symptoms for a total possible score of 24. Primary and secondary outcomes were time-to-RTL and total length-of-care, respectively. Multivariable Cox proportional hazards modeling was used to assess the effect of Cognitive Symptom Ratio (CSR), defined as cognitive symptom score divided by Post-Concussion Symptom Scale (PCSS) score, on RTL duration. RESULTS: Of 653 athletes evaluated within 5 days of their concussion, 343 patients were included in the final cohort. Athletes reported a median initial PCSS score of 21 (IQR 6-37) and a median cognitive symptom score of 4 (IQR 0-9). Most patients endorsed some degree of “difficulty concentrating” (n = 212, 61.3%). Median CSR was 0.18 (IQR 0.00-0.27). On multivariable regression analysis, higher CSR was associated with prolonged RTL duration (HR 0.30, 95% CI 0.13-0.69, p = .004). When initial PCSS was added to the model, the previously significant association between CSR and RTL was no longer significant (HR 0.67, 95% CI 0.29-1.59, p = .367). When dichotomized based on frequency distribution, a higher proportion of low CSR patients achieved RTL by 7 days post-injury (82.2% vs. 69.9%, p = .007), a difference not seen at 14 days (92.2% vs. 87.3%, p = .133). CONCLUSIONS: Acute cognitive symptom scores can predict who may be at increased risk for prolonged RTL and which patients with normal PCSS scores may experience difficulties once resuming school activities.

Predicting early versus late recovery from sport-related concussion using decision tree analysis.

Accurately predicting early (≤ 14 days) versus typical (15-27 days) or delayed (≥ 28 days) recovery from sport-related concussion (SRC) may allow for improved resource utilization and precision in planning and carrying out rehabilitation. In this study, the authors sought to develop an algorithm that enables accurate differentiation of recovery periods and duration after SRC. The authors hypothesized that data regarding initial symptom burden as quantified by a Post-Concussion Symptom Scale (PCSS) score, time to presentation, and number of prior concussions would be the most useful for analyzing predictive factors for concussion recovery duration. A retrospective case-control study was conducted to assess the primary outcome of days to clinical recovery following SRC in pediatric patients. Data from patients 12-18 years old presenting within 28 days of injury to an SRC clinic between November 11, 2017, and October 10, 2020, were analyzed. Patients with positive evidence of injury on head imaging or incomplete records were excluded. The primary outcome was duration of clinical recovery, grouped as early (≤ 14 days), typical (15-27 days), or delayed (≥ 28 days). Recovery was defined as follows: 1) symptom resolution or return to baseline, or 2) initiation of graduated return to play. CHAID (chi-square automatic interaction detection) analysis was used to optimize a decision tree based on 16 input factors, including age, sex, initial PCSS score, time to clinic presentation, number of prior concussions, and presence of defined symptom clusters. The cohort was randomized into training (70%) and test (30%) samples for algorithm validation. A total of 493 patients met the inclusion criteria (mean age 15.7 ± 1.5 years, 68.2% male, 70.0% White). The median time to presentation was 5 days (IQR 2-10 days). Most patients (52.3%) recovered within 14 days of injury, 21.5% recovered within 15-27 days, and 26.2% had a recovery period of 28 days or longer. The variables most predictive of recovery were initial PCSS score (cutoffs ≤ 6, 7-28, or ≥ 29), time to presentation (≤ 7 vs > 7 days), or prior concussions (0 vs ≥ 1). The model accurately discriminated between early versus typical or delayed recovery duration groupings (area under the curve 0.80, Youden index 0.44), and correctly classified > 90% of patients who recovered early. This novel three-factor predictive tool enabled accurate discrimination of early versus typical or delayed SRC recovery to better allocate resources, counsel patients, and make timely referrals.

