Examining Acute Symptoms After Sport-Related Concussion in Collegiate Athletes With Preinjury Migraines.

OBJECTIVE: To examine whether a personal history of migraines is associated with worse acute symptom burden after sport-related concussion (SRC). DESIGN: Retrospective cohort study. SETTING: National Collegiate Athletic Association Division III collegiate programs. PARTICIPANTS: Collegiate athletes from a prospective concussion surveillance system between 09, 2014, and 01, 2023. INTERVENTION: Preinjury migraines (yes/no) were self-reported by athletes. MAIN OUTCOME MEASURES: Post-Concussion Symptom Scale (PCSS) were collected within 3 days postinjury. Mann-Whitney U tests compared total PCSS scores and individual symptom scores between athletes with and without preinjury migraines. Chi-squared tests were used to compare proportions of athletes endorsing individual symptoms (ie, item score ≥1) between 2 groups. Multivariable regression analyzed potential predictors of PCSS scores. RESULTS: Of 1190 athletes with SRC, 93 (7.8%) reported a preinjury history of migraines. No significant difference in total PCSS scores was found between athletes with and without preinjury migraines (22.0 ± 16.4 vs 20.5 ± 15.8, U = 48 719.0, P = 0.471). Athletes with preinjury migraines reported greater severity of "sensitivity to light" (1.59 ± 1.59 vs 1.23 ± 1.41, P = 0.040) and "feeling more emotional" (0.91 ± 1.27 vs 0.70 ± 1.30; P = 0.008) and were more likely to endorse "feeling more emotional" (45.2% vs 29.5%, P = 0.002). No differences were found across all other symptoms, including headaches (migraine = 87.1% vs no migraine = 86.3%, P = 0.835). In a multivariable model, a history of migraine was not a significant predictor of acute PCSS scores, but those with a history of psychological disorders (ß = 0.12, P <0 .001) and greater number of days to symptom evaluation (ß = 0.08, P = 0.005) had higher PCSS scores. CONCLUSIONS: Collegiate athletes with a pre-existing history of migraines did not have higher acute symptom burden after SRC.

Recovery After Sport-Related Concussion in Collegiate Athletes With Self-Reported Pre-Injury Migraines.

Pre-injury migraines might be a risk factor for prolonged recovery after sport-related concussion (SRC). We sought to examine whether a pre-injury history of migraines is associated with worse recovery following SRC in collegiate athletes. Data were collected through a prospective concussion surveillance system in 11 National Collegiate Athletic Association (NCAA) Division III college athletic programs between September 2014 and March 2020. Our primary independent variable, pre-injury migraines, were self-reported by the athletes. Between those with and without migraines, the outcomes of days to return-to-learn (RTL) without academic accommodations and return-to-play (RTP) were compared using Mann-Whitney U tests. Each athlete's RTL and RTP status was dichotomized (i.e., returned vs. not returned) at various time points for RTL (i.e., 7/14/21/28 days) and RTP (i.e., 14/21/28/56 days). Chi-squared tests were performed to compare the proportions of RTL and RTP status between groups. Multivariable regressions analyzed potential predictors of RTL and RTP adjusting for age, gender, prior concussions, other health conditions, and symptom severity. Of 1409 athletes with an SRC, 111 (7.9%) had a pre-injury history of migraines. Compared with those without migraines, those with migraines had longer median (interquartile range [IQR]) days to RTL (migraines = 7.0 [3.0-12.3] vs. no migraines = 5.0 [2.0-10.0], U = 53,590.5, p = 0.022). No differences were found in RTP between the two groups (migraines = 16.0 [10.0-33.0] vs. nχo migraines 15.0 [11.0-23.0], U = 38,545.0, p = 0.408). Regarding RTL, significantly lower proportions of athletes in the migraine group had fully RTL, without accommodations, at ≤14 days (77.5% vs. 85.2%, χ2 = 4.33, p = 0.037), ≤21 days (85.3% vs. 93.0%, χ2 = 7.99, p = 0.005), and ≤28 days (88.2% vs. 95.6%, χ2 = 10.60, p = 0.001). Regarding RTP, a significantly lower proportion of athletes in the migraine group RTP at ≤28 days (72.0% vs. 82.7%, χ2 = 5.40, p = 0.020) and ≤56 days (84.0% vs. 93.0%, χ2 = 8.19, p = 0.004). In a multivariable model predicting RTL that was adjusted for age, gender, acute concussion symptoms, and other health variables (e.g., attention-deficit/hyperactivity disorder [ADHD], history of mental health difficulties), pre-injury history of migraine was associated with longer RTL (ß = 0.06, p = 0.030). In a multivariable model predicting RTP, pre-injury history of migraine was not associated with RTP (ß = 0.04, p = 0.192). In collegiate athletes, pre-injury migraine history was independently associated with longer RTL but not RTP. When comparing the proportions of those with successful RTP by days, significantly lower proportions of those with migraines showed successful RTP at ≤28 days and ≤56 days. Futures studies should study the generalizability of our findings in other school levels.

