Reliable Change Indices for the Serial Administration of the Concussion Clinical Profiles Screening Tool

CONTEXT

The Concussion Clinical Profile Screening Tool (CP Screen) self-report concussion symptom inventory that is often administered at weekly intervals. However, 1-week reliable change indices (RCI) for clinical cutoffs and the test-retest reliability of the CP Screen is unknown.

OBJECTIVE

Document RCI cutoff scores and 1-week test-retest reliability for each profile and modifier of the CP Screen for males and females.

DESIGN

Case Series.

SETTING

A large US university.

PATIENTS OR OTHER PARTICIPANTS

173 healthy college students.

MAIN OUTCOME MEASURE(S)

Participants completed two administrations of the CP Screen 7 days apart; CP Screen items yield five clinical profiles and two modifiers. Spearman rho coefficients (rs), intraclass correlation coefficients (ICCs) single measures and Unbiased Estimates of Reliability (UER) were used to assess test-retest reliability. Wilcoxon signed-rank tests assessed differences across time. RCI values and cutoff scores are provided at 90%/95% confidence intervals (CI). All analyses were performed for the total sample and separately for males and females.

RESULTS

RCI cutoffs for clinically significant change (increase/decrease) at a 90% CI for males were as follows: Ocular, Vestibular >2/>4, Anxiety/Mood, Cognitive/Fatigue, Migraine>3/>3, Sleep >4/>6, and Neck>2/>2. RCI cutoffs for clinically significant change (increase/decrease) at a 90% CI for females were as follows: Anxiety/Mood≥2/≥4; Cognitive/Fatigue, Migraine, Ocular, Vestibular, Sleep≥3/≥3; and Neck≥1/≥1. Correlations for CP ranged from .51 (Migraine) to .79 (Anxiety/Mood) for the total sample, .48 (Migraine) to .84 (Vestibular) for males, and .51 (Migraine) to .77 (Ocular) for females. Test-retest indices for each profile and modifier were moderate to good for the total sample (ICC: .64-.82; UER: .79-.90), males (ICC: .60-.87; UER: .76-.94), and females (ICC: .64-.80; UER: .78-.89).

CONCLUSION

The CP Screen is reliable and stable across a 1-week interval, and established RCIs for males and females can help identify meaningful change throughout recovery.

Comparison of physiological outcomes after dynamic exertion between athletes at return to sport from concussion and controls: Preliminary findings

OBJECTIVES

Compare physiological (heart rate, heart rate variability, and blood pressure), performance (change-of-direction task completion time and errors), and clinical (symptoms and rating of perceived exertion) outcomes during dynamic exertion between athletes at return to sport after concussion to healthy athlete controls.

DESIGN

Case control.

METHODS

A sample of 23 (Female = 10; 43.5 %) athletes at medical clearance to play/activity from concussion (CONCUSS) and 23 sex-, age-, and sport-matched healthy athletes (CONTROLS) completed a 5-min seated rest before and after the dynamic exertion test. Independent sample t-tests were used to compare CONCUSS and CONTROLS for completion time, heart rate, and blood pressure; and Mann-Whitney U tests for symptoms, perceived exertion, and errors. A series of ANOVAs were conducted to compare heart rate variability between groups across pre- and post-exercise rest periods.

RESULTS

There were no differences in heart rate, blood pressure, symptoms, perceived exertion, and errors. CONCUSS were faster on Zig Zag (p = .048) and Pro Agility (p = .018) tasks, reported lower symptom severity (p = .019), and had lower post-EXiT HRV (p < .049) than CONTROLS.

CONCLUSIONS

Performance, symptoms, perceived exertion, and blood pressure outcomes from dynamic exertion were equivocal between athletes at medical clearance from concussion and healthy controls, which provide empirical support for dynamic exercise to inform medical clearance clinical decision making for sport-related concussion. However, differences in autonomic nervous system functioning indicate that additional research is needed to examine temporal changes in heart rate variability and other physiological outcomes following dynamic exertion.

A Common Data Element-Based Adjudication Process for mTBI Clinical Profiles: A Targeted Multidomain Clinical Trial Preliminary Study

INTRODUCTION

The primary purpose of this study was to examine the prevalence and percent agreement of clinician-identified mild traumatic brain injury (mTBI) clinical profiles and cutoff scores for selected Federal Interagency Traumatic Brain Injury Research common data elements (CDEs). A secondary purpose was to investigate the predictive value of established CDE assessments in determining clinical profiles in adults with mTBI.

MATERIALS AND METHODS

Seventy-one (23 males; 48 females) participants (M = 29.00, SD = 7.60, range 18-48 years) within 1-5 months (M = 24.20, SD = 25.30, range 8-154 days) of mTBI completed a clinical interview/exam and a multidomain assessment conducted by a licensed clinician with specialized training in concussion, and this information was used to identify mTBI clinical profile(s). A researcher administered CDE assessments to all participants, and scores exceeding CDE cutoffs were used to identify an mTBI clinical profile. The clinician- and CDE-identified clinical profiles were submitted to a multidisciplinary team for adjudication. The prevalence and percent agreement between clinician- and CDE-identified clinical profiles was documented, and a series of logistic regressions with adjusted odds ratios were performed to identify which CDE assessments best predicted clinician-identified mTBI clinical profiles.

RESULTS

Migraine/headache, vestibular, and anxiety/mood mTBI clinical profiles exhibited the highest prevalence and overall percent agreement among CDE and clinician approaches. Participants exceeding cutoff scores for the Global Severity Index and Headache Impact Test-6 assessments were 3.90 and 8.81 times more likely to have anxiety/mood and migraine/headache profiles, respectively. The Vestibular/Ocular Motor Screening vestibular items and the Pittsburgh Sleep Quality Index total score were predictive of clinician-identified vestibular and sleep profiles, respectively.

CONCLUSIONS

The CDEs from migraine/headache, vestibular, and anxiety/mood domains, and to a lesser extent the sleep modifier, may be clinically useful for identifying patients with these profiles following mTBI. However, CDEs for cognitive and ocular may have more limited clinical value for identifying mTBI profiles.

Targeted multidomain intervention for complex mTBI: protocol for a multisite randomized controlled trial in military-age civilians

Background

Mild traumatic brain injury (mTBI) affects ~18,000 military personnel each year, and although most will recover in 3-4 weeks, many experience persisting symptoms and impairment lasting months or longer. Current standard of care for U.S. military personnel with complex mTBI involves initial (<48 h) prescribed rest, followed by behavioral (e.g., physical activity, sleep regulation, stress reduction, hydration, nutrition), and symptom-guided management. There is growing agreement that mTBI involves different clinical profiles or subtypes that require a comprehensive multidomain evaluation and adjudication process, as well as a targeted approach to treatment. However, there is a lack of research examining the effectiveness of this approach to assessing and treating mTBI. This multisite randomized controlled trial (RCT) will determine the effectiveness of a targeted multidomain (T-MD) intervention (anxiety/mood, cognitive, migraine, ocular, vestibular; and sleep, autonomic) compared to usual care (behavioral management) in military-aged civilians with complex mTBI.

Methods

This study employs a single-blinded, two-group repeated measures design. The RCT will enroll up to 250 military-aged civilians (18-49 yrs) with a diagnosed complex mTBI within 8 days to 6 months of injury from two concussion specialty clinics. The two study arms are a T-MD intervention and a usual care, behavioral management control group. All participants will complete a comprehensive, multidomain clinical evaluation at their first clinical visit. Information gathered from this evaluation will be used to adjudicate mTBI clinical profiles. Participants will then be randomized to either the 4-week T-MD or control arm. The T-MD group will receive targeted interventions that correspond to the patient's clinical profile (s) and the control group will receive behavioral management strategies. Primary outcomes for this study are changes from enrollment to post-intervention on the Neurobehavioral Symptom Inventory (NSI), Patient Global Impression of Change (PGIC), and functional near-infrared spectroscopy (fNIRS). Time to return to activity (RTA), and healthcare utilization costs will also be assessed.

Discussion

Study findings may inform a more effective approach to treat complex mTBI in military personnel and civilians, reduce morbidity, and accelerate safe return-to-duty/activity.

Ethics and dissemination

The study is approved by the University of Pittsburgh Institutional Review board and registered at clinicaltrials.gov. Dissemination plans include peer-reviewed publications and presentations at professional meetings.

Clinical Trial Registration

www.clinicaltrials.gov, identifier: NCT04549532.

Sex Differences on the Concussion Clinical Profiles Screening in Adolescents With Sport-Related Concussion

CONTEXT

Sex differences influence symptom presentations after sport-related concussion and may be a risk factor for certain concussion clinical profiles.

OBJECTIVE

To examine sex differences on the Concussion Clinical Profile Screen (CP Screen) in adolescents after sport-related concussion.

DESIGN

Cross-sectional study.

SETTING

A concussion specialty clinic.

PATIENTS OR OTHER PARTICIPANTS

A total of 276 adolescent (age = 15.02 ± 1.43 years; girls = 152 [55%]) athletes with a recently diagnosed concussion (≤30 days).

MAIN OUTCOME MEASURE(S)

The 5 CP Screen profiles (anxiety mood, cognitive fatigue, migraine, vestibular, ocular) and 2 modifiers (neck, sleep), symptom total, and symptom severity scores were compared using a series of Mann-Whitney U tests between boys and girls.

RESULTS

Girls (n = 152) scored higher than boys (n = 124) on the cognitive fatigue (U = 7160.50, z = -3.46, P = .001) and anxiety mood (U = 7059, z = -3.62, P < .001) factors but not on the migraine (U = 7768, z = -2.52, P = .01) factor. Girls also endorsed a greater number of symptoms (n = 124; U = 27233, z = -3.33, P = .001) and scored higher in symptom severity (U = 7049, z = -3.60, P < .001) than boys.

CONCLUSIONS

Among adolescents, symptom endorsement on the CP Screen varied based on sex, and clinicians need to be aware of these differences, especially when evaluating postconcussion presentation in the absence of baseline data.

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

OBJECTIVE

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.