411 The Cost of a Single Sport-Related Concussion in Adolescent Athletes

INTRODUCTION: Despite the ubiquity of sport-related concussions (SRC), the healthcare costs incurred by a single SRC are unknown. METHODS: We conducted a retrospective cohort study examining concussed athletes ages 12-23 who presented to a multi-disciplinary concussion center between 11/2017-10/2020. Athletes presenting for treatment more than 10 days post-injury and those sustaining &gt;1 concussion during the study period were excluded. The primary outcome was the direct cost of the concussion care episode, derived by matching visit and imaging dates with institution inflation-adjusted cost data. A multivariable linear regression examined predictors of total concussion care costs. Independent variables included relevant demographics, medical/family medical history, injury characteristics, and initial Post-Concussion Symptom Scale (PCSS) score. RESULTS: In total, 710 athletes were included. Median age was 16.1 years (IQR = 15.1-17.2; 66.5% male). Median initial PCSS was 26 (IQR = 6-39). Sports with the highest prevalence of SRC were football (n = 261, 36.8%), soccer (n = 102, 14.4%) and basketball (n = 97, 13.7%). The mean cost of an SRC care episode was $822 (SD = $1,233). The mean costs associated with a softball-related concussion were highest (M = $2,372, SD = $4,707), followed by basketball (M = $1,012 SD = $1,863), lacrosse (M = $924, SD = $1,101), and football (M = $814, SD = $993). A multivariable linear regression showed that higher initial PCSS (b = 4.87, 95% CI = 1.32-8.42, p = .007), number of prior concussions (b = 118.79, 95% CI = 42.71-194.88, p = .002), and having an emergency department/urgent care visit (b = 670.20, 95% CI = 497.66-842.74) were significant predictors of greater cost. CONCLUSIONS: With a mean value of $822 per SRC, healthcare costs associated with this common injury total over $3 billion annually in the U.S. Greater costs were associated with higher initial symptom burden, prior concussion history, and emergency department/urgent care utilization. A nuanced understanding of cost-driving factors associated with SRC is a prerequisite to understanding cost-effectiveness of prevention and treatment.

Investigation of Factors Contributing to Racial Differences in Sport-Related Concussion Outcomes

Following sport-related concussion (SRC), early studies have demonstrated racial differences in time to clinical recovery; however, these differences have not been fully explained. We sought to further explore these associations by considering possible mediating/moderating factors. Data from patients aged 12-18 years diagnosed with SRC from November 2017 to October 2020 were analyzed. Those missing key data, lost to follow-up, or missing race were excluded. The exposure of interest was race, dichotomized as Black/White. The primary outcome was time to clinical recovery (days from injury until the patient was either deemed recovered by an SRC provider or symptom score returned to baseline or zero.) RESULTS: A total of 389 (82%) White and 87 (18%) Black athletes with SRC were included. Black athletes more frequently reported no SRC history (83% vs. 67%, P= 0.006) and lower symptom burden at presentation (median total Post-Concussion Symptom Scale 11 vs. 23, P < 0.001) than White athletes. Black athletes achieved earlier clinical recovery (hazard ratio [HR]= 1.35, 95% CI 1.03-1.77, P=0.030), which remained significant (HR= 1.32, 95% CI 1.002-1.73, P= 0.048) after adjusting for confounders associated with recovery but not race. A third model adding the initial Post-Concussion Symptom Scale score nullified the association between race/recovery (HR=1.12, 95% CI 0.85-1.48, P= 0.410). Adding prior concussion history further reduced the association between race/recovery (HR= 1.01, 95% CI 0.77-1.34, P= 0.925). Overall, Black athletes initially presented with fewer concussion symptoms than White athletes, despite no difference in time to clinic. Black athletes achieved earlier clinical recovery following SRC, a difference explained by differences in initial symptom burden and self-reported concussion history. These crucial differences may stem from cultural/psychologic/organic factors.

Post-Concussion Symptoms, Cognition and Brain Connectivity in an Australian Undergraduate Population: A Quantitative Electroencephalography Study

