Recovery from mild concussion in high school athletes

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Object. A computerized neuropsychological test battery was conducted to evaluate memory dysfunction and self-reporting of symptoms in a group of high school athletes who had suffered concussion.

Methods. Neuropsychological performance prior to and following concussion was compared with the test performance of an age-matched control group. Potentially important diagnostic markers of concussion severity are discussed and linked to recovery within the 1st week of injury.

Conclusions. High school athletes who had suffered mild concussion demonstrated significant declines in memory processes relative to a noninjured control group. Statistically significant differences between preseason and postinjury memory test results were still evident in the concussion group at 4 and 7 days postinjury. Self-reported neurological symptoms such as headache, dizziness, and nausea resolved by Day 4. Duration of on-field mental status changes such as retrograde amnesia and posttraumatic confusion was related to the presence of memory impairment at 36 hours and 4 and 7 days post-injury and was also related to slower resolution of self-reported symptoms. The results of this study suggest that caution should be exercised in returning high school athletes to the playing field following concussion. On-field mental status changes appear to have prognostic utility and should be taken into account when making return-to-play decisions following concussion. Athletes who exhibit on-field mental status changes for more than 5 minutes have longer-lasting postconcussion symptoms and memory decline.

The management of sports-related mild traumatic brain injury (for example, concussion) has rightfully received recognition as a public health issue.1,6,7,10 Of particular concern is competition at the high school level, where a minimum of 1.25 million athletes compete in contact sports. Recent data suggest that an estimated 62,816 concussions occur annually in high school students, with football accounting for approximately 63% of the cases.22

Currently, neuropsychological testing is mandated within the National Hockey League15 and the majority of National Football League franchises are also routinely using this tool.14 To date, neuropsychological testing has not been widely implemented at the high school level, and there are no published studies in which recovery from concussion in high school athletes has been systematically investigated.

The lack of research with high school athletes is alarming for several reasons. First, based on participation levels, the largest majority of at-risk athletes are at the high school level or below. Second, at least 17 deaths related to second impact syndrome3 (which results from a second concussive insult closely following the first) were reported in the scientific literature between 1992 and 1997,2 and cases of second impact syndrome continue to be reported. The majority of victims have been high school athletes between the ages of 13 and 18 years, suggesting greater vulnerability to severe injury in children and young adults. In addition, investigators in recent laboratory studies in a rodent model have documented changes in brain metabolism that persist 7 days or more after mild injury.9 This research has also raised concerns about the cumulative effects of concussion in humans.

The goals of this study were threefold: 1) to evaluate memory impairment following mild concussion in high school athletes and document recovery within the 1st week postinjury; 2) to evaluate the relationship between duration of on-field markers of concussion and recovery of memory processes within the 1st week postinjury; and 3) to evaluate the relationship of self-reported postconcussion symptoms to performance on neuropsychological testing.

Clinical Material and Methods
Participant Population

Participants in the study were 64 high school athletes who had suffered concussion and 24 (control group) who had not. The control group (24 athletes) was included to provide information regarding the stability of the neuropsychological test results over time in a noninjured cohort. The concussion group consisted of 60 boys and four girls and the control group consisted of 16 boys and eight girls. The concussion group was composed of 44 football athletes, eight basketball athletes, seven soccer athletes, and five athletes from other sports. The control group was composed of 22 swimmers and two football players. Control group athletes were recruited from a single high school in Pennsylvania. All participants were screened for learning disabilities and attention deficit disorder and were not included if there was a history of either. All athletes with any history of alcohol or drug abuse or dependence were excluded from the study.