METHODS

This was a retrospective analysis of medical records from a concussion specialty clinic. Two hundred and three athletes (M = 16.48 ± 1.97 years; 44% [90/203] female) completed a clinical visit for concussion within 30 days of injury (M = 7.73 ± 5.54 days). 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.

RESULTS

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.

CONCLUSIONS

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.

Optimizing VOMS for identifying acute concussion in collegiate athletes: Findings from the NCAA-DoD CARE consortium

The Vestibular/Ocular-Motor Screening (VOMS), an important component in acute (<72 h) sport-related concussion (SRC) assessment, is increasingly used alongside the Sport Concussion Assessment Tool (SCAT) and as part of the Military Acute Concussion Evaluation 2 (MACE2). VOMS demonstrates clinically useful diagnostic accuracy for acute SRC and improves the overall utility when added to the SCAT3. However, potential overlap among VOMS's vestibular and oculomotor items suggests the possibility of a more efficient version. VOMS and SCAT3 scores were analyzed for 3,958 preseason (47.8% female) and 496 acute-SRC (37.5% female) NCAA-DoD Concussion Assessment, Research, and Education (CARE) consortium collegiate athlete evaluations. Analyses revealed very large effect sizes (d = 2.39-2.45) and high correlations (rho = 0.95-0.99) among all VOMS items except near point of convergence distance (d = 0.79, rho ≤ 0.341). Receiver operating characteristic (ROC) curve analyses showed clinically useful discriminative utility for VOMS Total (AUC = 0.85) and the VOMS Total change score, where pretest symptoms were incorporated (AUC = 0.81). A modified VOMS (mVOMS) consisting of four items (smooth pursuits, horizontal saccades, horizontal vestibulo-ocular reflex, visual motion sensitivity) yielded identical AUCs to VOMS Total. Integer cutoff analyses suggest a score of ≥4 for VOMS Total and ≥4 for mVOMS Total optimizes concussion identification. Incorporating VOMS or mVOMS into SCAT3 (AUC = 0.79) significantly improved the combined tool's acute utility for acute concussion identification by a maximum of 4% (SCAT3+VOMS AUC = 0.84, SCAT3+mVOMS AUC = 0.83). Future versions of SCAT or MACE may want to consider incorporating a more parsimonious VOMS for the purpose of identifying acute concussion.

Association of Multidomain Assessment Outcomes with Referral for Vestibular Therapy following Concussion

CONTEXT

Multiple aspects of a multidomain assessment have been validated for identifying concussion, however, researchers have yet to determine which components are related to referral for vestibular therapy.

OBJECTIVE

To identify which variables from a multidomain assessment were associated with receiving a referral for vestibular therapy following a concussion.

DESIGN

Retrospective chart review, level of evidence 3.

PATIENTS OR OTHER PARTICIPANTS

Participants (n=331; age: 16.9±7.2; 39.3% female) were diagnosed with a concussion per international consensus criteria by a clinical neuropsychologist after presenting to a concussion specialty clinic.

MAIN OUTCOME MEASURES

Medical chart data was extracted from the first clinical visit regarding pre-injury medical history, computerized neurocognition, Post-Concussion Symptom Scale (PCSS), Concussion Clinical Profiles Screen (CP-Screen) and Vestibular Ocular Motor Screening (VOMS) within 16.2±46.7 days of injury. Five backwards logistic regression models were built to associate the outcomes from each of the five included assessments with referral for vestibular therapy. A final logistic regression model was built using variables retained in the previous five models as potential predictors of referral for vestibular therapy.

RESULTS

The five models built from individual components of the multidomain assessment predicted referral for vestibular therapy (R2= 0.01-0.28) with 1 to 6 statistically significant variables. The final multivariate model (R2= 0.40) retained 9 significant variables, represented by each of the five multidomain assessments except neurocognition. Variables with the strongest association to vestibular therapy referral were motor vehicle accident mechanism of injury (odds ratio [OR]=15.45), migraine history (OR=3.25), increased headache when concentrating (OR=1.81) and horizontal vestibular ocular reflex (OR=1.63).

CONCLUSIONS

The present study demonstrates the utility of a multidomain assessment, and identifies outcomes associated with a referral for vestibular therapy following a concussion.

A-41 Establishing Empirically-Based Normative Cut-Offs For Identifying Anxiety Following Sports-Related Concussion

Purpose: The State–Trait Anxiety Inventory (form Y-1; STAI) is widely used for identifying anxiety in non-clinical and clinical samples. Cutoff scores ≥40 are widely used to identify clinically significant anxiety. However, these scores correspond with the 50th–60th percentile in STAI normative tables. Given that anxiety is recognized as a common post-concussion symptom, and as a post-injury clinical profile, establishing statistically appropriate cutoffs for clinical anxiety is warranted. Methods: We compared rates of individuals falling above static (≥40) versus empirically-derived (&gt;1, &gt;1.5, &gt;2 standard deviations) cutoffs, using a sample of 137 acutely concussed high school and college athletes (59% male, mean age 16.11 ± 1.56 years) who completed the STAI within 7 days of injury (mean 3.79 ± 1.4 days). Results: Approximately 47% of concussed athletes fell above the static cutoff of ≥40, whereas use of empirically-derived cutoffs identified 18% (1SD), 8% (1.5SD) and 3% (2SD). These empirically-derived cutoffs reflect the normal curve, and distribution of scores expected to fall outside 1, 1.5, and 2SD. Conclusions: Use of a static cutoff of ≥40 on the STAI identifies approximately 50% of high school and college athletes as anxious. As such, use of empirically-derived cutoffs are recommended over static cutoffs for clinical anxiety when using the STAI.

A-45 Clinical Considerations of Neuropsychologists for Treating Concussions

Purpose: The purpose of this study was to explore sex specific clinical considerations by neuropsychologists’ and general clinical considerations for the treatment of concussion. Methods: Fourteen clinical neuropsychologists who see concussion patients regularly (&gt;1 case per week) were interviewed using a semi-structured guide that included a generic patient vignette. Participants were asked about clinical considerations that they faced while assessing, managing, and treating concussion. Two investigators independently coded the transcriptions and met to compare coding processes, definitions, and categories. A final codebook was developed in an iterative fashion and reapplied to all transcripts. Independent coding and member checks contributed to the trustworthiness of the data. Results: Participants’ clinical experience in treating concussion ranged from 1 to 40 years, and the sample was 64% female (9/14). Four major themes were identified, including patients’ sex considerations, sleep and napping, patient education and reassurance, and mental health considerations. Several participants (4/14; 29%) noted the lack of action-oriented clinical recommendations for previously documented sex differences (i.e., menstruation). There was a lack of uniformity in sleep and napping recommendations across the participants (e.g., permitting napping vs recommended nap-length). Participants noted that a large portion of their clinical time was spent educating and reassuring patients that concussion is treatable. Comorbid mental health considerations such as anxiety were a prevailing clinical concern across participants. Conclusions: The study revealed the need for better action-oriented clinical recommendations in consensus statements that address the four main themes of sex considerations, sleep and napping considerations, patient education and reassurance, and mental health considerations.

A-13 A Description of Patient Characteristics and Predictors for Vestibular Therapy Referral Following Concussion

Purpose: To describe patient characteristics and predictors for vestibular therapy referral among concussion patients with vestibular and ocular motor dysfunction. Methods: Medical records from 1083 patients (12-50 yrs) seeking care for concussion within 30 days of injury were extracted. Demographics and clinical outcomes (symptoms, vestibular/oculomotor change scores, and state anxiety) were described and associations between referral and these variables were explored with chi-square analyses and a logistic regression. Results: Twenty-one percent (229/1083, Mage = 22.34, SD = 10.26 yrs, 64% female) of patients received vestibular therapy referral. The most frequent risk factors included symptom burden (94%), vestibular/ocular motor symptom provocation (88%), convergence insufficiency (73%), state anxiety (66%), and post-traumatic migraine (PTM) (52%). The LR (χ2(13, 1083) = 142.24, p &lt; 0.001) revealed vestibular/ocular motor provocation (adjusted OR = 3.88, p &lt; 0.001) showed the greatest likelihood for referral followed by symptom burden (adjusted OR = 2.78, p &lt; 0.001), convergence insufficiency (adjusted OR = 2.77, p &lt; 0.001), first clinical visit longer than one week (adjusted OR = 1.90, p &lt; 0.001), and on-field dizziness (adjusted OR = 1.51, p = 0.03). Conclusions: Approximately 25% of concussed patients receive vestibular therapy. These patients have more vestibular/ocular motor impairment, dizziness, and overall symptom burden.

In-Person Versus Telehealth for Concussion Clinical Care in Adolescents: A Pilot Study of Therapeutic Alliance and Patient Satisfaction

OBJECTIVE

To conduct a pilot study of caregiver ratings of therapeutic alliance and patient satisfaction outcomes between telehealth and in-person concussion clinical care in male and female adolescent athletes.

SETTING

Outpatient neuropsychology concussion clinic.

PARTICIPANTS

Fifteen patients (aged 15.40 ± 1.35 years; 33% female) with a concussion and their accompanying caregivers ( n = 15; 87% female) were randomly assigned to an in-person clinic visit and 15 patients (aged 15.13 ± 1.25 years; 40% female) with a concussion and their accompanying caregivers ( n = 15; 73% female) were randomly assigned to a telehealth clinic visit.

DESIGN

A prospective, randomized design.

MAIN MEASURES

Therapeutic alliance and patient satisfaction scores.

RESULTS

Therapeutic alliance scores were not significantly different for patients in the in-person or telehealth setting, and caregiver therapeutic alliance scores were significantly higher for the in-person condition than for the telehealth condition. There were no significant differences between in-person and telehealth session satisfaction scores for patients on depth, smoothness, positivity, arousal, and bad-good outcomes. Patient and caregiver satisfaction with the clinical setting was high (ie, General Endorsement).