An estimated 99 in 100,000 people experience a traumatic brain injury (TBI), with 85% being mild (mTBI) in nature. The Post-Concussion Symptom Scale (PCSS), is a reliable and valid measure of post-mTBI symptoms; however, diagnostic specificity is challenging due to high symptom rates in the general population. Understanding the neurobiological characteristics that distinguish high and low PCSS raters may provide further clarification on this phenomenon. To explore the neurobiological characteristics of post-concussion symptoms through the association between PCSS scores, brain network connectivity (using quantitative electroencephalography; qEEG) and cognition in undergraduates. high PCSS scorers will have (1) more network dysregulation and (2) more cognitive dysfunction compared to the low PCSS scorers. A sample of 40 undergraduates were divided into high and low PCSS scorers. Brain connectivity was measured using qEEG, and cognition was measured via neuropsychological measures of sustained attention, inhibition, immediate attention, working memory, processing speed and inhibition/switching. Contrary to expectations, greater frontoparietal network dysregulation was seen in the low PCSS score group (p = 0.003). No significant difference in cognitive dysfunction was detected between high and low PCSS scorers. Post-hoc analysis in participants who had experienced mTBI revealed greater network dysregulation in those reporting a more recent mTBI. Measuring post-concussion symptoms alone is not necessarily informative about changes in underlying neural mechanisms. In an exploratory subset analysis, brain network dysregulation appears to be greater in the early post-injury phase compared to later. Further analysis of underlying PCSS constructs and how to measure these in a non-athlete population and clinical samples is warranted.

A systematic review and meta-analysis of factors influencing ImPACT concussion testing in high school and collegiate athletes with self-reported ADHD and/or LD.

Sport concussion is a common injury, and athletes with attention-deficit/hyperactivity disorder (ADHD) and/or learning disorder (LD) are at increased risk and require specialized attention in clinical settings. Although systematic reviews of the relationship between ADHD/LD and concussion are reported in the literature, these reviews do not include quantitative syntheses. Additionally, no reviews have focused on the most commonly utilized concussion assessment, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). The current review provides an update of sport concussion assessment in athletes with ADHD and/or LD from 2000 to 2021 on these topics: baseline and postconcussion performance on ImPACT, baseline and postconcussion symptom reporting using the Postconcussion Symptom Scale, invalid baseline classification on ImPACT, and self-reported history of concussion. Meta-analyses were conducted on baseline ImPACT performance, symptom reporting, invalid baseline classification, and concussion rates. Thirty-four studies were included in systematic review and 19 were included in meta-analyses. Decreased baseline performance was found for athletes with ADHD (trivial to small effects), LD (small-to-medium effects), and ADHD/LD (small-to-medium effects). Increased baseline symptom reporting was found for athletes with ADHD (small effect). Increased odds of invalid baseline performance (trivial effect) and self-reported concussion history (small effect) were found in ADHD. These results provide the first quantitative synthesis of the literature in this area. It is recommended that future research further examines these topics in athletes with LD and co-occurring ADHD/LD (given the focus on ADHD), as well as the effects that all of these conditions may have on concussion recovery and return-to-play decision-making. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Characterizing the Network Structure of Post-Concussion Symptoms.

Assessment of post-concussion symptoms is implemented at secondary, post-secondary, and professional levels of athletics. Network theory suggests that disorders can be viewed as a set of interacting symptoms that amplify, reinforce, and maintain one another. Examining the network structure of post-concussion symptoms may provide new insights into symptom comorbidity and may inform targeted treatment. We used network analysis to examine the topology of post-concussion symptoms using the Post-Concussion Symptom Scale (PCSS) in high school athletes with recent suspected sport-related concussion. Using a cross-sectional design, the network was estimated from Post Concussion Symptom Scale scores from 3,292 high school athletes, where nodes represented symptoms and edges represented the association between symptoms. Node centrality was calculated to determine the relative importance of each symptom in the network. The network consisted of edges within and across symptom domains. "Difficulty concentrating" and "dizziness" were the most central symptoms in the network. Although not highly central in the network, headaches were the highest rated symptom. The interconnectedness among symptoms supports the notion that post-concussion symptoms are interrelated and mutually reinforcing. Given their central role in the network, "difficulty concentrating" and "dizziness" are expected to affect the activation and persistence of other post-concussion symptoms. Interventions targeting difficulties with concentration and dizziness may help alleviate other symptoms. Our findings could inform the development of targeted treatment with the aim of reducing overall symptom burden. Future research should examine the trajectory of post-concussion symptom networks to advance the clinical understanding of post-concussive recovery.

Symptom Provocation Following Post-concussion Computerized Neurocognitive Testing and Its Relationship to Other Clinical Measures of Concussion.