Concussion Symptoms and Neurocognitive Performance of Children and Adolescents on Antidepressants.

INTRODUCTION/PURPOSE: There is a well-established association between preexisting depression/anxiety and greater postconcussion symptom burden, but the potential impact of antidepressant medications has not been fully explored. The primary objective of this study was to compare preinjury/baseline and postinjury concussion symptom scores and neurocognitive performance of athletes on antidepressant medications, both with healthy controls and with those with depression/anxiety not on antidepressants. METHODS: This is a cross-sectional study using data collected from 49,270 junior and high school athletes from computerized neurocognitive assessments (Immediate Post-Concussion Assessment and Cognitive Test [ImPACT]) administered between 2009 and 2018 held by the Massachusetts Concussion Management Coalition. The main outcome measures were symptom scores and neurocognitive performance measures, all of which were assessed both at baseline and postinjury. Statistical analysis included analysis of variance and Tukey pairwise comparisons for continuous variables and Fisher's exact test for categorical variables. Multivariate regression models were used to adjust for potential confounding variables. RESULTS: Both at baseline and postinjury, athletes with depression/anxiety had mean total symptom scores that were more than double that of healthy controls regardless of antidepressant use. Although there were no significant differences in neurocognitive performance at baseline, depression/anxiety was associated with small but significant decreases in postinjury visual memory and visual motor scores. CONCLUSIONS: Both at baseline and after sustaining a concussion, young athletes with depression/anxiety experience significantly greater symptom burden compared with healthy controls regardless of antidepressant use.

Neighborhood Disadvantage and Clinical Outcome Following Concussion in Adolescents.

Whether social determinants of health are associated with clinical outcome following concussion among adolescents is not well established. The present study examined whether neighborhood-level determinants are associated with clinical recovery time following concussion in adolescents. Participants included adolescent student athletes (n = 130; mean age = 16.6, standard deviation = 1.2; 60.8% boys, 39.2% girls) who attended one of nine selected high schools in Maine, USA. The Area of Deprivation Index (ADI), an indicator of neighborhood disadvantage was used to group high schools as either high or low in neighborhood disadvantage. Athletic trainers entered injury and recovery dates into an online surveillance application between September 2014 and January 2020. Chi-squared analyses and Kaplan-Meier survival analyses were used to compare the groups on two clinical outcomes: days to return to school and days to return to sports. Results of chi-squared tests did not reveal between-group differences in return to school at 21 or 28 days. However, groups differed in the percentage of adolescents who had returned to sports by 21 days (greater neighborhood disadvantage, 62.5%, lesser neighborhood disadvantage 82.0%, χ2 = 4.96, p = 0.03, odds ratio [OR] = 2.73, 95% confidence interval [CI], 1.11-6.74) and 28 days (greater neighborhood disadvantage, 78.6%, lesser neighborhood disadvantage 94.0%, χ2 = 5.18, p = 0.02, OR = 4.27, 95% CI, 1.13-16.16) following concussion. A larger proportion of adolescents attending schools located in areas of greater neighborhood disadvantage took more than 21 and 28 days to return to sports. These results indicate an association between a multi-faceted proxy indicator of neighborhood disadvantage and clinical outcome following concussion. Further research is needed to better characterize factors underlying group differences in time to return to sports and the interactions between neighborhood disadvantage and other correlates of clinical recovery following concussion.