CONCLUSION

Telehealth is feasible for assessing and interpreting clinical concussion examination, interview, and neurocognitive findings, which are perceived by patients and their caregivers to be comparable with in-person care. Positive satisfaction scores also serve to reinforce the need for healthcare providers to seek ways to actively engage with patients and their caregivers through elements of communicative skills such as active listening, building patient rapport, encouraging patient autonomy, and providing an adequate amount of time for interaction and questions. Telehealth for concussion care is increasing in implementation across health systems, and demand is likely to grow in light of the current COVID-19 pandemic and advances in telehealth delivery.

Exploring the effect of napping on sleep quality and duration in collegiate athletes

Purpose: The purpose of this study was to extend research on napping and sleep behaviors in collegiate athletes, and to compare nappers and non-nappers on sleep quality and duration. Methods: Current varsity, club, and intramural athletes between 18-29 years completed the Short Napping Behavior Scale, Pittsburgh Quality Sleep Index, Generalized Anxiety Disorder-7, and the Patient Health Questionnaire-9. Results: Approximately 72% (129/179) reported napping. There were no significant differences in outcomes between nap frequency groups on sleep quality (Χ²(3)=4.97, p=.17) or duration (Χ²(3)=1.20, p=.75). Moreover, there was no significant differences for nap length groups on sleep quality (Χ²(3)=7.03, p=.07) or duration (Χ²(3)=1.32, p=.72). Furthermore, there were no significant differences for nap timing groups on sleep quality (Χ²(3)=1.54, p=.67) or duration (Χ²(3)=2.43, p=.49). Conclusion: In a sample of collegiate athletes, nap frequency, length, and timing were not associated with worse sleep quality or duration.

Ambulatory Assessment in Concussion Clinical Care and Rehabilitation

Concussion is a mild traumatic brain injury that is characterized by a wide range of physical, emotional, and cognitive symptoms as well as neurocognitive, vestibular, and ocular impairments that can negatively affect daily functioning and quality of life. Clinical consensus statements recommend a targeted, clinical profile-based approach for management and treatment. This approach requires that clinicians utilize information obtained via a clinical interview and a multi-domain assessment battery to identify clinical profile(s) (e.g., vestibular, mood/anxiety, ocular, migraine, cognitive fatigue) and prescribe a corresponding treatment/rehabilitation program. Despite this comprehensive approach, the clinical picture can be limited by the accuracy and specificity of patient reports (which often conflate timing and severity of symptomology), as well as frequency and duration of exposure to symptom exacerbating environments (e.g., busy hallways, sitting in the back seat of a car). Given that modern rehabilitation programs leverage the natural environment as a tool to promote recovery (e.g., expose-recover approach), accurate characterization of the patient clinical profile is essential to improving recovery outcomes. Ambulatory assessment methodology could greatly benefit concussion clinical care by providing a window into the symptoms and impairments experienced by patients over the course of their daily lives. Moreover, by evaluating the timing, onset, and severity of symptoms and impairments in response to changes in a patient's natural environment, ambulatory assessments can provide clinicians with a tool to confirm clinical profiles and gauge effectiveness of the rehabilitation program. In this perspective report, we review the motivations for utilizing ambulatory assessment methodology in concussion clinical care and report on data from a pilot project utilizing smart phone-based, ambulatory assessments to capture patient reports of symptom severity, environmental exposures, and performance-based assessments of cognition for 7 days following their initial evaluation.

Test-Retest, Interrater Reliability, and Minimal Detectable Change of the Dynamic Exertion Test (EXiT) for Concussion

BACKGROUND

The Dynamic Exertion Test (EXiT) was developed to inform return-to-play (RTP) decision-making following clinical recovery from sport-related concussion (SRC). The purpose of the current study was to document intrarater and test-retest reliability and minimal detectable change (MDC) scores for physiological [heart rate (HR) and blood pressure], performance (change-of-direction task completion time and errors), and clinical outcomes (endorsed symptoms, perceived exertion) of EXiT, and interrater reliability of performance outcomes.

HYPOTHESIS

Healthy athletes would exhibit stable physiological responses to the EXiT across visits, demonstrate consistent change-of-direction task completion time between consecutive trials at each visit, and the fastest time (of 2 trials) across visits, and endorse equivocal symptoms and effort across visits.

STUDY DESIGN

Cross-sectional, test-retest.

LEVEL OF EVIDENCE

Level 3.

METHODS

Seventy-nine (female: 34 [43%], 19.6 ± 5.0 years) athletes completed the EXiT at 2 study visits (8.7 ± 4.7 days between visits). Two-way, mixed, intraclass correlation coefficients (ICCs) were used to evaluate intrarater and test-retest reliability. Cronbach's alpha was used to document the internal consistency of symptoms at each visit, and MDC scores were calculated on the physiological, performance, and clinical outcomes.

RESULTS

Measured and percentage of age-estimated maximum HR were reliable following EXiT (ICC = 0.579-0.618). Change-of-direction task completion time (MDC range = 0.75-8.70 s) had good-to-excellent test-retest (ICC = 0.703-0.948) and interrater (ICC = 0.932-0.965) reliability. Symptoms had a high internal consistency at visits 1 (α = 0.894) and 2 (α = 0.805) and were reliable across visits (ICC = 0.588).

CONCLUSION

The current investigation established test-retest reliability in addition to MDC scores of an objective dynamic exercise assessment among healthy adolescent and adult athletes. The EXiT may be an objective approach to inform RTP decision-making following SRC recovery.

CLINICAL RELEVANCE

The EXiT is a clinically feasible exertion-based assessment that can be readily administered in a variety of outpatient clinical settings.

Utility of VOMS, SCAT3, and ImPACT Baseline Evaluations for Acute Concussion Identification in Collegiate Athletes: Findings From the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium

BACKGROUND

The Vestibular/Ocular-Motor Screening (VOMS) is a valuable component of acute (<72 hours) sports-related concussion (SRC) assessments and is increasingly used with the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) instrument and the third edition of the Sport Concussion Assessment Tool (SCAT3). Research has suggested that VOMS acute postinjury scores are useful in identifying acute concussion. However, the utility of preseason baseline measurements to improve diagnostic accuracy remains ambiguous. To this end, there is a need to determine how reliable VOMS baseline assessments are across years and whether incorporating individuals' baseline performance improves diagnostic yield for acute concussions.

PURPOSE

To analyze VOMS, SCAT3, and ImPACT to evaluate the test-retest reliability of consecutive-year preseason baseline assessments to directly compare the diagnostic utility of these tools when incorporating baseline assessments versus using postinjury data alone to identify acute SRC.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Preseason and postinjury VOMS, SCAT3, ImPACT Post-Concussion Symptom Scale (PCSS), and ImPACT composite scores were analyzed for 3958 preseason (47.7% female) and 496 acute (≤48 hours) SRC (37.5% female) collegiate athlete evaluations in the National Collegiate Athletic Association-Department of Defense Concussion Assessment Research and Education Consortium. Descriptive statistics, Kolmogorov-Smirnov significance, and Cohen d effect size were calculated. Consecutive-year baseline reliability was evaluated for a subset of 447 athlete encounters using Pearson r, Cohen κ, Cohen d, and 2-way mixed intraclass correlation coefficients (ICCs). Wilcoxon signed rank tests were used to determine the statistical significance between population performances, and the 90% reliable change index (RCI) was calculated from the test-retest results. Preseason to postinjury change scores were then calculated from each tool's RCI. Finally, receiver operating characteristic (ROC) curve analyses were conducted, and DeLong method was used to compare the area under the curve (AUC) of raw postinjury scores versus change scores from preseason baseline assessments. Potential effects of sex, medical history (learning disorders or attention-deficit/hyperactivity disorder), and outlier data were also explored.

RESULTS

Effect sizes were large, and overall predictive utilities were clinically useful for postinjury VOMS Total (d = 2.44; AUC = 0.85), the SCAT3 Symptom Evaluation total severity score (d = 1.74; AUC = 0.82), and the ImPACT PCSS total severity score (d = 1.67; AUC = 0.80). Comparatively, effect sizes were small and predictive utilities were poor for Standardized Assessment of Concussion (SAC), modified Balance Error Scoring System (mBESS), and all ImPACT composites (d = 0.11-0.46; AUC = 0.48-0.59). Preseason baseline test-retest reliability was poor to moderate (r = 0.23-0.52; κ = 0.32-0.36; ICC = 0.36-0.68) for all assessments except ImPACT Visual Motion Sensitivity (r = 0.73; ICC = 0.85). Incorporating baseline scores for VOMS Total, SCAT3 (Symptom Evaluation, SAC, mBESS), ImPACT PCSS, or ImPACT composites did not significantly improve AUCs.

CONCLUSION

VOMS Total and symptom severity (SCAT3, PCSS) total scores had large effect sizes and clinically useful AUCs for identifying acute concussion. However, all tools demonstrated high within-patient test-retest variability, resulting in poor reliability. The findings in this sample of collegiate athletes suggest that incorporating baseline assessments does not significantly increase diagnostic yield for acute concussion.

The Emerging Role of Telehealth for Concussion Clinical Care During the Coronavirus (COVID-19) Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has substantially altered the delivery of healthcare for providers and their patients. Patients have been reticent to seek care for many diseases and injuries including concussion due to fears of potential exposure to COVID-19. Moreover, because of social distancing recommendations and stay-at-home orders, patient screening, evaluation, and delivery of care have become less efficient or impossible to perform via in-person clinic visits. Consequently, there was a sudden need to shift healthcare delivery from primarily in-person visits to telehealth. This sudden shift in healthcare delivery brings with it both challenges and opportunities for clinical concussion care. This article is designed to discuss these challenges and opportunities and provide an experiential-based framework for providing concussion care via telehealth. We first provide an overview of a clinical concussion model utilized at concussion specialty clinics from 3 geographically disparate healthcare systems for in-person service delivery prior to COVID-19. We then discuss the creation of new clinical workflows to facilitate the continued provision of concussion specialty care using telehealth. Finally, we examine lessons learned during this healthcare delivery shift including limitations and potential barriers for telehealth for concussion care, as well as opportunities for expansion of concussion care in rural and underserved areas. We also discuss the need to empirically evaluate the comparative efficacy of telehealth and in-person concussion care moving forward.

Preliminary Evidence of a Dose-Response for Continuing to Play on Recovery Time After Concussion

OBJECTIVE

To investigate a dose-response relationship between continuing to play following concussion and outcomes.