The concussion group had a significantly more pronounced prestudy history of concussion than the control group (ϰ2 = 8.87, p = 0.003), although the concussion group and the control group did not differ significantly on baseline memory testing (F = 2.67, p < 0.11) or with regard to number of symptoms reported (F = 0.086, p < 0.77). The average time postbaseline to first follow-up evaluation for the concussion group was 51.3 days. The average time from injury to initial follow up was 1.5 days. The average time from injury to second follow up was 4.2 days, and the time from injury to third follow up was 7.6 days. These times represent average postconcussion evaluation times within our clinical program, which is designed to evaluate athletes carefully following concussion while minimizing time off the field. The control group underwent initial baseline evaluation followed by postbaseline evaluations at 7, 9, and 11 days. These intervals were chosen to approximate the post-concussion testing intervals of the concussion group.

Protocol and Outcome Measures

After review, approval for research with human volunteers was granted to conduct this study. Administration of the IMPACT computerized neuropsychological test battery18 was supervised by a team of clinical neuropsychologists, athletic trainers, and/or physicians who were thoroughly trained in the administration of the measures. Training was completed at each site through a half-day seminar presented by two of the authors (M.W.C. and M.R.L.). Because IMPACT is a self-administered test battery, all subtests were administered in a standardized manner and the test was automatically computer scored.

Preseason Baseline Evaluation

Baseline data collection for the concussion group was initiated prior to the 2000 and 2001 athletic seasons. Consistent with previous research on athletes,8,17 all baseline data were collected during the off-season (that is, prior to preseason contact drills). Regarding concussion history, a standardized concussion history questionnaire contained within the IMPACT battery was administered with the supervision of the test administrator.

The IMPACT battery is a computer-administered neuropsychological assessment tool that consists of seven individual modules that measure aspects of cognitive functioning including attention, memory, reaction time, and information processing speed. Previous studies using IMPACT have demonstrated that reaction time deficits resolved by Day 5 in a group of athletes who had sustained mild concussion.13 Given the focus of this paper on the relationship between on-field mental status changes (such as amnesia) and formal neuropsychological test performance, only performance on the memory composite index was included in this study. Tests that comprise the Memory Composite Index are listed in Table 1. A more thorough description of the IMPACT battery and rationale for the development of the individual tests has been described in detail previously.18

TABLE 1

IMPACT memory assessment module

TestCognitive Ability Assessed
word memory (immediate)verbal recognition memory
word memory (delayed)delayed verbal recognition memory
X's and O'svisual topographical memory/working
 memory
symbol match memoryvisual associative memory
three-letter memory (trigrams)verbal working memory

A Postconcussion Symptom Scale based on IMPACT is now being used throughout both amateur and professional sports.17 This scale consists of a listing of 21 symptoms commonly associated with concussion (for example, headache, dizziness, nausea, sleep disturbance) that are graded from 0 (asymptomatic) to 6 (severely symptomatic). This scale is used to assess the athlete's self-report of symptoms including both cognitive (for example, attention deficit, perceived memory dysfunction) and noncognitive symptoms such as headache, nausea, dizziness, sleep disturbance, emotional changes, and photophobia.

Postconcussion Evaluation

High school athletes who sustained concussion were referred for postinjury serial neuropsychological evaluation conducted at 36 hours and 4 and 7 days postinjury. These test intervals reflect the fact that many participants in this study were returned to play within 1 week of injury (if they were asymptomatic). Therefore, we are not routinely able to collect more long-term follow-up data on this group.

Concussion was diagnosed based on the following criteria: 1) any observable alteration in mental status/level of consciousness such as loss of consciousness, retrograde amnesia, posttraumatic amnesia, disorientation; and/or 2) any self-reported symptoms following a collision such as “fogginess,” “grogginess,” headache, nausea/vomiting, dizziness, balance problems, and/or visual changes. Seven of the athletes in this sample experienced frank loss of consciousness and were subsequently dropped from further analysis. These athletes were not included because of our desire to focus on athletes who had sustained mild concussion. Thirteen athletes experienced retrograde amnesia and 19 experienced posttraumatic amnesia. Twenty-eight were disoriented on the field. Twenty-seven athletes did not display any mental status changes on the field but did display other noncognitive symptoms that suggested concussion and resulted in their removal from the playing field. The initial diagnosis of concussion was made by certified athletic trainers or team physicians who were present on the sideline at the time of injury. Both the presence and duration of on-field mental status changes were documented. Structural brain imaging (computerized tomography scanning of the brain) is not routinely performed in athletes. Therefore, only three of our patients underwent computerized tomography scanning following injury and the results of all of these studies were normal. None of the participants in the study developed a structural brain lesion while participating in the program.