Neurocognitive Test Performance and Concussion-Like Symptom Reporting Among Adolescent Athletes With Self-Reported Autism on Preseason Assessments.

OBJECTIVE: To examine baseline neurocognitive functioning and symptom reporting among adolescents with self-reported autism. METHOD: Participants in this cross-sectional, observational study were 60,751 adolescents who completed preseason testing. There were 425 students (0.7%) who self-reported an autism spectrum disorder (ASD) diagnosis. Cognitive functioning was measured by Immediate Post-Concussion Assessment and Cognitive Testing and symptom ratings were obtained from the Post-Concussion Symptom Scale. RESULTS: Groups differed significantly across all neurocognitive composites (p values <.002); effect size magnitudes for most differences were small, though among boys a noteworthy difference on visual memory and among girls differences on verbal memory and visual motor speed composites were noted. Among boys, the ASD group endorsed 21 of the 22 symptoms at a greater rate. Among girls, the ASD group endorsed 11 of the 22 symptoms at a greater rate. Some examples of symptoms that were endorsed at a higher rate among adolescents with self-reported autism were sensitivity to noise (girls: odds ratio, OR = 4.38; boys: OR = 4.99), numbness or tingling (girls: OR = 3.67; boys: OR = 3.25), difficulty remembering (girls: OR = 2.01; boys: OR = 2.49), difficulty concentrating (girls: OR = 1.82; boys: OR = 2.40), sensitivity to light (girls: OR = 1.82; boys: OR = 1.76), sadness (girls: OR = 1.72; boys: OR = 2.56), nervousness (girls: OR = 1.80; boys: OR = 2.27), and feeling more emotional (girls: OR = 1.79; boys: OR = 2.84). CONCLUSION: Students with self-reported autism participating in organized sports likely experience a low degree of functional impairment, on average. If they sustain a concussion, their clinical management should be more intensive to maximize the likelihood of swift and favorable recovery.

Prior Concussion History and Clinical Recovery After Sport-Related Concussion in High School Athletes.

Clinical recovery after sport-related concussion varies as a function of pre-injury and acute factors. Whether, or the extent to which, concussion history is associated with clinical outcome after sport-related concussion is uncertain, because research has produced mixed findings. The present study aimed to assess whether a history of previous concussions was associated with prolonged clinical recovery after a subsequent sport-related concussion. The sample comprised 780 adolescent student athletes (mean age = 16.3, standard deviation = 1.3 years; 56.8% boys, 43.2% girls) whose school participated in the Maine Concussion Management Initiative (MCMI). Survival analyses were used to compare recovery times among adolescents with a history of 0, 1, or ≥2 previous concussions after a subsequent sport-related concussion. The two primary outcomes of interest were the number of days to return to school and sports. There were no statistically significant differences in total time to return to school and sports, or the proportion of adolescents who returned to school and sports at most intervals (e.g., 7, 14, 28 days), between those with 0, 1, or ≥2 previous concussions. A greater proportion of adolescents, however, with a history of ≥2 previous concussions remained out of sports at 28 days compared with those with no previous concussions (23.5% vs. 12.7%; odds ratio [OR] = 2.10, 95% confidence interval [CI] 1.18-3.73). Having sustained prior concussions was not associated with time to return to school after a subsequent sport-related concussion. A greater proportion of adolescents, however, with two or more previous concussions experienced a prolonged return to sports. Further research is warranted to identify risk factors for worse outcomes among the subset of adolescents with a history of multiple previous concussions who experience prolonged recoveries.

Acute effects of concussion among adolescents with attention-deficit/hyperactivity disorder.