PARTICIPANTS

A total of 130 athletes (age 11-19 years).

DESIGN

Repeated-measures design comparing symptoms, neurocognitive performance, and recovery time between 52 athletes immediately removed from play (Removed), 24 who continued to play for 15 minutes or less (Short-Play), and 32 who continued to play for more than 15 minutes (Long-Play).

MAIN MEASURES

Recovery was the number of days from injury to clearance. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) measured neurocognitive outcomes and the Post-Concussion Symptom Scale (PCSS) measured symptom severity.

RESULTS

Long-Play (44.09 ± 27.01 days) took longer to recover than Short-Play (28.42±12.74 days) and Removed (18.98 ± 13.76 days). Short-Play was 5.43 times more likely, and Long-Play 11.76 times more likely, to experience protracted recovery relative to Removed. Both Play groups had worse neurocognitive performance and higher symptom scores than Removed at days 1 to 7, with Long-Play demonstrating worse reaction time than Short-Play. At days 8 to 30, both Play groups performed worse than Removed on visual memory and visual motor speed, while only Long-Play performed worse on verbal memory and reaction time.

CONCLUSIONS

Results provide initial evidence of a dose-response effect for continuing to play on recovery from concussion, highlighting the importance of removal from play.

A-173 Clinical Cutoffs on the State–Trait Anxiety Inventory for Concussion

Objective

The State–Trait Anxiety Inventory (STAI) is a widely used measure of state anxiety with a proposed raw score cutoff of &gt;40 denoting probable clinical levels of anxiety. The mean score for high school aged individuals is approximately 40, corresponding with the 56th (male) and 51st (female) percentiles. The use of this cutoff classifies approximately 50% of individuals with clinically significant anxiety. In contrast, empirically based cut-offs (e.g., 1SD above the mean), classifies a more appropriate percentage of cases. The purpose of this study was to document the percentage of patients surpassing the proposed clinical cutoffs for the STAI using traditional and empirically based cutoffs in concussed high school athletes.

Methods

Participants were 273 concussed high school athletes (15.89 ± 1.1 yrs) who completed the STAI (Form Y-1) at their first clinical visit within 2–30 days of injury. Participants with a personal history of anxiety were excluded. The percentage of participants exceeding current clinical cutoffs for the STAI (i.e., &gt;40) and exceeding &gt;1, &gt;1.5, and &gt; 2 SD were calculated using high school normative data.

Results

Overall, 37% of participants exceeded the proposed raw score cutoff (&gt;40) for the STAI. Approximately 12%, 4%, and 2% of participants exhibited STAI scores that exceeded &gt;1, &gt;1.5, and &gt; 2 SD respectively.

Conclusions

The proposed cutoff score of &gt;40 for the STAI is overly inclusive and not appropriate for identifying probable clinical levels of state anxiety in concussed adolescent athletes. Use of empirically based cutoffs is more appropriate when attempting to identify clinically significant anxiety post-concussion.

Discriminative Validity of Vestibular Ocular Motor Screening in Identifying Concussion Among Collegiate Athletes: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research, and Education Consortium Study

BACKGROUND

Vestibular and ocular motor screening tools, such as the Vestibular/Ocular Motor Screening (VOMS), are recognized as important components of a multifaceted evaluation of sport-related concussion. Previous research has supported the predictive utility of the VOMS in identifying concussion, but researchers have yet to examine the predictive utility of the VOMS among collegiate athletes in the first few days after injury.

PURPOSE

To determine the discriminative validity of individual VOMS item scores and an overall VOMS score for identifying collegiate athletes with an acute sport-related concussion (≤72 hours) from healthy controls matched by age, sex, and concussion history.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Participants (N = 570) aged 17 to 25 years were included from 8 institutions of the National Collegiate Athletic Association-Department of Defense CARE Consortium (Concussion Assessment, Research, and Education): 285 athletes who were concussed (per current consensus guidelines) and 285 healthy controls matched by age, sex, and concussion history. Participants completed the VOMS within 3 days of injury (concussion) or during preseason (ie, baseline; control). Symptoms are totaled for each VOMS item for an item score (maximum, 40) and totaled across items for an overall score (maximum, 280), and distance (centimeters) for near point of convergence (NPC) is averaged across 3 trials. Receiver operating characteristic analysis of the area under the curve (AUC) was performed on cutoff scores using Youden index (J) for each VOMS item, overall VOMS score, and NPC distance average. A logistic regression was conducted to identify which VOMS scores identified concussed status.

RESULTS

A symptom score ≥1 on each VOMS item and horizontal vestibular/ocular reflex ≥2 significantly discriminated concussion from control (AUC, 0.89-0.90). NPC distance did not significantly identify concussion from control (AUC, 0.51). The VOMS overall score had the highest accuracy (AUC, 0.91) for identifying sport-related concussion from control. Among the individual items, vertical saccades ≥1 and horizontal vestibular/ocular reflex ≥2 best discriminated concussion from control.

CONCLUSION

The findings indicate that individual VOMS items and overall VOMS scores are useful in identifying concussion in collegiate athletes within 3 days of injury. Clinicians can use the cutoffs from this study to help identify concussion in collegiate athletes.

Risk Factors for Vestibular and Oculomotor Outcomes After Sport-Related Concussion

OBJECTIVE

To investigate the association between risk factors and vestibular-oculomotor outcomes after sport-related concussion (SRC).

STUDY DESIGN

Cross-sectional study of patients seen 5.7 ± 5.4 days (range 0-30 days) after injury.

SETTING

Specialty clinic.

PARTICIPANTS

Eighty-five athletes (50 male athletes and 35 female athletes) aged 14.1 ± 2.8 years (range 9-24 years) seeking clinical care for SRC.

INTERVENTIONS

Participants completed a clinical interview, history questionnaire, symptom inventory, and vestibular/ocularmotor screening (VOMS). Chi-square tests with odds ratios and diagnostic accuracy were used to examine the association between risk factors and VOMS outcomes.

MAIN OUTCOME MEASURES

The VOMS.

RESULTS

Female sex (χ2 = 4.9, P = 0.03), on-field dizziness (χ2 = 7.1, P = 0.008), fogginess (χ2 = 10.3, P = 0.001), and post-traumatic migraine (PTM) symptoms including headache (χ2 = 16.7, P = 0.001), nausea (χ2 = 10.9, P = 0.001), light sensitivity (χ2 = 14.9, P = 0.001), and noise sensitivity (χ2 = 8.7, P = 0.003) were associated with presence of one or more postconcussion VOMS score above clinical cutoff. On-field dizziness (χ2 = 3.8, P = 0.05), fogginess (χ2 = 7.9, P = 0.005), and PTM-like symptoms including nausea (χ2 = 9.0, P = 0.003) and noise sensitivity (χ2 = 7.2, P = 0.007) were associated with obtaining a postconcussion near-point convergence (NPC) distance cutoff >5 cm. The likelihood ratios were 5.93 and 5.14 for VOMS symptoms and NPC distance, respectively.

CONCLUSIONS

Female sex, on-field dizziness, fogginess, and PTM symptoms were predictive of experiencing vestibular-oculomotor symptoms/impairment after SRC.

The relationship between accelerometer-measured sleep and next day ecological momentary assessment symptom report during sport-related concussion recovery

OBJECTIVES

Research examining sleep and concussion symptoms following sport-related concussion (SRC) is limited by retrospective self-report rather than objective data from wearable technology and real-time symptom report. The purpose of this study is to use actigraphy and ecological momentary assessment (EMA) to examine the relationship between sleep parameters and next day symptoms.

METHODS

Seventeen athletes (47.1%F) aged 12-19 (15.35+/-2.09) years (<72 hours post-SRC) wore Actigraph GT3x+ to measure nighttime sleep and completed post-concussion symptom scales (PCSS) three times via mobile EMA, resulting in a range of 91-177 observations for each outcome. Generalized linear mixed models, utilizing independent variables of sleep efficiency (SE%: ratio of awake time to sleep time) and total sleep time (TST) examined the associations between nightly sleep and symptoms next-day and throughout recovery.

RESULTS

SE% (IRR .97, 95%CI: .95, .99, P= .009) and TST (IRR .91, 95%CI: .84, .999, P = .047) were negatively associated with next day night symptoms. The negative relationship between SE% and the cognitive-migraine-fatigue (CMF) factor was significant for next day/night symptoms (P = .01), while TST was associated with symptom severity for the affective symptom factor (P = .015). Sleep was negatively associated with total symptoms and afternoon symptoms in Week 1 and total, morning, afternoon, and night symptoms in Week 2 (ps=.001-.021) of recovery.

CONCLUSION

Sleep was negatively associated with symptoms the next day, especially late in the day and among CMF and emotional symptoms. The relationship between sleep and symptom burden was strongest in the subacute stage of concussion recovery, highlighting the potential importance of sleep intervention post-injury.

Using change scores on the vestibular ocular motor screening (VOMS) tool to identify concussion in adolescents

OBJECTIVE

To develop clinical cutoffs using change scores for the VOMS individual items and an overall VOMS change score that identified concussion in adolescent athletes.

METHODS

Change score clinical cutoffs were calculated from a sample of adolescents (13-18 years) with SRC (n = 147) and a sample of uninjured adolescents CONTROL (n = 147). Receiver operating characteristic (ROC) curves, with area under the curve (AUC), based on Youden's J statistic were used to identify optimal cutoffs for identifying SRC from CONTROLS using VOMS individual item change scores, an overall VOMS change scores, and NPC distance (cm).

RESULTS

AUC values for VOMS item change scores ranged from .55 to .71. Optimal change score cutoffs were ≥1 for VOMS items and ≥3 for overall VOMS change score. The optimal cutoff for NPC distance was ≥3 cm. A ROC analysis revealed a three-factor model (AUC = .76) for identifying SRC that included vertical vesibular ocular reflex (VVOR), visual motion sensitivity (VMS), and NPC distance items. The AUC (.73) for the overall VOMS change score was higher than any individual VOMS AUC values.