Data Analysis

Data from all participating high school institutions were pooled and analyzed using a commercially available software program (SPSS, Chicago, IL). Statistical comparisons were made using repeated-measures ANOVA techniques as well as nonparametric analyses, where appropriate.

Results

Given the multisite nature of the study, an analysis was first conducted to evaluate the consistency of baseline memory and symptom data among contributing sites. Data from the individual sites were pooled into groups comprising three geographic regions and compared statistically: East (Pennsylvania and Maine), Midwest (Illinois and Michigan), and West (Oregon). No significant differences between regional groups were found in preseason baseline memory testing (F = 0.003, p < 0.996) or total symptom score (F = 0.81, p < 0.451).

Table 2 provides the IMPACT baseline and follow-up memory composite and symptom total scores (and SDs) for the concussion and control groups. A graphic depiction of memory performance and symptom profiles of the concussion and control groups is provided in Figs. 1 and 2.

TABLE 2

Memory performance and symptoms for concussion and control groups

Group/VariableBaseline36 HoursDay 4Day 7
comparison group*    
 memory composite89.0 ± 6.2 89.1 ± 8.6 87.0 ± 7.4 87.7 ± 9.9 
 postconcussion symptoms total3.4 ± 7.1 1.4 ± 3.4 1.3 ± 3.5 1.4 ± 5.3 
concussion group    
 memory composite83.9 ± 8.6 75.5 ± 14.2 76.3 ± 13.5 80.2 ± 13.1 
 postconcussion symptoms total9.9 ± 12.9 25.3 ± 23.8 13.6 ± 19.8 6.6 ± 13.9 

The control group obtained higher memory scores and reported fewer symptoms than the concussion group at the baseline assessment (Mann—Whitney U-test, p < 0.005).

Baseline postconcussion symptom total scores greater than at all follow-up intervals; p < 0.05.

Fig. 1.
Fig. 1.

Graph showing IMPACT memory composite score for concussion and control groups. Scores represent mean performance on the memory composite index of IMPACT. The performance of the control group did not differ significantly across the evaluation periods. Athletes in the concussion group differed across the evaluation periods.

Fig. 2.
Fig. 2.

Graph showing IMPACT symptom score for the concussion and control groups. Scores represent total symptom scores for the groups. The control group demonstrated lower symptom scores at follow up than at baseline; however, the concussion group displayed significantly higher symptom scores at follow up.

Control Group

The primary function of the control group in the study was to allow for the examination of the effects of prior exposure or practice on memory test performance and symptom reporting. Repeated-measures ANOVAs revealed relatively equivalent memory scores for the control group across the four testing sessions (F [2.6, 60.9] = 0.88, p = 0.445) and therefore no significant practice effects. These findings provide the basis for comparison of postconcussion changes in the concussion group. Regarding symptom reporting in the control group, all three follow-up symptom scores were significantly lower than the baseline score, based on a probability value less than 0.05 (range 0.012–0.049). This indicates that the control group reported fewer symptoms at follow up than at baseline.

Concussion Group

To evaluate recovery in the concussion group during the 1st week postinjury, change in memory and symptom scores were examined using the repeated-measure ANOVA methodology described previously. For the memory composite score, significant changes in performance were seen between preseason and postconcussion (F [3, 189] = 12.6, p < 0.00001). Furthermore, pairwise comparisons between memory scores revealed significantly lower memory scores at 36 hours, at Day 4, and at Day 7 compared with baseline (Table 3).