Adolescents with ADHD have a greater lifetime history of concussion and experience concussion-like symptoms in the absence of a concussion, complicating concussion assessment and management. It is well established that individuals who experience greater acute symptoms following concussion are at risk for slower recovery and persistent symptoms. We examined whether youth with ADHD experience worse acute effects, within the first 72 h following concussion, compared to youth without ADHD. We hypothesized that youth with ADHD would perform worse on neurocognitive testing and endorse more severe symptoms acutely following injury, but the magnitude of change from pre injury to post injury would be similar for both groups, and thus comparable to baseline group differences. The sample included 852 adolescents with pre-injury and post-injury ImPACT results (within 72 h); we also conducted supplementary case-control analyses on a subset of youth with and without ADHD matched on demographics and pre-injury health history. For both samples, there were significant interaction effects for the Verbal Memory and Visual Motor Speed composites (p < 0.01, η2=.01-.07, small-medium effect), such that youth with ADHD showed a greater magnitude of diminished cognitive functioning from pre-injury to post-injury testing. There were no significant differences in the magnitudes of changes from pre injury to post injury with regard to overall symptom reporting (i.e., total symptom severity scores, total number of symptoms endorsed); however, there were group differences in endorsement rates for several individual symptoms. Further research is needed to determine whether such differential acute effects are associated with recovery time in youth with ADHD.

Greater Acute Concussion Symptoms Are Associated With Longer Recovery Times in Adolescents.

We examined the association between the severity of acute concussion symptoms and time to return to school and to sports in adolescent student athletes. We hypothesized that there would be an association between the severity of acute symptoms experienced in the first 72 hours and functional recovery such that adolescents with the lowest burden of acute symptoms would have the fastest return to school and sports and those with the highest burden of symptoms would have the slowest return to school and sports. This injury surveillance cohort included 375 adolescent student athletes aged 14-19 years who sustained a sport-related concussion between 2014 and 2020. Athletic trainers documented time to return to school and to sports. A greater proportion of adolescents with the highest acute symptoms remained out of school at 3 (odds ratio [OR] = 2.5, 95% confidence interval [CI] 1.5-4.4), 5 (OR = 2.4, 95% CI 1.4-4.0), 7 (OR = 2.6, 95% CI 1.5-4.3), and 10 days (OR = 2.3, 95% CI 1.3-3.9) compared to those with the lowest acute symptoms. Similarly, a greater proportion of athletes with the highest acute symptoms remained out of sports at 7 (OR = 3.5, 95% CI 1.5-8.1), 10 (OR = 3.1, 95% CI 1.8-5.6), 14 (OR = 1.8, 95% CI 1.1-3.0), and 21 days (OR = 1.9, 95% CI 1.0-3.6) compared to those with the lowest acute symptoms. This study underscores the adverse effect of high acute symptom burden following concussion on return to school and to sports among adolescent student athletes. Conversely, student athletes with a low burden of acute symptoms have a faster return to school and to sports.

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.

Preseason Symptom Reporting and Cognition in Middle School Athletes with Past Concussions.

This study examined the association between past concussions and current preseason symptom reporting and cognitive performance in 9,257 youth ages 11-13. Participants completed neurocognitive testing prior to participating in a school sports between 2009 and 2019. We stratified the sample by gender and number of prior concussions and assessed group differences on the Post-Concussion Symptom Scale total score and the ImPACT cognitive composite scores. Those with≥2 prior concussions reported more symptoms than those with 0 concussions (d=0.43-0.46). Multiple regressions examining the contribution of concussion history and developmental/health history to symptom reporting showed the most significant predictors of symptoms scores were (in descending order): treatment for a psychiatric condition, treatment for headaches, history of learning disability (in boys only), history of attention-deficit/hyperactivity disorder, and age. Concussion history was the weakest statistically significant predictor in boys and not significant in girls. Cognitively, boys with 1 prior concussion had worse speed those with 0 concussions (d=0.11), and girls with≥2 prior concussions had worse verbal/visual memory than girls with 0 concussions (ds=0.38-0.39). In summary, youth with≥2 prior concussions reported more symptoms than those with no concussions. Boys with multiple concussions performed similarly on cognitive testing, while girls had worse memory scores.

Sleep Insufficiency and Baseline Preseason Concussion-Like Symptom Reporting in Youth Athletes.