CONCLUSIONS

This study supports an alternate scoring approach and clinical interpretation of VOMS items involving change scores that account for pretest symptoms.

Sport Concussion Assessment Tool Symptom Inventory: Healthy and Acute Postconcussion Symptom Factor Structures

CONTEXT

Previous researchers have examined factor structures for common concussion symptom inventories. However, they failed to discriminate between the acute (<72 hours) and subacute (3 days-3 months) periods after concussion. The Sport Concussion Assessment Tool (SCAT) is an acute assessment that, when compared with other concussion symptom inventories, includes or excludes symptoms that may result in different symptom factors.

OBJECTIVE

The primary purpose was to investigate the symptom factor structure of the 22-item SCAT symptom inventory in healthy, uninjured and acutely concussed high school and collegiate athletes. The secondary purpose was to document the frequency of the unique SCAT symptom inventory items.

DESIGN

Case series.

SETTING

High school and college.

PATIENTS OR OTHER PARTICIPANTS

A total of 1334 healthy, uninjured and 200 acutely concussed high school and collegiate athletes.

MAIN OUTCOME MEASURE(S)

Healthy, uninjured participants completed the SCAT symptom inventory at a single assessment. Participants in the acutely concussed sample completed the SCAT symptom inventory within 72 hours after concussion. Two separate exploratory factor analyses (EFAs) using a principal component analysis and varimax extraction method were conducted.

RESULTS

A 3-factor solution accounted for 48.1% of the total variance for the healthy, uninjured sample: cognitive-fatigue (eg, feeling "in a fog" and "don't feel right"), migraine (eg, neck pain and headache), and affective (eg, more emotional and sadness) symptom factors. A 3-factor solution accounted for 55.0% of the variance for the acutely concussed sample: migraine-fatigue (eg, headache and "pressure in the head"), affective (eg, sadness and more emotional), and cognitive-ocular (eg, difficulty remembering and balance problems) symptom factors.

CONCLUSIONS

The inclusion of unique SCAT symptom inventory items did not alter the symptom factor structure for the healthy, uninjured sample. For the acutely concussed sample, all but 1 unique SCAT symptom inventory item (neck pain) loaded onto a factor.

Predictive Accuracy of the Sport Concussion Assessment Tool 3 and Vestibular/Ocular-Motor Screening, Individually and In Combination: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education Consortium Analysis

BACKGROUND

Vestibular and ocular symptoms in sport-related concussions are common. The Vestibular/Ocular-Motor Screening (VOMS) tool is a rapid, free, pen-and-paper tool that directly assesses these symptoms and shows consistent utility in concussion identification, prognosis, and management. However, a VOMS validation study in the acute concussion period of a large sample is lacking.

PURPOSE

To examine VOMS validity among collegiate student-athletes, concussed and nonconcussed, from the multisite National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education (CARE) Consortium. A secondary aim was to utilize multidimensional machine learning pattern classifiers to deduce the additive power of the VOMS in relation to components of the Sport Concussion Assessment Tool 3 (SCAT3).

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Preseason and acute concussion assessments were analyzed for 419 student-athletes. Variables in the analysis included the VOMS, Balance Error Scoring System, Standardized Assessment of Concussion, and SCAT3 symptom evaluation score. Descriptive statistics were calculated for all tools, including Kolmogorov-Smirnov significance and Cohen d effect size. Correlations between tools were analyzed with Spearman r, and predictive accuracy was evaluated through an Ada Boosted Tree machine learning model's generated receiver operating characteristic curves.

RESULTS

Total VOMS scores and SCAT3 symptom scores demonstrated significant increases in the acute concussion time frame (Cohen d = 1.23 and 1.06; P < .0001), whereas the Balance Error Scoring System lacked clinical significance (Cohen d = 0.17). Incorporation of VOMS into the full SCAT3 significantly boosted overall diagnostic ability by 4.4% to an area under the curve of 0.848 (P < .0001) and produced a 9% improvement in test sensitivity over the existing SCAT3 battery.

CONCLUSION

The results from this study highlight the relevance of the vestibular and oculomotor systems to concussion and the utility of the VOMS tool. Given the 3.8 million sports-related and 45,121 military-related concussions per year, the addition of VOMS to the SCAT3 is poised to identify up to an additional 304,000 athletes and 3610 servicemembers annually who are concussed, thereby improving concussion assessment and diagnostic rates. Health care providers should consider the addition of VOMS to their concussion assessment toolkits, as its use can positively affect assessment and management of concussions, which may ultimately improve outcomes for this complex and common injury.

How long after maximal physical exertion should baseline computerized neurocognitive testing and symptom assessment be administered?

Objective: Prior research suggests maximal physical exertion (MPE) may negatively affect the reliability and validity of computerized neurocognitive testing (CNT); the purpose of this study was to identify aclinically relevant recovery interval following MPE for the administration of baseline CNT.Design: Random-crossover.Participants: Thirty (M = 21.87 ± 2.29 y), moderately-active,healthy participants, without history of ADHD, learning disabilities, psychological disorders or concussion (within the last six months).Intervention: Participants completed four randomly ordered experimental trials. Except for the control trial, CNT was administered following MPE with assigned recovery intervals [Immediate, 10-minutes,or 20-minutes]. Aseries of repeated measures analysis of variance (ANOVAs) were performed on CNT composite and total symptom scores.Results: Total symptom scores were significantly greater (p < .01) at the immediate, 10-minute,and 20-minuterecovery intervals compared to the control trial. Processing speed was significantly faster at the 20-minuterecovery interval compared to the control trials. Visual memory, verbal memory, or reaction time did not differ across recovery intervals.Conclusions: Clinicians should wait more than 20 minutes before assessing baseline concussion symptoms following about of MPE.

Concussions in the National Football League: the evolution of video review for assessing the frequency and reliability of visible signs

Background: The use of video review to document visible signs (VS) of sport-related concussion in the National Football League (NFL) is a novel method to recognize head injuries. Hypothesis/Purpose: The current pilot studies used varying methodologies to (1) examine the frequency of VS in concussed NFL players using the Australian Football League's (AFL) checklist, and (2) assess the reliability of VS between non-expert and expert raters. Study design: Cohort study Methods: In the first pilot study, two non-expert raters rated VS of SRC occurring in the 2015 NFL season (n = 96) using a single VS from the AFL checklist. Based on this pilot study, two expert raters then rated VS of SRC during the 2017 NFL season (n = 211) using all VS from the AFL checklist. The frequency, total percent agreement (TPA), and reliability (kappa coefficients) were calculated for all VS of concussion for the two seasons. Kappa agreement was classified as fair (.41-.60), moderate (.61-.80), or substantial (.81-1.00). Significance was set at p < .05. Results: The most frequent VS of concussion identified by both non-expert and expert raters were no behavior observed, slow to get up, and motor incoordination. The least frequent VS were impact seizure, blank/vacant look, and facial injury. For non-expert raters, the average TPA for VS ranged from 84% to 100% and kappa coefficients ranged from .52 to .68. For expert raters, the average TPA ranged from 83% to 100%, and kappa coefficients ranged from .56 to .86. Conclusion: In these preliminary analyses, use of multiple VS was a superior methodology, and the reliability of VS rating was stronger for experts. Due to the inherent differences in gameplay and protective equipment used in the NFL compared to other professional sports, it is our hope these data can generate new ways to improve existing practices and identify potentially novel VS of SRC.

Preliminary investigation of a multimodal enhanced brain function index among high school and collegiate concussed male and female athletes

Objective: The primary purpose of this study was to examine the longitudinal effects of sports-related concussion (SRC) on a multi-faceted assessment battery which included neuropsychological testing, symptom reporting, and enhanced brain function index (eBFI) among athletes with and without SRC. A secondary purpose was to explore longitudinal sex differences among these measures in athletes with and without SRC. Methods: A case-control, repeated-measures design was used for this study. A total of 186 athletes (concussed group:n= 87 controls:n= 99) participated in the study. A repeated-measures design was used in which each athlete was tested at four time points following an SRC: within 72 h of injury (Day 0; 2.0 ± 0.9 days following injury), 5 days following injury (Day 5; 5.0 ± 0.0), at return to play (RTP; 18.3 ± 13.8 days following injury), and within 45 days following RTP (RTP45; 66.2 ± 19.0 days following injury). All analyses were conducted separately using a 2 (Group: concussed, control) × 2 (Sex: male, female) × 4 (Time:Day 0, Day 5, RTP, RTP45) univariate multi-level model including the random intercept for each participant. A higher eBFI score indicates a better performance. Alpha level was set aprior at .05. This study was registered on clinicaltrials.gov (Objective Brain Function Assessment of mTBI/Concussion in College/high school Athletes NCT02477943, NCT02661633, CAS 13-25 NCT03963804). Results: Concussed athletes exhibited impaired eBFI within 72 h of SRC and at Day 5 compared to controls (p<.001). Analysis of eBFI scores between male and female athletes revealed a main effect of sex (p=.05), with female athletes exhibiting lower eBFI (33.9 ± 30.7) relative to male athletes (40.4 ± 33.0), however, it did not indicate interactions between sex, group, and time (p's ≥ 0.786). Conclusion: The eBFI appears to be a useful tool in determining concussed athletes during the acute stages of an SRC. However, this index may lack the sensitivity to detect sex-related differences between groups at various time points during recovery.

How Do ImPACT Quick Test Scores Compare with ImPACT Online Scores in Non-Concussed Adolescent Athletes?

OBJECTIVE

To compare neurocognitive scores between the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) Quick Test (QT) and Online Versions in non-concussed high school athletes.

METHODS

A sample of 47 high school athletes completed the ImPACT Online Version pre-season and the ImPACT QT approximately 3 months later. Paired sample t-tests and Pearson's correlations examined differences and relationships between the ImPACT batteries.

RESULTS

The ImPACT QT scores were significantly higher for performance on the Three Letters: Average Counted (p < .001, d = .88), Three Letters: Average Counted Correctly (p < .001, d = .80), and Symbol Match: Correct RT Visible (p < .001, d = .72), and Symbol Match: Correct RT Hidden (p = .002, d = .50) subtests. There were significant relationships for Three Letters: Average Counted (r = .85, p < .001), Three Letters: Average Counted Correctly (r = .82, p < .001), and Symbol Match: Total Correct Hidden (r = .40, p = .006) subtests.