TABLE 3

Documenting recovery of the concussion group through pairwise comparisons

Pairwise ComparisonEffect p ValueEffect Size Size (d)*Classification
memory composite 
 baseline—36 hrs<0.0001 0.74medium–large
 baseline—Day 4<0.0001 0.69medium–large
 baseline—Day 7<0.017 0.34small
postconcussion symptoms 
 baseline—36 hrs<0.000001 0.84large
 baseline—Day 4NS 
 baseline—Day 7NS 

Effect sizes represent the magnitude of difference between two groups in SD units. This helps to establish the clinical relevance of statistically significant findings. Abbreviations: NS = not significant; — = not done.

Regarding self-reported symptoms, there was also a significant difference in reporting of symptoms between preseason baseline and 36 hours postconcussion (F [3, 171] = 25.2, p < 0.000000001), with the concussion group reporting more symptoms after concussion than they did during the preseason. No significant differences in symptom reporting, however, were found at Days 4 and 7. The pairwise comparison results and associated effect sizes for the total symptoms score are presented in Table 3.

Comparisons of Athletes With Brief and Prolonged On-Field Symptoms of Concussion

To examine more closely the issue of concussion severity within this group suffering mild concussion, the athletes were sorted into two groups based on duration of on-field symptoms. Athletes were classified into more severe and less severe concussion groups, which were defined by duration of on-field markers of concussion. The group with more severe concussion was defined as those presenting with 1) retrograde amnesia for more than 5 minutes; 2) posttraumatic amnesia more than 5 minutes; or 3) disorientation more than 5 minutes. The less severe concussion group either had no mental status changes or exhibited mental status changes that lasted less than 5 minutes. This classification scheme was used to allow the separation of transient postconcussion cognitive disturbance from longer-lasting sequelae of the injury. The injury severity characteristics of these two groups are presented in Table 4.

TABLE 4

Percentages of individuals by group with each injury severity characteristic

CharacteristicMore Severe Concussion (13 patients)Mild Concussion (43 patients)
retrograde amnesia  
 yes46.2 9.3 
 1–10 secs7.7 2.3 
 11–59 secs0 2.3 
 1–5 mins23.1 4.7 
 6–15 mins7.7 0 
 >15 mins7.7 0 
anterograde amnesia  
 yes84.6 11.6 
 1–5 mins15.7 11.6 
 6–15 mins15.4 0 
 16–30 mins38.5 0 
 >30 mins15.4 0 
disorientation  
 yes76.9 34.9 
 10–59 secs7.7 0 
 1–5 mins0 34.9 
 6–30 mins38.5 0 
 >30 mins30.8 0 

Average memory composite scores for the two concussion groups are presented in Fig. 3. An ANOVA revealed significant differences in memory performance between athletes with transient or more long-lasting on-field mental status changes (F [1, 54] = 5.5; p < 0.024). Self-report symptom profiles for the two groups are presented in Fig. 4.

Fig. 3.
Fig. 3.

Graph showing IMPACT memory composite scores stratified by concussion severity. Scores represent mean performance on the memory composite index of IMPACT. Athletes in the concussion group performed more poorly across time. Athletes with more severe injuries (as defined by on-field markers lasting longer than 5 minutes) displayed poorer performance compared with those with brief on-field difficulties.

Fig. 4.
Fig. 4.

Graph showing IMPACT symptom total score stratified by concussion severity. Scores represent total symptom scores for the two severity groups. Athletes in the concussion group performed significantly more poorly across time. A comparison between athletes in the subgroups of the concussion group with more severe and mild injuries (as defined by on-field markers of concussion lasting longer than 5 minutes) did not reach statistical significance, although there was a trend toward more symptom reporting in the more severe group.

An additional analysis was conducted to assess differences across the three follow-up intervals and these data are presented in Table 5. Pairwise comparisons revealed significant declines in memory performance relative to baseline at all three follow-up intervals for players with a longer duration of symptoms (p < 0.017, 0.004, and 0.037, respectively).