The objective of this study was to document the prevalence of post-computerized neurocognitive test (post-CNT) increases in symptoms in athletes with sport-related concussion, and to examine the effect of post-CNT symptom increases on concussion neurocognitive and vestibular/ocular motor clinical outcomes. This was a retrospective analysis of medical records from a concussion specialty clinic. Two hundred and three athletes (M = 16.48 ± 1.97years; 44% [90/203] female) completed a clinical visit for concussion within 30days of injury (M = 7.73 ± 5.54days). Computerized neurocognitive testing (the Immediate Post-concussion Assessment and Cognitive Testing: ImPACT), the Post-Concussion Symptom Scale (PCSS), and the Vestibular Ocular Motor Screening (VOMS) were the main outcome measures for the current study. Sixty-nine percent (141/203) of the sample did not report significant increases in PCSS scores following post-concussion CNT and were classified into a No Provocation (NO PROV) group. Thirty-one percent (62/203) of participants did report a significant increase in symptoms following post-concussion CNT and were classified into a Provocation (PROV) group. Neurocognitive performance was similar between groups. However, the PROV group reported significantly higher scores on the VOMS symptom items than the NO PROV group. The majority of adolescent athletes can complete a post-concussion CNT without experiencing significant increases in concussion symptoms. Individuals that report symptom increases from completing a post-concussion CNT are more likely to exhibit increased vestibular/ocular motor symptoms. These findings underscore the relationship between the clinical findings from both CNT and vestibular/ocular motor measures following concussion.

School performance in youth after a concussion.

This study aimed to identify school problems and levels of cognitive activity in youths aged 5-18 years with a concussion during the recovery stages of return to school (RTS). In a prospective cohort, participants completed in-person assessments at three time points: First Visit Post-injury, Symptom Resolution Visit, and Follow-Up Visit. These time points varied based on the participants' recovery progress. The post-concussion symptom scale (PCSS) and a cognitive activity scale were completed every 2 days until symptom resolution was achieved. Participants and their parents completed a school questionnaire detailing how their concussion had impacted their school learning/performance and their level of concern about their injury as well as the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Sixty-three percent (N = 44/70) of participants returned to school by the First Visit Post-injury (average 7.7 days following injury), and of these, 50% (N = 22) were experiencing school problems. Sixty-five participants (out of 70) returned to school at the Follow-Up Visit, and of these, 18% reported school problems. There was a significant difference in the school problems reported by parents and youth. At the First Visit Post-injury, the youth reported more problems (p = 0.02), and the In-Person Symptom Resolution Visit with parents reported more problems (p = 0.01). The cognitive activity score increased, while the PCSS score decreased from RTS Stage 1 to Stage 5. This study identified that 50% of youth experienced school problems at the First Visit Post-injury, whereas only 18% reported school problems at the Follow-Up Visit. There is a significant difference in the perception of school problems reported by youth and their parents at different stages of recovery. The amount and complexity of cognitive activity increased with decreasing symptoms and increasing RTS stage. Findings can guide youth with a concussion and their parents in supporting a cautious return to school with accommodations. Healthcare providers and researchers can use this knowledge to better support youth in their return to school and understand the importance of gathering information from youth and their parents to gain the best insight into recovery.

Severity and correlates of brain fog in people with traumatic brain injury.

Brain fog is one symptom that has been underexplored in traumatic brain injury (TBI). We explored the cognitive and affective correlates of brain fog in people with symptomatic mild TBI (n = 15), moderate-to-severe TBI (n = 15), and a healthy control group (n = 16). Measures across the studies assessed "brain fog" (Mental Clutter Scale), objective cognition (Useful Field of View® and Cogstate Brief Battery®), post-concussive symptoms (Post-Concussion Symptom Scale), and depressive symptoms (Profile of Moods Scale). Brain fog was higher in symptomatic mild TBI and moderate-to-severe TBI compared with healthy controls. Greater brain fog corresponded to greater depressive symptoms in symptomatic mild TBI. Greater brain fog corresponded to poorer episodic memory and working memory in moderate-to-severe TBI. Brain fog appears to reflect challenges in recovery, including depressive symptoms and worse cognitive function. Screening for brain fog might be worthwhile in people with brain injuries.