CONCLUSIONS

Post-injury evaluation data using ImPACT QT should be compared to normative referenced data, and not to pre-season data from the ImPACT Online Version.

Sport Concussion Assessment Tool Symptom Inventory: Healthy and Acute Postconcussion Symptom Factor Structures

CONTEXT

Previous researchers have examined factor structures for common concussion symptom inventories. However, they failed to discriminate between the acute (<72 hours) and subacute (3 days-3 months) periods after concussion. The Sport Concussion Assessment Tool (SCAT) is an acute assessment that, when compared with other concussion symptom inventories, includes or excludes symptoms that may result in different symptom factors.

OBJECTIVE

The primary purpose was to investigate the symptom factor structure of the 22-item SCAT symptom inventory in healthy, uninjured and acutely concussed high school and collegiate athletes. The secondary purpose was to document the frequency of the unique SCAT symptom inventory items.

DESIGN

Case series.

SETTING

High school and college.

PATIENTS OR OTHER PARTICIPANTS

A total of 1334 healthy, uninjured and 200 acutely concussed high school and collegiate athletes.

MAIN OUTCOME MEASURE(S)

Healthy, uninjured participants completed the SCAT symptom inventory at a single assessment. Participants in the acutely concussed sample completed the SCAT symptom inventory within 72 hours after concussion. Two separate exploratory factor analyses (EFAs) using a principal component analysis and varimax extraction method were conducted.

RESULTS

A 3-factor solution accounted for 48.1% of the total variance for the healthy, uninjured sample: cognitive fatigue (eg, feeling "in a fog" and "don't feel right"), migraine (eg, neck pain and headache), and affective (eg, more emotional and sadness) symptom factors. A 3-factor solution accounted for 55.0% of the variance for the acutely concussed sample: migraine fatigue (eg, headache and "pressure in the head"), affective (eg, sadness and more emotional), and cognitive ocular (eg, difficulty remembering and balance problems) symptom factors.

CONCLUSIONS

The inclusion of unique SCAT symptom inventory items did not alter the symptom factor structure for the healthy, uninjured sample. For the acute concussed sample, all but 1 unique SCAT symptom inventory item (neck pain) loaded onto a factor.

Concussion Symptom Cutoffs for Identification and Prognosis of Sports-Related Concussion: Role of Time Since Injury

BACKGROUND

Symptom reporting with scales such as the Post-Concussion Symptom Scale (PCSS) is one of the most sensitive markers of concussed status and/or recovery time, It is known that time from injury until initial clinic visit affects symptom presentation and recovery outcomes, but no study to date has evaluated changes in clinical cutoff scores for the PCSS based on earlier versus later clinical presentation postconcussion.

PURPOSE

To evaluate if time since injury after sports-related concussion (SRC) affects clinical cutoff scores for total PCSS and PCSS factors in differentiating athletes with SRC from healthy controls and predicting prolonged recovery (>30 days) after SRC.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A chart review was conducted of clinical data from patients with SRC (age, 13-25 years; n = 588; female, n = 299) who presented to concussion specialty clinics. Participants were categorized on the basis of time from injury: early (≤7 days; n = 348) and late (8-21 days; n = 240). Outcomes were total symptom severity (ie, total PCSS score) and total score for each of 4 symptom factors (cognitive/migraine/fatigue [CMF], affective, sleep, and somatic). Area under the curve (AUC) analyses were conducted using the Youden index to optimize sensitivity and specificity cutoffs.

RESULTS

In the early group, the CMF factor (cutoff, ≥7; AUC = 0.944), affective factor (cutoff, ≥1; AUC = 0.614), and total PCSS (cutoff, ≥7; AUC = 0.889) differentiated athletes with SRC from controls. In the late group, the CMF factor cutoff was reduced (cutoff, ≥4; AUC = 0.945), while the total PCSS score (cutoff, ≥7; AUC = 0.892), affective factor (cutoff, ≥1; AUC = 0.603), and sleep factor (cutoff, ≥1; AUC = 0.609) remained the same. In the early cohort, the CMF factor was the strongest predictor of protracted recovery (cutoff, ≥23; AUC = 0.717), followed by the total PCSS (cutoff, ≥39; AUC = 0.695) and affective factor (cutoff, ≥2; AUC = 0.614). The affective factor (cutoff, ≥1; AUC = 0.642) and total PCSS (cutoff, ≥35; AUC = 0.592) were significant predictors in the late cohort, but the cutoff threshold was reduced.

CONCLUSION

The findings indicate that PCSS symptom clinical cutoffs for identifying injury and recovery prognosis change on the basis of time since injury. Specifically, the combination of CMF, affective, and sleep factors is the best differentiator of athletes with SRC from controls regardless of time since injury. Furthermore, the CMF factor is the most robust predictor of prolonged recovery if the patient is within 1 week of SRC, whereas the affective factor is the most robust predictor of prolonged recovery if the patient is within 2 to 3 weeks of SRC.

A-41 Exploring the Influence of Referral Source on State Anxiety Levels of Concussed Patients

Objective

To explore the influence of referral source on state anxiety in concussed athletes.

Method

One hundred thirty athletes (mean age = 16.46, SD = 1.93 yrs; 42% female) seeking care for a concussion at a specialty clinic within 30 days of injury (M = 8.83, SD = 6.12 days) were enrolled in the study. Demographic (e.g., age, sex, and history of anxiety) and referral source (e.g., emergency department/urgent care, primary care/pediatrician, and athletic trainer) information were collected, and the State-Trait Anxiety Inventory (STAI) was administered to all participants. A one-way analysis of variance (ANOVA) was conducted to compare STAI scores between referral groups, and a logistic regression (LR) was used to assess the relationship between referral sources and patients with and without clinical levels of state anxiety (STAI &gt; 40). Statistical significance for all analyses was (p &lt; .05).

Results

Approximately 25% (32/130) of patients reported a history of anxiety, and 46% (60/130) scored above clinical cutoffs for clinical anxiety. The referral groups did not differ on STAI scores (F(3, 130) = 1.12, p = .34), and the LR was not significant, (χ2(2, N = 130) = 3.75, p = 0.15).

Conclusions

History of anxiety was highly correlated with state anxiety at the first clinical visit; however, patients referred from different medical sources did not differ on clinical levels of anxiety at the first clinical visit following concussion.

A-48 Athletes that self-report no physical activity/rest are more likely to exhibit clinical levels of state anxiety following concussion

Objective

To investigate the influence of self-reported physical activity (PA) on state anxiety in athletes with concussion

Method

Participants were 230 athletes (mean age = 16.46, SD = 1.94; 43% female) seeking care for a concussion at a specialty clinic within 30 days of injury (M = 8.83, SD = 6.12 days). Demographic data were collected during the clinical interview: age, sex, and history of concussion, migraine, learning disability, attention deficit hyperactivity disorder, anxiety, and depression. Patients completed the State-Trait Anxiety Inventory (STAI) and self-reported current levels of PA; 113 participants reported rest or no physical activity (REST) and 117 reported at least minimal PA (ACTIVE). The groups were compared on demographic variables to ensure group equivalence. Independent samples t-test examined differences between groups on state anxiety scores and a chi-square with odds ratios (ORs) examined the relationship between PA groups and clinical levels of state anxiety (STAI &gt; 40). Statistical significance for all analyses was (p &lt; .05).

Results

The groups were similar on all demographic variables (p &gt; .05). The NO PA/REST group exhibited significantly higher state anxiety scores at first clinic visit than the PA group (t (228) = 2.82, p = .005), and the NO PA/REST group was 2.26 times more likely to exhibit clinical levels of state anxiety than the PA group at first clinic visit (χ2 (1, N = 230) = 9.16, p = .002).

Conclusions

Anxiety that is secondary to concussive injury could be mitigated with physical activity. Healthcare providers should encourage individuals with concussion to engage in physical activity during recovery.

A-24 Influence of Biopsychosocial Factors on First-Appointment Presentation After Sport Related Concussion (SRC)

Objective

To examine the influence of biopsychosocial factors on clinical outcomes and recovery time following SRC

Method

59 athletes with SRC (51% male) aged 14.42, SD= 1.65 years from two concussion specialty clinics between May 2019 and January 2020. Patients completed the Behavioral Regulation Assessment for Concussion (BRAC) inventory measuring sleep, diet, hydration, physical activity and stress; on a 4-point Likert scale, ImPACT, and PCSS. Analyses included one-way ANOVAs with Tukey’s post-hoc test and chi-square analyses.

Results

Verbal memory scores were higher F(3,55)= 2.85, p&lt;.05 in participants reporting 8-10hrs of sleep “most of the time” (M= 85.12, SD = 10.58) vs. “some of the time “ (M= 75.65, SD= 11.91). Verbal memory differed when engaged in stress regulation F(4,54)= 2.65, p&lt;.05; “MOT” (M=81.38, SD= 10.95); “SOT” (M=82.33, SD= 12.64) and “never” (M= 84.05, SD= 13.07). PCSS sleep factor scores increased when individuals obtained 8-10hrs of sleep “MOT” (M=.30, SD=.423) “SOT” (M= 1.40, SD= 1.54) and “seldom/rarely” (M= 1.95, SD= 1.58). PCSS somatic scores were associated with decreased sleep X2(1, N=57) = 37.68; p= .001, and hydration X2(1, N=57) = 60.70 p&lt; .001. Sleep and recovery time X2(1, N=55) = 120.82 p= .028.

Conclusions

Findings suggest that biopsychosocial factors including sleep, stress, and hydration are associated with symptoms, cognitive function, and recovery time following SRC and should be monitored by clinicians.

A-38 A Different Approach for Examining Gender Differences on Computerized Neurocognitive Testing: Percentile Ranks Versus Composite Scores

Objective

ImPACT is a popular tool used to assess neurocognitive function after concussion. Age- and gender-based percentile ranks are provided as part of the ImPACT clinical report, but only raw composite scores are provided for research. Percentile ranks may provide an alternate look at gender differences on neurocognitive testing. We sought to compare the use of percentile ranks versus composite scores when comparing neurocognitive performance between male and females.