TABLE 5

Recovery from concussion in more severe and less severe concussions based on duration of symptoms: pairwise comparisons

Pairwise Comparisonp ValueEffect Size (d)*Effect Size Classification
more severe concussion 
 memory composite 
  baseline—36 hrs0.017 1.21very large
  baseline—Day 40.004 1.31very large
  baseline—Day 70.037 0.67medium
 postconcussion symptoms 
  baseline—36 hrs0.003 1.37very large
  baseline—Day 40.061 0.81
  baseline—Day 7NS 0.03
less severe concussion 
 memory composite 
  baseline—36 hrs0.003 0.47medium
  baseline—Day 40.013 0.43medium
  baseline—Day 7NS 0.17
 postconcussion symptoms 
  baseline—36 hrs0.00007 0.73large
  baseline—Day 4NS 0.01
  baseline—Day 7NS 0.27

Effect sizes represent the magnitude of difference between two groups in SD units. This helps to establish the clinical relevance of statistically significant findings.

For the group with a duration of symptoms of less than 5 minutes, pairwise within-group comparisons revealed significant declines in memory performance relative to baseline at 36 hours (p < 0.003) and at Day 4 (p < 0.013) but not at 7 days postinjury.

There was a trend toward differences in self-reported symptoms between shorter and longer duration groups, with the longer duration group reporting more symptoms (F [1, 49] = 2.9; p < 0.096). As shown in Table 5, pairwise comparisons revealed a significant increase in symptoms from baseline to 36 hours for athtletes whose on-field mental status changes were of longer duration (p < 0.003). There was a trend toward greater symptom reporting at Day 4, relative to baseline (p < 0.061). For the less severe concussion group, pairwise within-group comparisons revealed significantly greater symptoms from baseline to 36 hours (p < 0.00007). By Days 4 and 7, there were no significant differences compared with baseline.

The 13-point drop in memory performance displayed by the concussion group compared with their baseline scores represents a major decline between preseason and immediate follow up (> 1.5 SD decline in performance). Furthermore, the athletes with longer duration of on-field mental status changes were 5.3 times more likely to demonstrate a major drop in memory performance at 36 hours than the athletes with mild concussions.

Discussion

No area of sports medicine involves more clinical uncertainty and controversy than the management of concussion. Reasons for controversy in this area include an overall difficulty in accurately diagnosing the phenomenon, a current lack of understanding regarding the pathophysiology of mild concussion, and a lack of consensus regarding return-to-play guidelines. Although the issue of sports-related concussion has become one of the most popular topics of discussion in sports medicine and has led to the publication of two recent journal issues covering the subject,19,21 surprisingly little research has been published on high school aged students. In fact, no studies have been published in which the recovery process in this age group has been investigated using formal neuropsychological testing.

In this study, we have provided data regarding the neuropsychological consequences of concussion in this younger group of athletes who have experienced what has traditionally been characterized as mild concussion. For the current study, we excluded athletes who experienced any degree of postinjury loss of consciousness and chose to focus on athletes with varying degrees of symptoms, disorientation, and posttraumatic and/or retrograde amnesia. Individuals who had lost consciousness were excluded from the study for several reasons. First, concussions that involve a loss of consciousness almost always result in immediate removal from competition and restriction of return to play for at least 1 week. Concussions that do not involve a loss of consciousness have historically been viewed as a more trivial injury and athletes have often returned to play during the same contest. In addition, although concussion without loss of consciousness is the most common type of sports-related head injury it is more difficult to detect and may often be misdiagnosed by sports medicine practitioners.4

This study demonstrates that even in this more mildly injured group, there can be pronounced memory decline in some high school athletes who suffer concussion, which remained at least 7 days postinjury. Decline in memory functioning was clearly linked to concussion injury as a noninjured control group exhibited stable memory performance across similar testing sessions. Overall findings suggest the need for careful evaluation and monitoring of high school athletes sustaining concussion of any severity.