Concussion Recovery in Children and Adolescents: A Retrospective Study

Concussion is a common injury among children and adolescents, with a growing body of literature supporting a variety of diagnostic and treatment modalities. Recovery is variable and depends on multiple factors that can be evaluated through a clinic visit: a thorough history, physical examination, and use of the Post-concussion Symptom Scale (PCSS). The purpose of this study was to evaluate factors associated with overall recovery from concussion in children and adolescents in the clinical setting. It was hypothesized that the presence of 1 of a number of pre- or postinjury characteristics will be associated with poor concussion recovery. Case-control study; Level of evidence, 3. We conducted a retrospective chart review of adolescents and children aged 6 to 17 years with a diagnosis of concussion who were evaluated at a single sports medicine center between January 2015 and December 2019. Cases were categorized into recovered (PCSS <7) and poorly recovered (PCSS ≥7) cohorts based on the last PCSS scores during clinical follow-ups for concussion management. Of the 162 charts reviewed, 110 cases met inclusion criteria. Significant statistical differences were found between the recovered and poorly recovered cohorts regarding mean days from injury to last clinic visit, previous migraine diagnosis, and emergency room (ER) visit before the first clinic visit (P < .01 for all). Binary logistic regression analysis revealed that the most predictive factors associated with poorer recovery were having an ER visit before the first clinic evaluation (P = .01) and previous migraine diagnosis (P = .04). While many factors may contribute to overall recovery from concussion in pediatric populations, our study suggested that a history of migraine and an ER visit before clinic evaluation may be associated with poor recovery of concussive symptoms.

Young Pediatric Buffalo Concussion Exam Identified Physiological Dysfunction in an Adolescent after Repetitive Concussions

<h3>Research Objectives</h3> To describe the utility of a brief pediatric physical exam, the Young Pediatric Buffalo Concussion Physical Exam (YPBCPE), in an adolescent after hockey-related concussions. <h3>Design</h3> Case Report. <h3>Setting</h3> Academically-affiliated research laboratory. <h3>Participants</h3> A 16–year old male with a history of two concussions sustained within the past 12 months while playing hockey at the school/travel level was examined 10-weeks post-injury. One 15-minute, in-person visit was completed. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> The Post-Concussion Symptom Scale (PCSS) was used to examine the perceived severity (0 being no symptoms and 6 being the highest severity) of concussion-related symptoms. The YPBCPE was used to identify the presence of persistent post-concussive signs and symptoms (PPCS). <h3>Results</h3> The patient reported no (0) balance symptoms and mild (2) visual problems on the PCSS. On the YPBCPE, the patient experienced lightheadedness when standing up from a supine position during the 2-minute supine to 1-minute stand test. Optic nerve exam revealed a reduction in visual fields. Dizziness and sustained nystagmus were observed when horizontal smooth pursuits were tested. Testing near point convergence revealed a prolonged break and recovery at 9 cm and 16 cm, respectively. The patient maintained his balance for < 10 seconds during the single-leg (eyes closed) stance. <h3>Conclusions</h3> While self-report questionnaires provide meaningful information regarding symptoms, field-expedient physical exams help to more objectively establish ongoing physiological dysfunction in youth with PPCS, which may guide treatment. Resolution of abnormal findings also assists in more reliably clearing youth to return to activities. Currently, no markers exist to quantify PPCS in children. The YPBCPE could be valuable in identifying therapies to aid youth with PPCS who report few symptoms on self-report measures. <h3>Author(s) Disclosures</h3> The authors declare no conflict of interest.

The Effect of Aerobic Exercise on Recovery in Adolescents who Report Emotional and Cognitive Symptoms after Sport-Related Concussion