Method

Pre-season baseline data from 3,238 collegiate athletes were exported from a larger multi-site database, 1,714 male (53%) and 1,524 female (47%), ages 18–22 (Mean = 19.3, SD = 1.2). ImPACT composite scores were extracted (Verbal Memory, Visual Memory, Visual Motor Speed, Reaction Time) and Percentile Ranks were calculated using age- and gender-based reference tables in the ImPACT 2017–2012 Technical Manual. One-way analyses of variance (ANOVA) were conducted with gender as the IV and the four composite scores and their associated percentile ranks as the DVs. Bonferroni correction for 8 comparisons set the alpha level to p &lt; .006.

Results

ANOVAs revealed a significant effect of gender on ImPACT Verbal Memory [F(1,3236) = 16.32, p &lt; .001], Visual Memory [F(1,3236) = 66.06, p &lt; .001], Visual Motor Speed [F(1,3236) = 15.61,p &lt; .001] but not Reaction Time [F(1,3236) = 2.59, p = .11]. When using percentile ranks, ANOVAs revealed a significant effect of gender on only Visual Motor Speed [F(1,3236) = 31.07, p &lt; .001], but not Verbal Memory [F(1,3236) = 2.43, p = .12], Visual Memory [F(1,3236) = 0.48, p = .49], or Reaction Time [F(1,3236) = 0.61, p = .44].

Conclusions

Use of ImPACT Composite Scores in concussion research may exaggerate or inappropriately promote gender differences on computerized neurocognitive testing. Given that age- and gender-based normative data are available, use of percentile ranks is recommended.

Association of Time Since Injury to the First Clinic Visit With Recovery Following Concussion

Importance

Recovery after concussion varies, with adolescents taking longer (approximately 30 days) than adults. Many factors have been reported to influence recovery, including preinjury factors, perceptions about recovery, comorbid conditions, and sex. However, 1 factor that may play a role in recovery but has received little attention from researchers is the timeliness of clinical evaluation and care.

Objective

To investigate the association of time since injury with initiation of clinical care on recovery time following concussion.

Design, Setting, and Participants

This retrospective, cross-sectional study was conducted in a sports medicine clinic between August 2016 and March 2018. Eligible participants were aged 12 to 22 years and had a diagnosed, symptomatic concussion; patients were excluded if recovery data were incomplete. Participants were divided into 2 groups: those seen within 7 days of the injury (early) vs between 8 and 20 days of the injury (late). Data were analyzed between June 2019 and August 2019.

Exposures

Time from injury (concussion) to initiation of clinical care.

Main Outcomes and Measures

Recovery time; testing with the Post-Concussion Symptom Scale, Immediate Post-Concussion Assessment and Cognitive Testing, and Vestibular/Ocular Motor Screening instruments; demographic factors, medical history, and injury information.

Results

A total of 416 individuals were eligible, and 254 (61.1%) were excluded, leaving 162 (38.9%) in analyses. The early group (98 patients) and late group (64 patients) did not differ in age (mean [SD] age, early, 15.3 [1.6] years; late, 15.4 [1.6] years), number of female patients (early, 51 of 98 [52.0%]; late, 40 of 64 [62.5%]), or other demographic, medical history, or injury information. The groups also were similar on symptom severity, cognitive, ocular, and vestibular outcomes at the first clinic visit. Results from a logistical regression supported being in the late group (adjusted odds ratio, 5.8 [95% CI, 1.9-17.6]; P = .001) and visual motion sensitivity symptoms greater than 2 (adjusted odds ratio, 4.5 [95% CI, 1.1-18.0]; P = .04) as factors significantly associated with recovery time.

Conclusions and Relevance

Findings suggest that earlier initiation of clinical care is associated with faster recovery after concussion. Other factors may also influence recovery time. Further research is needed to determine the role of active rehabilitation and treatment strategies, as well as demographic factors, medical history, and injury characteristics on the current findings.

Do Initial Symptom Factor Scores Predict Subsequent Impairment Following Concussion?

OBJECTIVE

Symptom factors present during the first week following concussion may predict subsequent concussion outcomes and recovery duration. We hypothesized that a high loading on cognitive-fatigue-migraine and somatic factors would be predictive of neurocognitive impairment following concussion. We also hypothesized that the affective factor would be related to vestibular symptoms and impairment.

DESIGN

Prospective repeated measures.

SETTING

Concussion specialty clinic.

PARTICIPANTS

Athletes aged 13 to 20 years diagnosed with a concussion within the past 7 days.

INDEPENDENT VARIABLE

Symptom factors at the initial visit 1 to 7 days after injury.

MAIN OUTCOME MEASURE

Symptom factor score, neurocognitive testing, and vestibular/ocular motor assessment at the second visit (2-4 weeks after injury).

RESULTS

The somatic symptom factor from the initial visit was significant (P < 0.05) in all vestibular/ocular screening components (P < 0.05) but not neurocognitive test performance (P > 0.05) at the second visit. The cognitive-migraine-fatigue and affective symptom factors predicted symptom burden at the second visit (P < 0.001) but did not predict recovery time (P = 0.200).

CONCLUSIONS

The somatic symptom factor during the first week after injury predicted symptom provocation during vestibular/ocular screening at 2 to 4 weeks after injury. Specifically, higher scores on somatic symptom factor at the initial visit predicted worse symptom reporting for all vestibular/ocular screening components at the second visit. Patients with higher scores on the cognitive-migraine-fatigue and affective symptom factors at the initial visit predicted total symptom burden at the second visit.

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

BACKGROUND

Current concussion symptom inventories emphasize total number or symptoms and severity and overlap with other conditions, such as mental health disorders, which may limit their specificity and clinical utility.

OBJECTIVE

To develop and test the reliability and validity of a new Concussion Clinical Profiles Screening tool (CP Screen) in both healthy controls and concussed.

METHODS

CP Screen is a 29-item self-report, clinical profile-based symptom inventory that measures the following 5 concussion clinical profiles: 1) anxiety/mood, 2) cognitive/fatigue, 3) migraine, 4) ocular, and 5) vestibular; and the following 2 modifying factors: 1) sleep and 2) neck. Post-Concussion Symptom Scale (PCSS), vestibular/ocular motor screening (VOMS) tool, and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) were conducted. CP Screen was administered in community a concussion surveillance program and 2 sports medicine concussion clinics. Responses include 248 athletes, 121 concussed, and 127 controls, enrolled between 2018 and 2019.

RESULTS

Internal consistency of the CP Screen in the control (Cronbach's alpha = .87) and concussed (Cronbach's alpha = .93) samples was high. Moderate to high correlations among the CP Screen factors and PCSS factors and VOMS items, supporting concurrent validity. ROC curve analysis for identifying concussed from controls was significant (P &lt; .001) for all CP Screen factor and modifier scores with excellent AUCs for migraine (.93), ocular (.88), vestibular (.85), and cognitive (.81) factors, demonstrating predictive validity.

CONCLUSION

The CP Screen demonstrated strong reliability, concurrent validity with commonly used concussion assessment (ie, PCSS, VOMS, and ImPACT), and predictive validity for identifying concussion. The CP Screen extends current symptom inventories by evaluating more specific symptoms that may reflect clinical profiles and inform better clinical care.

Preliminary Study of Fear of Re-Injury following Sport-Related Concussion in High School Athletes

The influence of fear of re-injury that this variable has on recovery outcomes following sports-related concussion remains unknown. We examined changes in fear of re-injury throughout concussion recovery, and compared changes in neurocognitive, symptom, vestibular/ocular motor, and recovery time outcomes between concussed adolescent athletes who endorsed high and low fear of re-injury. Individuals with high fear of re-injury were more symptomatic and more likely to exhibit vestibular/ocular motor symptoms over clinical cutoffs than those with low fear of re-injury. Recovery time was not significantly different between the groups. These findings may help explain performance on more subjective concussion assessments.

Motion Sickness Susceptibility and Baseline Vestibular and Ocular-Motor Performance in Adolescent Athletes

CONTEXT

High school athletes with a history of motion sickness susceptibility exhibit higher baseline vestibular and ocular-motor scores than those without a history of motion sickness susceptibility.

OBJECTIVE

To examine the effects of motion sickness susceptibility on baseline vestibular and ocular-motor functioning, neurocognitive performance, and symptom scores.

DESIGN

Cross-sectional study.

SETTING

Preseason concussion testing.

PATIENTS OR OTHER PARTICIPANTS

A convenience sample of high school athletes (N = 308, age = 15.13 ± 1.21 years) involved in a variety of sports.

MAIN OUTCOME MEASURE(S)

Vestibular/Ocular Motor Screening, computerized neurocognitive assessment, symptom scale, and Motion Sickness Susceptibility Questionnaire-Short Form (MSSQ-S).

RESULTS

Participants were categorized into 3 groups based on a median split of the scores (eg, NONE, LOW, and HIGH). The LOW (n = 95) and HIGH (n = 92) groups (ie, MSSQ-S score > 0) were 2.64 times more likely (χ²_1,257 = 7.94, P = .01, 95% confidence interval = 1.32, 5.26) to have baseline Vestibular/Ocular Motor Screening scores larger than the clinical cutoffs for the NONE group (n = 70). No between-groups main effects were present for the NONE (n = 52), LOW (n = 89), and HIGH (n = 90) MSSQ-S groups for verbal (F_2,230 = .09, P = .91, η² = .001) and visual (F_2,230 = .15, P = .86, η² = .001) memory, processing speed (F_2,230 = .78, P = .46, η² = .007), or reaction time (F_2,230 = 2.21, P = .11, η² = .002). The HIGH group exhibited higher total baseline symptom scores than the LOW (U = 3325.50, z = -1.99, P = .05, r = .15) and NONE (U = 1647.50, z = -2.83, P = .005, r = .24) groups.

CONCLUSIONS

Motion sickness should be considered a preexisting risk factor that might influence specific domains of the baseline concussion assessment and postinjury management.