In addition to evaluating decline in memory as a result of mild concussions, this study also evaluated overall symptom reporting during the 1st week of recovery. Self-reported symptoms generally resolved within 4 days of injury. Importantly, our findings suggest a lack of agreement between formal memory testing and self-report of symptoms, with longer lasting memory decline and earlier resolution of symptoms. This finding is of concern given that most high schools do not use neuropsychological testing and athlete self-report is often the primary determinant in return to play. This study suggests that neuropsychological test results provide unique information to the sports medicine practitioner. These findings are also consistent with past research with college athletes in which earlier resolution of somatic symptoms relative to neuropsychological test performance was documented.4,13 Differences between neuropsychological test performance and symptom self-report are common in athletes who have sustained a concussion and are likely to reflect both neurological and nonneurological (for example, vestibular) aspects of the injury. Symptom self-reporting is also likely to be influenced by the expectations of the patient and other psychological processes.20 In addition, some athletes are known to minimize symptoms in hopes of a faster return to the playing field, rink, or court.16 The use of neuropsychological testing helps to assure that the athlete is indeed recovered prior to returning to the playing field.

In addition to providing evidence of postconcussion memory decline and increased symptoms in high school athletes who have suffered mild concussion, this study also found a relationship between duration of initial on-field mental status changes and rate of recovery during the 1st week postinjury. Specifically, athletes with postinjury anterograde amnesia, retrograde amnesia, or disorientation lasting longer than 5 minutes, as a group, did not fully recover by Day 7. In contrast, athletes with on-field mental status changes lasting less than 5 minutes demonstrated a return to baseline within 4 days. In designing this study, we chose a 5-minute time cutoff to differentiate transient from more severe injuries. This cutoff was used because it represents a common unit of time that can be tracked relatively easily on the athletic playing field. In using this cutoff, however, we do not wish to recommend its adoption as a new marker of severity at this time. Rather, we are hopeful that this study will spark more research aimed at the continued delineation of the acute recovery period following concussion.

Regarding the issue of possible age-related differences in recovery following concussion, existing research has failed to yield clinically useful data regarding potential age-related differences in recovery from concussion, although there is considerable published literature addressing more severe traumatic brain injury.11,12 To date, clinical research in the area of sports concussion has been limited to college and professional athletes. In these studies, neuropsychological recovery has been found to occur anywhere from 48 hours to 5 days postinjury. The current study provides evidence of memory deficits at least 7 days postinjury within a sample of high school athletes suffering “mild” concussions. Unfortunately, it was not possible in this study to track athletes beyond 7 days. Given the persistence of memory dysfunction at 7 days postinjury, it would have been particularly useful to perform more long-term follow-up studies to document more long lasting deficits in the athletes who had not shown complete recovery by Day 7. Future studies of neuropsychological recovery completed within our program will track these athletes on a more long-term basis.

Finally, our finding of memory deficits 7 days postinjury is consistent with animal research demonstrating neurometabolic disruption 7 to 10 days postinjury.9 Animal research has also suggested that the brain may be more vulnerable to additional injury during this acute recovery period and that reinjury prior to complete recovery may result in additional (cumulative) deficits. More recently, preliminary research with high school athletes has also suggested that the effects of concussion may be cumulative,5 although this issue requires further evaluation. To better understand the relationship between brain metabolism and neuropsychological test performance our future research will involve functional brain imaging studies in athletes during the acute recovery process. This will allow simultaneous evaluation of both metabolic and neuropsychological markers of concussion recovery.

Conclusions

This is the first study to compare acute neurocognitive recovery after sports-related concussion in high school athletes. Results suggest that there is measurable memory decline at least 7 days postinjury in a subgroup of athletes. Currently, formal neuropsychological baseline evaluations are routinely implemented at the professional and major college levels. Our results suggest that administration of baseline—postinjury neuropsychological testing should be considered at the high school level and that neuropsychological test results, in conjunction with other diagnostic information, can provide valuable information regarding return to play.

