Abstract
Background
Symptom resolution is a key marker in determining fitness for return to activity following concussion, but in some cases, distinguishing persistent symptoms due to concussion versus symptoms related to other factors can be challenging.
Objective
To determine base rates of postconcussional syndrome (PCS) diagnostic categorization in healthy cadets and student athletes with no recent concussion.
Methods
13,009 cadets and 21,006 student athletes completed baseline preseason testing. After inclusion/exclusion criteria were applied, the final sample included 12,039 cadets [9123 men (75.8%); 2916 women (24.2%)] and 18,548 student athletes [10,192 men (54.9%); 8356 women (45.1%)]. Participants completed the Sport Concussion Assessment Tool–3rd Edition (SCAT3) symptom evaluation as part of baseline preseason testing. The PCS diagnostic categorization was classified by the International Classification of Diseases, 10th Revision (ICD-10) symptom criteria for PCS.
Results
In the absence of recent concussion, subgroups of cadets (17.8% of men; 27.6% of women) and student athletes (11.4% of men; 20.0% of women) reported a cluster of symptoms that would meet the ICD-10 symptom criteria for PCS. Participants with insufficient sleep and/or preexisting conditions (e.g., mental health problems), freshmen cadets, and cadets at the U.S. Coast Guard Academy and at the U.S. Air Force Academy (freshmen were tested during basic cadet training) were more likely to report a cluster of symptoms that would meet the ICD-10 symptom criteria for PCS.
Conclusion
The ICD-10 symptom criteria for PCS can be mimicked by preexisting conditions, insufficient sleep, and/or stress. Findings support person-specific assessment and management of symptoms following concussion.
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References
McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838–47.
Harmon KG, Clugston JR, Dec K, et al. American medical society for sports medicine position statement on concussion in sport. Br J Sports Med. 2019;53(4):213–25.
Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for disease control and prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018;172(11):e182853.
Makdissi M, Schneider KJ, Feddermann-Demont N, et al. Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. Br J Sports Med. 2017;51(12):958–68.
Iverson GL, Lange RT. Post-concussion syndrome. In: The little black book of neuropsychology. Springer; 2011. p. 745–63.
Broshek DK, De Marco AP, Freeman JR. A review of post-concussion syndrome and psychological factors associated with concussion. Brain Inj. 2015;29(2):228–37.
Iverson GL. Network analysis and precision rehabilitation for the post-concussion syndrome. Front Neurol. 2019;10:489.
Bailey CM, Samples HL, Broshek DK, et al. The relationship between psychological distress and baseline sports-related concussion testing. Clin J Sport Med. 2010;20(4):272–7.
Mihalik JP, Lengas E, Register-Mihalik JK, et al. The effects of sleep quality and sleep quantity on concussion baseline assessment. Clin J Sport Med. 2013;23(5):343–8.
Iverson GL, Silverberg ND, Mannix R, et al. Factors associated with concussion-like symptom reporting in high school athletes. JAMA Pediatr. 2015;169(12):1132–40.
Asken BM, Snyder AR, Smith MS, et al. Concussion-like symptom reporting in non-concussed adolescent athletes. Clin Neuropsychol. 2017;31(1):138–53.
Asken BM, Snyder AR, Clugston JR, et al. Concussion-like symptom reporting in non-concussed collegiate athletes. Arch Clin Neuropsychol. 2017;32(8):963–71.
Cottle JE, Hall EE, Patel K, et al. Concussion baseline testing: preexisting factors, symptoms, and neurocognitive performance. J Athl Train. 2017;52(2):77–81.
Elbin RJ, Kontos AP, Kegel N, et al. Individual and combined effects of LD and ADHD on computerized neurocognitive concussion test performance: evidence for separate norms. Arch Clin Neuropsychol. 2013;28(5):476–84.
Zuckerman SL, Lee YM, Odom MJ, et al. Baseline neurocognitive scores in athletes with attention deficit–spectrum disorders and/or learning disability. J Neurosurg Pediatr. 2013;12(2):103–9.
Brown DA, Elsass JA, Miller AJ, et al. Differences in symptom reporting between males and females at baseline and after a sports-related concussion: a systematic review and meta-analysis. Sports Med. 2015;45(7):1027–40.
Broglio SP, McCrea M, McAllister T, et al. A national study on the effects of concussion in collegiate athletes and US military service academy members: The NCAA–DoD concussion assessment, research and education (CARE) consortium structure and methods. Sports Med. 2017;47(7):1437–51.
SCAT3. Br J Sports Med. 2013;47(5):259.
Chin EY, Nelson LD, Barr WB, et al. Reliability and validity of the sport concussion assessment Tool–3 (SCAT3) in high school and collegiate athletes. Am J Sports Med. 2016;44(9):2276–85.
Broglio SP, Katz BP, Zhao S, et al. Test-retest reliability and interpretation of common concussion assessment tools: Findings from the NCAA-DoD CARE consortium. Sports Med. 2018;48(5):1255–68.
