Influence of Anxiety on Baseline Cognitive Testing and Symptom Reporting in Adolescent Student Athletes

Screening for Anxiety and Depression Symptoms Using Concussion Symptom Scales Among Varsity Athletes

OBJECTIVE

This study examined associations between Sport Concussion Assessment Tool-5 (SCAT-5) symptom reporting and gold-standard measures of anxiety and depression, and explored the utility SCAT-5 symptom subscales to identify anxiety and depression symptomology.

DESIGN

Prospective cross-sectional study.

SETTING

York University in Toronto, Canada.

PARTICIPANTS

Preseason data were collected for varsity athletes (N = 296) aged between 17 and 25 years ( M = 20.01 years, SD = 1.69 years; 52% male).

MAIN OUTCOME MEASURES

The SCAT-5 symptom evaluation scale was used to assess baseline symptoms. The Generalized Anxiety Disorder Index-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) were used to assess symptoms of anxiety and depression, respectively.

RESULTS

Endorsement of SCAT-5 symptoms of feeling anxious, sadness, irritability, and feeling more emotional had the strongest correlations with the GAD-7 ( r' s > 0.400; P' s < 0.001). Sadness, trouble falling asleep, concentration problems, feeling slowed down, anxious, irritability, mental fog, fatigue, and memory problems had the highest correlations with the PHQ-9 ( r' s >0 .400; P' s < 0.001). The Emotional subscale from the SCAT-5 predicted mild to severe anxiety on the GAD-7 ( P < 0.001). The Sleep, Cognitive, and Emotional subscales predicted mild to severe depression on the PHQ-9 ( P' s < 0.05).

CONCLUSIONS

These findings provide better delineation of symptoms endorsed on the SCAT-5 symptoms that aid in identification of athletes with symptoms of anxiety or depression who may be at risk for developing a clinical disorder or experiencing persistent symptoms after a concussion.

National Athletic Trainers' Association Bridge Statement: Management of Sport-Related Concussion

OBJECTIVE

To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers' Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport.

BACKGROUND

Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice.

RECOMMENDATIONS

These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies.

The Sport Concussion Assessment Tool: A multidimensional symptom model for detecting elevated post-concussion symptoms

Objective: Investigate whether a four-factor model of post-concussion symptoms (i.e. cognitive, physical, affective, and sleep-arousal) aids in identifying student-athletes with persistent concerns not reflected by a total symptom score. Method: Collegiate student-athletes (N = 32,066) from the Concussion Assessment Research and Education consortium completed the Sport Concussion Assessment Tool, 3rd edition Symptom Evaluation at baseline and two post-injury follow-ups (i.e. beginning RTP and 6-month). Confirmatory factor analysis was used to compare a one- and four-factor model of post-concussion symptoms. Normative reference data were compared across stratifications (e.g. sex, prior concussions, and number of pre-existing conditions) using Mann-Whitney U tests, and elevation rates (i.e. ≥ 84th percentile) for subscales and the total score were recorded. Results: The four-factor model fit well before and after injury (CFIs > .95). Greater symptom severity on the subscale and total scores was associated with female sex (ps<.001, r range: .07 to .14) and more pre-existing conditions (ps<.001, η 2 range: .01 to .04), while having more prior concussions was only related to total symptom scores (ps<.001, η 2<.01). After a concussion, a sizeable portion of student-athletes (i.e., RTP = 11.8%; 6-month = 8.3%) had subscale elevations despite no total score elevation. Physical subscale elevations at RTP were the most common (i.e., 11.9%), driven by head and neck pain. Conclusion: After a sport-related concussion, a four-factor symptom model can be used to assess persistent symptoms in collegiate student-athletes. Identifying athletes with domain-specific elevations may help clinicians identify areas for further assessment and, in some cases, personalized rehabilitation plans.

What tests and measures accurately diagnose persisting post-concussive symptoms in children, adolescents and adults following sport-related concussion? A systematic review

OBJECTIVE

To determine what tests and measures accurately diagnose persisting post-concussive symptoms (PPCS) in children, adolescents and adults following sport-related concussion (SRC).

DESIGN

A systematic literature review.

DATA SOURCES

MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL and SPORTDiscus through March 2022.

ELIGIBILITY CRITERIA

Original, empirical, peer-reviewed findings (cohort studies, case-control studies, cross-sectional studies and case series) published in English and focused on SRC. Studies needed to compare individuals with PPCS to a comparison group or their own baseline prior to concussion, on tests or measures potentially affected by concussion or associated with PPCS.