References

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    American Academy of Neurology: Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology 48:5815851997American Academy of Neurology: Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology 48:

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    Cantu RC: Cerebral concussion in sport. Management and prevention. Sports Med 14:64741992Cantu RC: Cerebral concussion in sport. Management and prevention. Sports Med 14:

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    Cantu RC: Second-impact syndrome. Clin Sports Med 17:37441998Cantu RC: Second-impact syndrome. Clin Sports Med 17:

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    Collins MWGrindel SHLovell MRet al: Relationship between concussion and neuropsychological performance in college football players. JAMA 282:9649701999JAMA 282:

  • 5.

    Collins MWLovell MRIverson GLet al: Cumulative effects of concussion in high school athletes. Neurosurgery 51:117511812002Neurosurgery 51:

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    Collins MWLovell MRMcKeag DB: Current issues in managing sports-related concussion. JAMA 282:228322851999JAMA 282:

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    Grindel SHLovell MRCollins MW: The assessment of sport-related concussion: the evidence behind neuropsychological testing and management. Clin J Sport Med 11:1341432001Clin J Sport Med 11:

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    Hinton-Bayre ADGeffen GMGeffen LBet al: Concussion in contact sports: reliable change indices of impairment and recovery. J Clin Exp Neuropsychol 21:70861999J Clin Exp Neuropsychol 21:

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    Hovda DAPrins MBecker DPet al: Neurobiology of concussionBailes JELovell MRMaroon JC (eds): Sports-Related Concussion. St. Louis: Quality Medical19991251Sports-Related Concussion.

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    Kelly JP: Traumatic brain injury and concussion in sports. JAMA 282:9899911999Kelly JP: Traumatic brain injury and concussion in sports. JAMA 282:

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    Lang DATeasdale GMMacpherson Pet al: Diffuse brain swelling after head injury: more often malignant in adults than children? J Neurosurg 80:6756801994J Neurosurg 80:

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    Levin HSAldrich EFSaydjari Cet al: Severe head injury in children: experience of the Traumatic Coma Data Bank. Neurosurgery 31:4354441992Neurosurgery 31:

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    Lovell MR: Concussion in sports. Br J Sports Med 35:3672001 (Abstract)Lovell MR: Concussion in sports. Br J Sports Med 35:

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    Lovell MR: Evaluation of the professional athleteBailes JELovell MRMaroon JC (eds): Sports-Related Concussion. St. Louis: Quality Medical1999200214Sports-Related Concussion.

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    Lovell MRBurke CW: Concussion in ice hockeyRC Cantu (ed): Neurologic Athletic Head and Spine Injuries. Philadelphia: WB Saunders2000Neurologic Athletic Head and Spine Injuries.

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    Lovell MRCollins MW: Neuropsychological assessment of the college football player. J Head Trauma Rehabil 13:9261998J Head Trauma Rehabil 13:

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    Macciocchi SNBarth JTAlves Wet al: Neuropsychological functioning and recovery after mild head injury in collegiate athletes. Neurosurgery 39:5105141996Neurosurgery 39:

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    Maroon JCLovell MRNorwig Jet al: Cerebral concussion in athletes: evaluation and neuropsychological testing. Neurosurgery 47:6596722000Neurosurgery 47:

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    Meeuwisse W (ed): Thematic issue: concussion in sport. Clin J Sport Med 11:1312092001Meeuwisse W (ed): Thematic issue: concussion in sport. Clin J Sport Med 11:

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    Mittenberg WStrauman S: Diagnosis of mild head injury and postconcussion syndrome. J Head Trauma Rehabil 15:7837912000J Head Trauma Rehabil 15:

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    Perrin DHGuskiewicz KM (eds): Special issue: concussion in athletes. J Athl Train 36:2133482001J Athl Train 36:

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    Powell JWBarber-Foss KD: Traumatic brain injury in high school athletes. JAMA 282:9589631999JAMA 282:

Article Information

Address reprint requests to: Mark R. Lovell, Ph.D., University of Pittsburgh Medical Center Sports Medicine Concussion Program, 3200 South Water Street, Pittsburgh, Pennsylvania 15203. email: lovellmr@msx.upmc.edu.