Family History of Migraine Associated With Posttraumatic Migraine Symptoms Following Sport-Related Concussion

OBJECTIVE

To determine whether family history of migraine increased the likelihood of posttraumatic migraine (PTM) symptom presentation in adolescents following concussion, and examine the influence of family history of migraine and PTM on postinjury outcomes.

SETTING

Outpatient concussion clinic.

PARTICIPANTS

A total of 153 patients with concussion (103 males and 50 females) aged 15.72 ± 1.48 years (range 12-18 years).

DESIGN

Cross-sectional, observational study of patients presenting for initial evaluation 4.72 ± 3.05 days (range 1-14) postinjury.

MAIN MEASURES

Computerized neurocognitive testing, symptom report, and vestibular/oculomotor screening.

RESULTS

Patients with a family history of migraine were 2.6 times (odds ratio = 2.60, confidence interval = 1.35-5.02, P = .003) more likely to present with PTM compared with patients without a family history. Results of multivariate analyses of covariance, controlling for concussion history, revealed significant main effects for PTM on (1) Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT)/Post-Concussion Symptom Scale (PCSS) (F = 15.43, P <.001) and (2) Vestibular/Ocular Motor Screening (VOMS) (F = 8.52, P < .001). There was no main effect for family history of migraine on ImPACT/PCSS (P = .22) and VOMS (P = .83) or interaction between family history of migraine and PTM on ImPACT/PCSS (P = .84) and VOMS (P = .52).

CONCLUSION

Family history of migraine is associated with PTM symptoms following sport-related concussion, suggesting a genetic predisposition for migraine may serve as a catalyst or trigger for onset of PTM. However, only presence of PTM, rather than family history of migraine, was related to worse neurocognitive and vestibular/oculomotor outcomes.

Persistent vestibular-ocular impairment following concussion in adolescents

OBJECTIVES

The current study investigated the role of persistent vestibular-ocular symptoms and impairment following sport-related concussion on recovery time and clinical outcomes among adolescents.

DESIGN

Prospective cohort.

METHODS

50 (F-22/M-28) adolescents aged 12-20 years completed a vestibular-ocular motor screening, neurocognitive assessment, and the Post-Concussion Symptom Scale (PCSS) at clinical assessments conducted at 0-10 and 11-21 days after concussion. Participants were assigned to: 1) persistent vestibular-ocular (PERSIST), 2) vestibular-ocular improvement (IMPROVE), or 3) no vestibular-ocular impairment (NONE) groups based on vestibular-ocular motor screening conducted during each assessment. A 3 (GROUP) X 2 (TIME) ANOVA was performed on neurocognitive and symptom scores, and a between-subjects ANOVA was performed for recovery time.

RESULTS

49 subjects were identified among the PERSIST (n=17), IMPROVE (n=12) and NONE (n=20) groups. There were no neurocognitive performance differences between groups at 0-10 days post-concussion, but groups differed on PCSS at 11-21 days (p=.001), with the PERSIST (29.0±24.9) group reporting higher symptoms than the NONE (5.45±10.0; p=.005) group. The PERSIST group took significantly longer to recover (34.9±11.6 days) than the NONE (22.9±14.9 days) group (p=.03). All groups improved on verbal (p<.001) and visual memory (p=.028), visual motor speed (p=.005), and reaction time (p=.004) from 0-10 to 11-20 days following SRC and no significant group by time interactions for cognitive scores identified.

CONCLUSIONS

Persistent post-concussion vestibular-ocular symptoms and impairment may influence neurocognitive performance and clinical recovery following sport-related concussion.

The Relationship Between the Post-Concussion Symptom Scale and State-Trait Anxiety Inventory in Concussed Athletes

Purpose

To document the relationship between concussion symptoms and state anxiety in concussed adolescent athletes.

Methods

One hundred fifty-three concussed athletes (mean age=16.06, SD=1.62 yrs.) completed the Post-Concussion Symptom Scale (PCSS) and the State-Trait Anxiety Inventory (STAI) at their initial clinical visit within 30 days of injury (M=8.29, SD=6.46 days). Due to violations of normality (Shapiro-Wilk=.95), Spearman’s Rank Order correlations were conducted between STAI state scores and PCSS affective, somatic, cognitive-migraine-fatigue, and sleep clusters and total symptoms. Correlations were also conducted within sub-samples of patients seen within one week (M=3.80, SD=1.72days) and 8 – 30 days post-injury (M=13.91, SD=5.76 days). Statistical significance was set at (p<.05).

Results

In the total sample (n=153), STAI state scores were significantly associated with total symptoms (r=.54), and the affective (r=.53), sleep (r=.44), cognitive-migraine-fatigue (r=.47), and somatic (r=.33) symptom clusters. All significant relationships among STAI state scores and PCSS total symptoms and symptom clusters were retained for patients seen within 1 week as well as patients completing their first clinical visit 8-30 days post-concussion (p<.05).

Conclusion

Post-concussion endorsement of concussion symptoms increases as a function of state anxiety. Although the PCSS affective symptom cluster is not a validated measure to diagnose anxiety; these findings support the utility of the PCSS to evaluate for potentially elevated anxiety in concussed adolescent athletes.

Addressing the ``Replication Crisis'' in Sports Neuropsychology: Validation of the Two-Factor Theory of ImPACT

Purpose

The "replication crisis" in psychology and across the broader field of social sciences raises criticism due to a lack of data to show that esoteric research findings can be replicated. The present study replicated and validated the two-factor “memory” and “speed” structure of ImPACT (Schatz & Maerlender, 2013).

Methods

High school aged athletes (N=18,918, Mean age=15.4, SD=1.2) who completed pre-season baseline ImPACT testing were randomly assigned to one of 5 independent samples of approximately 3,780 athletes. Exploratory factor analyses (FA) for a two-factor solution were conducted with ImPACT composite scores within each of the five groups. Post-Concussion Symptom Scale (PCSS) scores were included, with the expectation they would load on a third, unique factor.

Results

All five samples met assumptions for FA (KMO Measure of Sampling Adequacy above .600), and all five analyses yielded the same “memory” and “speed” two-factor structure. Visual Motor Speed and Reaction Time loaded on the first "Speed" factor and Verbal and Visual Memory loaded on a second "Memory" factor. The PCSS scores loaded on a third, unique “symptom” factor.

Conclusion

Replication of the two-factor structure for ImPACT in a five large high school sample further validates the model. Given that both visual and verbal memory involve encoding of information presented visually, use of a “memory” factor may improve interpretation of ImPACT scores. Similarly, similarities between constructs measuring speed of responding (Reaction Time) and speed of processing (Visual Motor Processing Speed) may be best explained using a “speed” factor.

Exploring Athletic Trainers' Self-Confidence for Interpreting Results from Concussion Assessments

Purpose

To explore athletic trainers' self-confidence for interpreting results from concussion assessments.

Methods

An online survey was administered via the National Athletic Trainers’ Association (NATA) membership listserv to a cross-sectional sample of 10,000 certified athletic trainers (ATCs) employed in high school and collegiate settings. The survey included: 1) ATC demographics (i.e., age, sex, years of experience); 2) ATC concussion management practices (i.e., previous concussion training, continuing education received on concussion, concussion assessments administered); and 3) a 4-point Likert scale (1=no confidence, 4=high confidence) assessing ATC self-confidence for interpreting results from concussion assessments. A total of 725 ATCs completed the survey yielding a response rate of 7.25%; 114 were excluded for missing data and 611 ATCs were included in final analyses. Sample demographics, ATC concussion management practices, and ATC self-confidence scores were examined with demographic statistics (i.e., means, standard deviations, frequencies, percentages) for 16 commonly used concussion assessments.

Results

The sample of ATCs (mean age 38.97±14.89 years) was predominately female (59.2%) and reported an average of 10.08±7.58 years of clinical experience. Clinical examinations (63.2%) and symptom scales (61.4%) were among the most frequent assessments with high ATC self-confidence for interpretation. Vestibular/oculomotor measures (27.2%) and computerized neurocognitive testing (26.2%) were among the most frequent assessments with low ATC self-confidence for interpretation.

Conclusion

Low ATC self-confidence scores for interpreting results from vestibular/oculomotor measures and computerized neurocognitive testing highlight the importance of incorporating a multi-disciplinary team approach and including sport neuropsychologists for the proper management of concussion.

Exposure to Serial Post-Concussion Neurocognitive Testing Does not Affect Future “Updated” Baseline Neurocognitive Performance in Adolescent Athletes

Purpose

We investigated a dose response for serial post-concussion neurocognitive testing exposure on updated post-concussion baseline testing performance.

Methods

Athletes (13-18 yrs) that completed two, valid baseline neurocognitive testing (ImPACT) sessions approximately 1-3 years apart participated in this study. A sub-sample of athletes that sustained a SRC between baseline sessions were categorized into dose-response groups based on the number of serial, post-concussion neurocognitive tests completed following SRC: ONE (n=76), TWO (n=99), and THREE OR MORE (n=111). Athletes that did not sustain a SRC comprised the ZERO group (n=289). Change scores between the first to the second baseline were calculated for the ImPACT Composite and Symptom Scores and compared between the dose-response groups and controls with 5 ANOVAs, with a Bonferroni-corrected p-value of (p<.01). Baseline testing was administered using ImPACT stimuli within the “Baseline” administration, and all post-concussion ImPACT testing was administered using alternate-form associated with that specific post-injury assessment (Post-Injury1, Post-Injury2, etc).

Results

ANOVAs revealed no effect of number of post-concussion assessments (0, 1, 2, or 3+) on magnitude of the change between first and final baselines, for Verbal Memory (p=.08), Visual Memory (p=.96), Visual Motor Speed (p=.47), Reaction Time (p=.91), or Total Symptom Scores (p=.86).

Conclusion

Repeated exposure to neurocognitive testing has revealed improvements in Visual Motor Speed among normal controls, across test-retest intervals of 1-month, 1-year, and 2-years. However, in this study, exposure to post-concussion, serial neurocognitive testing had no effect on future performance on post-concussion baseline neurocognitive testing.