OBJECTIVE: To examine the association between insufficient sleep and baseline symptom reporting in healthy student athletes. DESIGN: Cross-sectional cohort study. SETTING: Preseason testing for student athletes. PARTICIPANTS: Student athletes (n = 19 529) aged 13 to 19 years who completed the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), including the number of hours slept the night before, and denied having developmental/health conditions, a concussion in the past 6 months, and a previous history of 2 or more concussions. INDEPENDENT VARIABLES: Total hours of sleep the night before testing (grouped by ≤5, 5.5-6.5, 7-8.5, and ≥9 hours), gender, and concussion history. MAIN OUTCOME MEASURES: Symptom burden on the Post-Concussion Symptom Scale (modified to exclude sleep-related items), cognitive composite scores, and prevalence of athletes who reported a symptom burden resembling the International Classification of Diseases, 10th Revision (ICD-10) diagnosis of postconcussional syndrome (PCS). RESULTS: Fewer hours of sleep, gender (ie, girls), and 1 previous concussion (vs 0) were each significantly associated with higher total symptom scores in a multivariable model (F = 142.01, P < 0.001, R2 = 0.04). When a gender-by-sleep interaction term was included, the relationship between sleep and symptoms was stronger for girls compared with boys. In healthy athletes who slept ≤5 hours, 46% of girls and 31% of boys met the criteria for ICD-10 PCS compared with 16% of girls and 11% of boys who slept ≥9 hours. Sleep duration was not meaningfully associated with neurocognitive performance. CONCLUSIONS: Insufficient sleep the night before testing is an important factor to consider when interpreting symptom reporting, especially for girls. It will be helpful for clinicians to take this into account when interpreting both baseline and postinjury symptom reporting.

Baseline preseason ImPACT® testing in Mandarin with adolescent student-athletes in the United States.

Researchers have examined differences on ImPACT® in baseline symptom reporting and neurocognitive performances based on the language of administration and racial/ethnic identity. This is the first study to examine differences between student-athletes tested in Mandarin versus English on ImPACT® during preseason baseline assessments conducted in high schools in the United States. Participants included 252 adolescent student-athletes who completed ImPACT® testing in the state of Maine in Mandarin and 252 participants who completed testing in English, matched on age, gender, and health and academic history. Participants were compared on neurocognitive composite scores and symptom ratings. Boys tested in Mandarin, but not girls, had modestly better neurocognitive performance on one of four composite scores (i.e., Visual Motor Speed, p < .001, d = .45). Although language groups did not differ in total symptom severity, boys tested in Mandarin endorsed multiple physical symptoms at higher rates than boys tested in English. These results suggest that the current ImPACT® neurocognitive normative data are reasonably appropriate for use with adolescents evaluated in Mandarin. There were some differences in the reporting of physical symptoms, with greater rates of symptom endorsement by boys tested in Mandarin than boys tested in English; but overall symptom severity ratings were comparable between the language groups.

Examining Criteria for Defining Persistent Post-concussion Symptoms in Children and Adolescents.

Researchers operationalize persistent post-concussion symptoms in children and adolescents using varied definitions. Many pre-existing conditions, personal characteristics, and current health issues can affect symptom endorsement rates in the absence of, or in combination with, a recent concussion, and the use of varied definitions can lead to differences in conclusions about persistent symptoms and recovery across studies. This study examined how endorsement rates varied by 14 different operational definitions of persistent post-concussion symptoms for uninjured boys and girls with and without pre-existing or current health problems. This cross-sectional study included a large sample (age range: 11-18) of girls (n = 21,923) and boys (n = 26,556) without a recent concussion who completed the Post-Concussion Symptom Scale at preseason baseline. Endorsements rates varied substantially by definition, health history, and current health issues. The most lenient definition (i.e., a single mild symptom) was endorsed by most participants (54.5% of boys/65.3% of girls). A large portion of participants with pre-existing mental health problems (42.7% of boys/51.5% of girls), current moderate psychological distress (70.9% of boys/72.4% of girls), and insufficient sleep prior to testing (33.4% of boys/47.6% of girls) endorsed symptoms consistent with mild ICD-10 postconcussional syndrome; whereas participants with no current or prior health problems rarely met this definition (1.6% of boys/1.6% of girls). The results illustrate the tremendous variability in the case definitions of persistent symptoms and the importance of harmonizing definitions across future studies.

Greater Acute Concussion Symptoms Are Associated With Longer Recovery Times in NCAA Division III Collegiate Athletes.