© AANS, except where prohibited by US copyright law."

Headings

Figures

  • View in gallery

    Graph showing IMPACT memory composite score for concussion and control groups. Scores represent mean performance on the memory composite index of IMPACT. The performance of the control group did not differ significantly across the evaluation periods. Athletes in the concussion group differed across the evaluation periods.

  • View in gallery

    Graph showing IMPACT symptom score for the concussion and control groups. Scores represent total symptom scores for the groups. The control group demonstrated lower symptom scores at follow up than at baseline; however, the concussion group displayed significantly higher symptom scores at follow up.

  • View in gallery

    Graph showing IMPACT memory composite scores stratified by concussion severity. Scores represent mean performance on the memory composite index of IMPACT. Athletes in the concussion group performed more poorly across time. Athletes with more severe injuries (as defined by on-field markers lasting longer than 5 minutes) displayed poorer performance compared with those with brief on-field difficulties.

  • View in gallery

    Graph showing IMPACT symptom total score stratified by concussion severity. Scores represent total symptom scores for the two severity groups. Athletes in the concussion group performed significantly more poorly across time. A comparison between athletes in the subgroups of the concussion group with more severe and mild injuries (as defined by on-field markers of concussion lasting longer than 5 minutes) did not reach statistical significance, although there was a trend toward more symptom reporting in the more severe group.

References

1.

American Academy of Neurology: Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology 48:5815851997American Academy of Neurology: Practice parameter: the management of concussion in sports (summary statement). Report of the Quality Standards Subcommittee. Neurology 48:

2.

Cantu RC: Cerebral concussion in sport. Management and prevention. Sports Med 14:64741992Cantu RC: Cerebral concussion in sport. Management and prevention. Sports Med 14:

3.

Cantu RC: Second-impact syndrome. Clin Sports Med 17:37441998Cantu RC: Second-impact syndrome. Clin Sports Med 17:

4.

Collins MWGrindel SHLovell MRet al: Relationship between concussion and neuropsychological performance in college football players. JAMA 282:9649701999JAMA 282:

5.

Collins MWLovell MRIverson GLet al: Cumulative effects of concussion in high school athletes. Neurosurgery 51:117511812002Neurosurgery 51:

6.

Collins MWLovell MRMcKeag DB: Current issues in managing sports-related concussion. JAMA 282:228322851999JAMA 282:

7.

Grindel SHLovell MRCollins MW: The assessment of sport-related concussion: the evidence behind neuropsychological testing and management. Clin J Sport Med 11:1341432001Clin J Sport Med 11:

8.

Hinton-Bayre ADGeffen GMGeffen LBet al: Concussion in contact sports: reliable change indices of impairment and recovery. J Clin Exp Neuropsychol 21:70861999J Clin Exp Neuropsychol 21:

9.

Hovda DAPrins MBecker DPet al: Neurobiology of concussionBailes JELovell MRMaroon JC (eds): Sports-Related Concussion. St. Louis: Quality Medical19991251Sports-Related Concussion.

10.

Kelly JP: Traumatic brain injury and concussion in sports. JAMA 282:9899911999Kelly JP: Traumatic brain injury and concussion in sports. JAMA 282:

11.

Lang DATeasdale GMMacpherson Pet al: Diffuse brain swelling after head injury: more often malignant in adults than children? J Neurosurg 80:6756801994J Neurosurg 80:

12.

Levin HSAldrich EFSaydjari Cet al: Severe head injury in children: experience of the Traumatic Coma Data Bank. Neurosurgery 31:4354441992Neurosurgery 31:

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Lovell MR: Concussion in sports. Br J Sports Med 35:3672001 (Abstract)Lovell MR: Concussion in sports. Br J Sports Med 35:

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