<h3>Research Objectives</h3> Aerobic exercise speeds recovery from sport-related concussion (SRC) and reduces the incidence of prolonged symptoms; however, evidence for emotional and cognitive symptom recovery among this population is limited. This study determined whether aerobic exercise following SRC improved recovery in adolescents who reported emotional and cognitive symptoms. <h3>Design</h3> Meta-analysis of two published randomized control trials. <h3>Setting</h3> Four sports medicine clinics specializing in concussion management. <h3>Participants</h3> Male and female adolescents (13-18 years, n=212, 59% male) who were diagnosed with SRC within ten days of injury and reported emotional or cognitive symptoms on the Post-Concussion Symptom Scale (PCSS) or Post-Concussion Symptom Inventory (PCSI). <h3>Interventions</h3> Participants were assigned to individualized aerobic exercise (n=109) or to a placebo-like stretching program (n=103). <h3>Main Outcome Measures</h3> Recovery from SRC, defined as a participant having no concussion-like symptoms, a normal physical examination, and a return to normal exercise tolerance. <h3>Results</h3> A fixed-effects meta-analysis determined the probability of recovery between aerobic vs. stretching exercise. Participants with high emotional (≥1/24), low emotional (=0/24) and low cognitive (≤10/30) symptom scores had a higher probability of recovering when prescribed aerobic exercise, respectively (61% p=0.028, 60% p=0.030, 47%, p=0.025). However, results were inconclusive regarding recovery in those with high cognitive (>10/30) symptoms when prescribed aerobic exercise (p=0.175). <h3>Conclusions</h3> Our data suggest that participants with emotional symptoms and with low cognitive symptom burden benefited from aerobic exercise more than from stretching. Clinicians ideally should manage SRC based on individual clinical profiles and should recommend aerobic exercise for patients with significant emotional symptoms. Patients with high cognitive symptoms also benefit from aerobic exercise but appear to need specialized intervention. <h3>Author(s) Disclosures</h3> Authors have no disclosures.

The Post-Concussion Symptom Scale: Normative Data for Adolescent Student-Athletes Stratified by Gender and Preexisting Conditions

Background: The Post-Concussion Symptom Scale (PCSS) is a self-report questionnaire measuring symptoms that commonly occur after a concussion; however, these symptoms are nonspecific and can be related to co-occurring orthopaedic injuries (eg, cervical strain) or patient characteristics and preexisting conditions, even in the absence of a recent injury. As such, clinicians may have difficulty determining whether symptom elevations are attributable to a recent concussion as opposed to a confounding injury or a preexisting condition, which may be especially difficult when preinjury baseline symptom data are unavailable. Purpose: This study aimed to further validate the 4-factor model of the PCSS (ie, cognitive, sleep-arousal, physical, and affective symptoms) with adolescent student-athletes and provide normative reference data for each factor and the total score, stratified by gender and preexisting health conditions. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Participants were 9358 adolescent student-athletes who completed the PCSS during a preseason baseline evaluation (mean age, 14.9 years; SD, 1.3 years [range, 13-18 years]; 49.3% boys). The 4-factor model of the PCSS was tested for the full sample and separately for boys and girls using confirmatory factor analysis. Symptom severity percentiles were created for the PCSS total score and each factor, stratified by gender and preexisting conditions (ie, attention-deficit/hyperactivity disorder, mental health history, headache/migraine history, learning disability/dyslexia, academic problems, and concussion history). Results: The 4-factor model of the PCSS replicated in the full sample (comparative fit index [CFI] = 0.959) and in both gender groups (boys: CFI = 0.961; girls: CFI = 0.960). The total PCSS score at the 84th percentile varied by preexisting conditions as follows: healthy participants = 8, attention-deficit/hyperactivity disorder = 18, mental health history = 26, headache/migraine history = 18, learning disability = 19, and academic problems = 17. On all PCSS subscales, participants with a mental health history had the highest scores, and high scores were associated with having >1 preexisting condition. Girls had higher scores than boys for each stratification. Conclusion: The 4-factor model of the PCSS replicates for adolescent student-athletes. Gender, number of preexisting conditions, and mental health history are important factors to account for when interpreting PCSS symptom severity. The normative data provided herein could assist clinicians in determining whether an adolescent student-athlete is presenting with persistent postconcussion symptoms or a typical symptom experience based on their gender and personal health history.

Characterizing Symptoms Before and Following Concussion in Professional Hockey.