RESULTS

Of 3298 records screened, 26 articles were included in the qualitative synthesis, including 1016 participants with concussion and 531 in comparison groups; 7 studies involved adults, 8 involved children and adolescents and 11 spanned both age groups. No studies focused on diagnostic accuracy. Studies were heterogeneous in participant characteristics, definitions of concussion and PPCS, timing of assessment and the tests and measures examined. Some studies found differences between individuals with PPCS and comparison groups or their own pre-injury assessments, but definitive conclusions were not possible because most studies had small convenience samples, cross-sectional designs and were rated high risk of bias.

CONCLUSION

The diagnosis of PPCS continues to rely on symptom report, preferably using standardised symptom rating scales. The existing research does not indicate that any other specific tool or measure has satisfactory accuracy for clinical diagnosis. Future research drawing on prospective, longitudinal cohort studies could help inform clinical practice.

Relationship between psychosocial and psychiatric risk factors and poor long-term outcome following mild traumatic brain injury: A systematic review

BACKGROUND AND PURPOSE

Mild traumatic brain injury (mTBI) has an estimated worldwide incidence of >60 million per year, and long-term persistent postconcussion symptoms (PPCS) are increasingly recognized as being predicted by psychosocial variables. Patients at risk for PPCS may be amenable to closer follow-up to treat modifiable symptoms and prevent chronicity. In this regard, similarities seem to exist with psychosocial risk factors for chronicity in other health-related conditions. However, as opposed to other conditions, no screening instruments exist for mTBI.

METHODS

A systematic search of the literature on psychological and psychiatric predictors of long-term symptoms in mTBI was performed by two independent reviewers using PubMed, Embase, and Web of Science.

RESULTS

Fifty papers were included in the systematic analysis. Anxiety, depressive symptoms, and emotional distress early after injury predict PPCS burden and functional outcome up to 1 year after injury. In addition, coping styles and preinjury psychiatric disorders and mental health also correlate with PPCS burden and functional outcome. Associations between PPCS and personality and beliefs were reported, but either these effects were small or evidence was limited.

CONCLUSIONS

Early psychological and psychiatric factors may negatively interact with recovery potential to increase the risk of chronicity of PPCS burden after mTBI. This opens opportunities for research on screening tools and early intervention in patients at risk.

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.

Association of Preexisting Mental Health Conditions With Increased Initial Symptom Count and Severity Score on SCAT5 When Assessing Concussion

Background:

Mental health conditions, such as depression, anxiety, and learning disabilities, are associated with symptoms that can overlap with those seen in persons with concussion. While concussion screening tools such as the Sport Concussion Assessment Tool–5th Edition (SCAT5) quantify the number of symptoms and symptom severity, it is not known whether these outcomes differ among individuals with concurrent mental health conditions compared with those without them.

Purpose:

To determine whether, during initial concussion assessment, individuals with a self-reported mental health condition have a significantly different number of self-reported concussion symptoms or symptom severity compared with those without a self-reported mental health condition (controls).

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective chart review was performed on consecutive patients aged ≥13 years who underwent post-concussion assessment at the Fowler Kennedy Sport Medicine Clinic between May 2018 and March 2020 (N = 765). Most participants did not self-report a mental health condition (n = 606; 79.2%). Participants with a self-reported mental health condition (n = 159) were classified as having a learning disability (n = 14; 8.8%), anxiety (n = 62; 39.0%), depression (n = 20; 12.6%), or multiple conditions (≥2 conditions: n = 63; 39.6%). Each participant with a mental health condition was matched with 2 control participants (overall pool, n = 318) based on age, sex, student status, and sport-related risk. Mann-Whitney U tests were used to determine the statistical significance of differences between each subgroup and their matched controls for the self-reported number of concussion symptoms and symptom severity as measured using the SCAT5.

Results:

The anxiety and multiple-conditions subgroups had a significantly greater number of reported symptoms than their corresponding control subgroups (median, 17 vs 15 [P = .004] and 18 vs 14.5 [P < .001], respectively). Additionally, the SCAT5 symptom severity score was significantly greater in the anxiety and multiple-conditions subgroups than their corresponding controls (median, 49 vs 34.5 [P = .018] and 62 vs 32 [P < .001], respectively).

Conclusion:

During initial concussion assessment, both the number of concussion-related symptoms and the symptom severity were greater in study participants with anxiety and multiple mental health conditions than participants without these conditions.