We examined the association between the severity of acute concussion symptoms and time to return to school and to sports in National Collegiate Athletic Association (NCAA) Division III collegiate athletes. We hypothesized that students with the lowest burden of acute symptoms, measured in the first 72 h, would have the fastest return to school and sports and those with the highest burden of symptoms would have the slowest return to school and sports. This injury surveillance cohort included 808 athletes from 11 NCAA Division III colleges who sustained a concussion between 2014 and 2019. Athletic trainers documented time to return to school and to sports. Kruskal-Wallis tests with post-hoc planned comparison Mann-Whitney U tests were used to assess whether athletes took longer to return based on their acute symptom burden (Low, Medium, or High). Survival analysis (Kaplan Meier with log rank tests) was used to compare the recovery times based on acute symptom burden (censored at 28 days). Chi-square tests compared the proportion of those who had not yet returned to school or sports at various recovery benchmarks (i.e., 1 week, 10 days, 2 weeks, 3 weeks, 4 weeks) based on acute symptom burden. Women (median = 5 days) took slightly longer than men (median = 4 days) to return to school (p = 0.001; r = -0.11, small effect). Women and men did not differ on time to return to sports (p = 0.32, r = -0.04). A greater proportion with high acute symptoms remained out of school at 5 (odds ratio, OR = 4.53), 7 (OR = 4.98), and 10 (OR = 4.80) days compared to those with low acute symptoms. A greater proportion with high acute symptoms remained out of sports at 10 (OR = 4.11), 14 (OR = 3.46), and 21 (OR = 3.01) days compared to those with low acute symptoms. This study shows a strong association between having a high burden of acute post-concussion symptoms and having a slower return to school and sports in Division III collegiate athletes. Moreover, it also illustrates the converse: that those athletes with a low burden of acute symptoms have a faster return to school and sports.

Acute Effects of Concussion in Youth With Pre-existing Migraines.

OBJECTIVE: To examine associations between pre-existing migraines and postconcussion symptoms and cognitive performance acutely (within 72 hours) after a suspected concussion. DESIGN: Nested case-control study. SETTING: High schools in Maine, USA. PARTICIPANTS: From a sample of 39 161 adolescent athletes who underwent baseline preseason testing, 633 were assessed within 3 days of a suspected concussion. Of these, 59 reported a history of treatment for migraines at baseline (9.3%). These athletes were individually matched to 2 athletes who had a suspected concussion but denied preinjury migraines (total N = 177; age: M = 15.8, SD = 1.3). ASSESSMENT OF RISK FACTORS: Self-reported history of treatment for migraines by a physician. MAIN OUTCOME MEASURES: Post-Concussion Symptom Scale total score, ImPACT composite scores, and individual symptom endorsement. RESULTS: Individuals with a pre-existing migraine disorder endorsed greater symptom severity (M = 8.4, SD = 9.9) compared with controls (M = 4.5, SD = 6.5; Cohen's d = 0.47) at preinjury baseline and acutely after suspected injury (migraine: M = 26.0, SD = 25.5; controls: M = 16.7, SD = 15.4; d = 0.44). Acutely after a suspected concussion, greater proportions of athletes with migraine disorders reported mental fogginess (49.2% vs 33.9%) and memory problems (39.0% vs 24.6%; P < 0.05). Baseline ImPACT composite scores were similar between migraine and control groups (d = 0.04-0.13). Adolescents with pre-existing migraine disorders performed worse after a suspected concussion compared with the control participants on verbal memory (F = 4.32, P = 0.041) and visual memory (F = 3.95, P = 0.049). CONCLUSIONS: Individuals with pre-existing migraine disorders may be at higher risk for worse outcomes, including greater overall burden of symptoms and worse cognitive functioning in the memory domain, in the first 72 hours after concussion.

Multiple Past Concussions in High School Hockey Players: Examining Cognitive Functioning and Symptom Reporting.