Examine SCAT5 baseline and acute symptom subscales in professional hockey players. Longitudinal case-control. Preseason medical evaluations and suspected concussion evaluations. NHL/AHL players were given the NHL-modified SCAT5 before the 2018-2019 season (n = 1924). During the season, English-speaking players evaluated within 1 day of injury and diagnosed with concussion (n = 140) were compared with players evaluated for possible concussion, but not given a concussion diagnosis (n = 174). Concussion diagnosis and demographic characteristics. Postconcussion Symptoms Scale (PCSS) items were subdivided into affective/emotional, cognitive, somatic/physical, sleep, and headache subscales. Cognitive (13%), somatic/physical (10%), sleep (26%), affective (18%), and headache (6%) symptoms were reported by players at baseline. Concussed players reported more acute symptoms than active controls on each of the subscales (all P's < 0.001). Players who underwent a suspected concussion evaluation were more likely to be diagnosed with concussion if they reported affective/emotional symptoms at baseline (P < 0.001). Postinjury cognitive (P < 0.001), somatic/physical (P < 0.001), and headache (P < 0.001) symptoms best differentiated concussed players and active controls. Player reports of increased cognitive difficulties, somatic/physical difficulties, and headache were most associated with concussion diagnosis at the acute evaluation. An abbreviated "acute" PCSS that includes only headache, cognitive, and/or physical symptoms may be useful for diagnostic purposes when evaluation time is limited. Approximately 2% of players reported significantly elevated affective/emotional symptoms at baseline and report of affective/emotional symptoms at baseline was associated with an increased likelihood of concussion diagnosis among players referred for a suspected concussion evaluation.

Cognitive and Behavioral Outcomes in Male and Female NCAA Soccer Athletes across Multiple Years: A CARE Consortium Study.

The purpose of this study was to determine changes in neurocognitive, psychosocial, and balance functioning in collegiate male and female soccer players across three consecutive years of baseline testing compared with a control group of noncontact athletes. Generalized estimating equations were used to compare changes in annual, preseason baseline measures of neurocognitive function, neurobehavioral and psychological symptoms, and postural stability between collegiate soccer players ( n = 75; 51 [68%] female soccer players) and noncontact athletes ( n = 210; 133 [63%] female noncontact athletes) across three consecutive years. Among all participants, the group-time interaction was not significant for any outcome measures. Overall, soccer players reported lower (better) Brief Symptom Inventory 18 Depression ( P = 0.004, Exp(B) = 0.36, 95% confidence interval [CI] = 0.18-0.73), Global Severity Index ( P = 0.006, Exp(B) = 0.53, 95% CI = 0.33-0.84), and Post-Concussion Symptom Scale Symptom Severity ( P < 0.001, Exp(B) = 0.45, 95% CI = 0.22-0.95) scores than noncontact athletes. No other outcome measures were different between soccer players and noncontact athletes. Among collegiate athletes, soccer players report similar or better psychosocial functioning and symptom scores than noncontact athletes. Importantly, neurocognitive functioning, neurobehavioral and psychological symptoms, and postural stability do not worsen over time in collegiate soccer players relative to their noncontact counterparts. Our findings suggest that despite possible exposure to repetitive head impacts, collegiate soccer players do not exhibit changes in observable function and symptoms across multiple seasons.

A diagnostic, test-accuracy study to evaluate the ability of the Eye Guide Visual Tracking System and the Post-Concussion Symptom Scale to diagnose mild TBI and predict protracted recovery

Abstract Mild traumatic brain injury (mTBI) is the most common type of traumatic brain injury (TBI), and 100–300 individuals per every 100 000 seek medical care for mTBI annually. The Eye Guide is a portable device that evaluates oculomotor function. This device has promising potential to detect trauma-related neurological deficits that are otherwise undetected by a non-contrast computed tomography scan, the current gold standard. However, to our knowledge, a study has yet to be conducted that evaluates its ability to detect mTBIs specifically. By contrast, the Post-Concussion Symptom Scale (PCSS) is a 22-item, self-reported symptom survey that has become one of the most trusted tools in evaluating mTBI-related sequelae. Although this scale has been well validated in adolescent athletes, there is a notable lack of studies defining its clinical utility in adults with non-sports-related trauma. Patients with mTBI are expected to have detectable alterations in the PCSS score and the Eye Guide visual tracing. Thus, this study aims to determine each tool’s diagnostic accuracy in detecting mTBI and prognostic accuracy in predicting a protracted recovery in our patient population. Additionally, for both tools, we seek to establish cut-off values for future clinical decision-making in non-athlete, adult populations. A prospective, observational cohort test-accuracy study will be conducted in two clinics that form part of the ValleSalud Clinic Network in Cali, Colombia. Both are Level III referral trauma centers. The sensitivity, specificity and positive predictive value of both the Eye Guide and PCSS tests in diagnosing mTBI and predicting protracted recovery will serve as primary outcomes of the study. Additionally, the area under the curve analyses will be undertaken to determine the optimal sensitivity and specificity cut-offs for each test. The ground truth labels will be the diagnosis of mTBI by neurological examination as evaluated by an experienced neurosurgeon and recovery at 1 month post-injury according to the Extended Glasgow Outcome Scale. This study will follow the principles set forth by the Declaration of Helsinki.