Acute Effects of Concussion in Adolescent Athletes With High Preseason Anxiety

OBJECTIVE

To examine associations between pre-existing anxiety symptoms, and symptoms and cognitive functioning acutely following a suspected concussion.

DESIGN

Nested case-control study.

SETTING

High schools in Maine, USA.

PARTICIPANTS

Participants were identified from a dataset of 46 920 student athletes ages 13 to 18 who received baseline preseason testing. A subset of 4732 underwent testing following a suspected concussion. Of those, 517 were assessed within 72 hours after their suspected concussion and met other inclusion criteria. Nineteen injured athletes endorsed anxiety-like symptoms on the Post-Concussion Symptom Scale (PCSS) during baseline testing and were placed in the high anxiety group. Each athlete was matched to 2 injured athletes who did not endorse high levels of anxiety-like symptoms (N = 57).

MAIN OUTCOME MEASURES

Immediate Post-Concussion Assessment and Cognitive Testing cognitive composite scores, PCSS total score, and symptom endorsement.

RESULTS

Cognitive composite scores were similar between groups across testing times ( = 0.004-0.032). The high anxiety group endorsed a greater number of symptoms than the low anxiety group ( = 0.452) and rated symptoms as more severe ( = 0.555) across testing times. Using a modified symptom score that excluded anxiety-like symptoms, a mixed analysis of variance indicated a group by injury interaction ( = 0.079); the high anxiety group reported greater increases in overall symptom severity following injury.

CONCLUSIONS

Adolescent athletes who have an anxious profile at baseline are likely to experience greater symptom burden following injury. Consideration of pre-injury anxiety may inform clinical concussion management by tailoring intervention strategies (eg, incorporating mental health treatments) to facilitate concussion recovery.

Anxiety Is Associated With Diverse Physical and Cognitive Symptoms in Youth Presenting to a Multidisciplinary Concussion Clinic

Introduction

Pre-injury and post-injury anxiety are prevalent and important to consider in the medical management of concussions in youth. We examined the association between anxiety and other physical, cognitive, and emotional symptoms in injured adolescents and young adults undergoing an initial evaluation in a specialty concussion clinic.

Methods

Participants were 158 adolescents and young adults presenting to a multidisciplinary concussion clinic for evaluation and treatment (54.4% girls and women; mean age = 17.3 years; SD = 2.9). Their median days post injury was 29 (interquartile range = 14–49; range = 7–349). They were divided into binary groups based on whether they had a pre-injury history of anxiety diagnosis or treatment and whether they were experiencing current anxiety in the week prior to the evaluation, and then compared on the Post-Concussion Symptom Scale.

Results

Youth with a pre-injury history of anxiety reported greater post-concussion symptoms (Md total score = 36.0, IQR = 21.5–53.0) compared to youth with no pre-injury history of anxiety (Md total score = 20.5, IQR = 6.0–36.0; MW U = 1,520.00 p = 0.001, r = 0.26, small-medium effect size). They reported significantly worse headaches, nausea, balance difficulty, dizziness, vision problems, fatigue, concentration difficulty, irritability, nervousness, sadness, feeling more emotional, trouble falling asleep, and sleeping more than usual. Youth with high post-injury anxiety reported greater post-concussion symptoms (Md total score = 55.0, IQR = 33.0–62.5) compared to youth with low post-injury anxiety (Md total score = 19.0, IQR = 6.0–35.0; MW U = 681.00, p < 0.001, r = 0.49, large effect size). They reported significantly worse headaches, nausea, vomiting, dizziness, vision problems, fatigue, sensitivity to light, feeling mentally foggy, feeling slowed down, concentration difficulty, memory difficulty, irritability, sadness, feeling more emotional, drowsiness, trouble falling asleep, sleeping less than usual, and sleeping more than usual. Logistic regressions revealed that both pre-injury and post-injury anxiety were strong predictors of persistent post-concussion symptoms, with high post-injury anxiety presenting the strongest independent predictor, while attention-deficit hyperactivity disorder and pre-injury migraines were not significant predictors. Essentially all adolescents with high post-injury anxiety (97.1%) and nearly 9 of 10 adolescents with pre-injury treatment for anxiety (87.8%) met criteria for persistent post-concussion symptoms.

Discussion

Pre-injury and post-injury anxiety are important risk factors for greater post-concussion symptoms among adolescents and young adults. Elevated post-injury anxiety was the strongest predictor of persistent post-concussion symptoms. Assessment of anxiety is important among adolescents presenting for concussion care and delivery of evidence-supported treatments for anxiety are important considerations for treatment planning for these youth.