Silverberg ND, Berkner PD, Atkins JE, et al. Relationship between short sleep duration and preseason concussion testing. Clin J Sport Med. 2016;26(3):226–31.
Chen H, Cohen P, Chen S. How big is a big odds ratio? interpreting the magnitudes of odds ratios in epidemiological studies. Commun Stat Simul Comput. 2010;39(4):860–4.
Hosmer Jr DW, Lemeshow S, Sturdivant RX. Applied logistic regression. Wiley; 2013.
Belanger HG, Spiegel E, Vanderploeg RD. Neuropsychological performance following a history of multiple self-reported concussions: a meta-analysis. J Int Neuropsychol Soc. 2010;16(2):262–7.
King D, Brughelli M, Hume P, Gissane C. Assessment, management and knowledge of sport-related concussion: systematic review. Sports Med. 2014;44(4):449–71.
Asken BM, Houck ZM, Bauer RM, Clugston JR. SCAT5 vs. SCAT3 symptom reporting differences and convergent validity in collegiate athletes. Arch Clin Neuropsychol (epub ahead of print).
Acknowledgements
Contributing care consortium investigators include: April Marie (Reed) Hoy, MS, ATC (Azusa Pacific University); Joseph B. Hazzard Jr, EdD, ATC (Bloomsburg University); Louise A. Kelly, PhD (California Lutheran University); Justus D. Ortega, PhD (Humboldt State University); Nicholas Port, PhD (Indiana University); Margot Putukian MD (Princeton University); T. Dianne Langford, PhD (Temple University); Christopher C. Giza, MD and Joshua T. Goldman, MD, MBA (University of California, Los Angeles); Holly J. Benjamin MD (University of Chicago); Julianne D. Schmidt, PhD, ATC (University of Georgia); James T. Eckner, MD, MS (University of Michigan); Jason P. Mihalik, PhD, CAT(C), ATC (University of North Carolina at Chapel Hill); Jessica Dysart Miles, PhD, ATC (University of North Georgia); Scott Anderson, ATC (University of Oklahoma); Christina L. Master, MD (University of Pennsylvania); Anthony P. Kontos, PhD (University of Pittsburgh Medical Center); Sara P.O. Chrisman, MD, MPH (University of Washington); Alison Brooks, MD, MPH (University of Wisconsin-Madison); Stefan Duma, PhD and Steve Rowson, PhD (Virginia Tech); Christopher M. Miles, MD (Wake Forest University); Laura Lintner DO (Winston-Salem University).
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Funding
This publication was made possible, in part, with support from the Grand Alliance CARE Consortium, funded by the NCAA and the DoD. The USAMRAA, Fort Detrick, MD, USA, is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Psychological Health and Traumatic Brain Injury Program under Award No. W81XWH-14-2-0151. Opinions, interpretations, conclusions and recommendations are those of the authors and are not necessarily endorsed by the DoD (DHP funds).
Conflict of interest
Grant Iverson, Ph.D. serves as a scientific advisor for BioDirection, Inc., Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including athletes). He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He has received research funding as a principal investigator from the National Football League, and salary support as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. He acknowledges unrestricted philanthropic support from ImPACT Applications, Inc., the Heinz Family Foundation, the Mooney-Reed Charitable Foundation, and the Spaulding Research Institute. None of the other authors have any conflicts of interest to declare.
Ethics approval
The local Institutional Review Board at each of the performance sites and the US Army Medical Research and Materiel Command Human Research Protection Office (HRPO) reviewed and approved all study procedures. This study was performed in accordance with the standards of ethics outlined in the Declaration of Helsinki.
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Participants provided written informed consent prior to participation.
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The CARE Consortium datasets generated and analyzed during the current study are available in the FITBIR repository (https://fitbir.nih.gov/).
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Author contributions
JBC was involved in the conception and design of the study, the analysis and interpretation of data, drafting the article, and final approval of the version to be submitted. GLI and TAB were involved in the conception and design of the study, the interpretation of data, revising the article for important intellectual content, and final approval of the version to be submitted. KJH was involved in the conception and design of the study, the analysis of data, revising the article for important intellectual content, and final approval of the version to be submitted. All of the remaining authors were involved in the conception and design of the study, revising the article for important intellectual content, and final approval of the version to be submitted.
Additional information
This article is part of a Collection on The NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium.
The members of CARE Consortium Investigators are listed in the Acknowledgements section.
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Caccese, J.B., Iverson, G.L., Hunzinger, K.J. et al. Factors Associated with Symptom Reporting in U.S. Service Academy Cadets and NCAA Student Athletes without Concussion: Findings from the CARE Consortium. Sports Med 51, 1087–1105 (2021). https://doi.org/10.1007/s40279-020-01415-4
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DOI: https://doi.org/10.1007/s40279-020-01415-4