The effects of augmenting traditional rehabilitation with audio biofeedback in people with persistent imbalance following mild traumatic brain injury.

Complaints of non-resolving imbalance are common in individuals with chronic mild traumatic brain injury (mTBI). Vestibular rehabilitation therapy may be beneficial for this population. Additionally, wearable sensors can enable biofeedback, specifically audio biofeedback (ABF), and aid in retraining balance control mechanisms in people with balance impairments. In this study, we described the effectiveness of vestibular rehabilitation therapy with and without ABF to improve balance in people with chronic mTBI. Participants (n = 31; females = 22; mean age = 40.9 ± 11 y) with chronic (>3 months) mTBI symptoms of self-reported imbalance were randomized into vestibular rehabilitation with ABF (n = 16) or without ABF (n = 15). The intervention was a standard vestibular rehabilitation, with or without ABF, for 45 min biweekly for 6 weeks. The ABF intervention involved a smartphone that provided auditory feedback when postural sway was outside of predetermined equilibrium parameters. Participant's completed the Post-Concussion Symptom Scale (PCSS). Balance was assessed with the sensory organization test (SOT) and the Central Sensorimotor Integration test which measured sensory weighting, motor activation, and time delay with sway evoked by surface and/or visual surround tilts. Effect sizes (Hedge's G) were calculated on the change between pre-and post-rehabilitation scores. Both groups demonstrated similar medium effect-sized decreases in PCSS and large increases in SOT composite scores after rehabilitation. Effect sizes were minimal for increasing sensory weighting for both groups. The with ABF group showed a trend of larger effect sizes in increasing motor activation (with ABF = 0.75, without ABF = 0.22) and in decreasing time delay (with ABF = −0.77, without ABF = −0.52) relative to the without ABF group. Current clinical practice focuses primarily on sensory weighting. However, the evaluation and utilization of motor activation factors in vestibular rehabilitation, potentially with ABF, may provide a more complete assessment of recovery and improve outcomes.

Responsiveness of the Post-Concussion Symptom Scale to Monitor Clinical Recovery After Concussion or Mild Traumatic Brain Injury.

Background:The Post-Concussion Symptom Scale (PCSS) is used to assess the number and intensity of symptoms after a concussion/mild traumatic brain injury. However, its responsiveness to monitor clinical recovery has yet to be determined.Purpose:To evaluate the responsiveness of the PCSS to change and longitudinal validity in patients with persistent postconcussive symptoms as well as to explore the responsiveness of other clinical outcome measures to monitor recovery of physical symptoms in patients with persistent postconcussive symptoms.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:Patients with persistent symptoms after a concussion (N = 109) were evaluated using self-reported questionnaires at baseline and after a 6-week rehabilitation program. The program consisted of an individualized symptom-limited aerobic exercise program combined with education. Questionnaires included the PCSS, Neck Disability Index (NDI), Headache Disability Inventory (HDI), Dizziness Handicap Inventory (DHI), and Numeric Pain Rating Scale (NPRS) related to 1) neck pain and 2) headache. Internal responsiveness was evaluated using the effect size (ES) and standardized response mean (SRM), and external responsiveness was determined with the minimal clinically important difference (MCID) calculated using a receiver operating characteristic curve. The global rating of change was used as the external criterion. Pearson correlations were used to determine the longitudinal validity.Results:The PCSS was highly responsive (ES and SRM, >1.3) and had an MCID of 26.5 points (of 132) for the total score and 5.5 (of 22) for the number of symptoms. For longitudinal validity, low to moderate correlations were found between changes in PCSS and changes in NDI, HDI, and DHI. The NDI, HDI, DHI, and NPRS were also highly responsive (ES and SRM, >0.8).Conclusion:All questionnaires including the PCSS were highly responsive and can be used with confidence by clinicians and researchers to evaluate change over time in a concussion population with persistent symptoms.