OBJECTIVE: To investigate (1) if there are meaningful differences in baseline preseason cognitive functioning or symptom reporting between high school ice hockey players with and without prior concussions and (2) determine which health history variables predict symptom reporting. DESIGN: Cross-sectional study. SETTING: High schools across the state of Maine. PARTICIPANTS: Participants were 1616 male high school ice hockey players (mean age = 15.6 years; SD = 1.5 years) who completed baseline testing between 2009 and 2015. INDEPENDENT VARIABLES: Athletes were grouped according to their self-reported concussion history [0 (n = 1136), 1 (n = 321), 2 (n = 112), or 3+ (n = 47) previous concussions]. MAIN OUTCOME MEASURES: Cognitive functioning was measured by the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery, and symptom ratings were obtained from the Post-Concussion Symptom Scale. RESULTS: There were no statistically significant differences between groups in cognitive functioning as measured by ImPACT. The group with ≥3 prior concussions endorsed higher total symptom scores, but the effect sizes were small and not statistically significant. In a multivariate model, prior treatment for headaches (not necessarily migraines), prior treatment for a psychiatric condition, and prior treatment for substance/alcohol use all significantly predicted total symptom scores, with concussion history being the weakest independent predictor. CONCLUSIONS: Players with a history of prior concussions performed similarly to players with no prior concussions on cognitive testing. Health history factors were more strongly associated with symptom reporting than concussion history.

Preseason Baseline Neurocognitive Performances and Symptom Reporting on Immediate Post-Concussion Assessment and Cognitive Testing: A Comparison of Adolescent Student-Athletes Tested in Spanish and English.

CONTEXT: Student-athletes are commonly administered the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery at preseason baseline and postconcussion. The ImPACT is available in many languages, but few researchers have examined differences in cognitive performances and symptom ratings based on the language of administration. OBJECTIVE: To examine differences in ImPACT neurocognitive composites and symptom reporting at preseason baseline testing between student-athletes who completed ImPACT in Spanish versus English. DESIGN: Cross-sectional study. SETTING: Preseason baseline testing for a high school concussion-management program in Maine. PATIENTS OR OTHER PARTICIPANTS: Adolescent student-athletes who completed testing in Spanish (n = 169) and English (n = 169) were matched on age, gender, and health and academic history. Language groups were compared on each outcome for the full sample and for gender-stratified subsamples. MAIN OUTCOME MEASURE(S): Neurocognitive composite scores and individual and total symptom severity ratings from the ImPACT battery. RESULTS: Athletes tested in Spanish displayed lower levels of neurocognitive performance on 2 of 5 composite scores (visual motor speed: P < .001, d = 0.51; reaction time: P = .004, d = 0.33) and reported greater symptom severity (P < .001, r = 0.21). When the analyses were stratified by gender, similar visual motor speed differences were observed between language groups among boys (P = .001, d = 0.49) and girls (P = .001, d = 0.49), whereas reaction time showed a larger group difference for boys (P = .012, d = 0.42) than for girls (P = .128, d = 0.21). Language-group differences in symptom reporting were similar for boys (P = .003, r = 0.22) and girls (P = .008, r = 0.21), with more frequent endorsement of physical and affective symptoms by athletes tested in Spanish. CONCLUSIONS: Language-group differences in total symptom severity were small (r = 0.21) and in neurocognitive performances were small to medium (d = 0.05-0.51). Versus previous authors who compared athletes tested in Spanish and English with ImPACT, we observed smaller effects, which may be attributable to close matching on variables related to neurocognitive performances and symptom reporting.

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

Anxiety symptoms are commonly endorsed by student athletes. This study examined the possible influence of anxiety on baseline cognitive testing and symptom reporting in a large sample of adolescent student athletes. Participants were 37,945 adolescent student athletes from the state of Maine who completed baseline testing using ImPACT®. ImPACT includes an evaluation of cognitive functioning and a questionnaire assessing the presence and severity of common post-concussion symptoms. Participants were divided into high and low anxiety groups based on endorsement of anxiety-like symptoms. Student athletes in the high anxiety group were more likely to be girls and to have a greater lifetime history of treatment for mental health problems and headaches (ps < 0.001). The high anxiety group scored slightly lower on cognitive tests (Cohen ds = 0.15-0.26) and reported a much greater amount of baseline pre-season symptoms (Cohen d = 3.38). More than eight of 10 youth in the high anxiety group (82.7%) met International Statistical Classification of Diseases and Related Health Problems-10th Revision (ICD-10) symptom criteria for at least a mild form of the postconcussional syndrome compared with less than two of 10 (18.4%) in the low anxiety group. Students in the high anxiety group had slightly lower scores on neurocognitive testing, but the differences were not practically meaningful; however, they endorsed dramatically more physical, cognitive, and emotional symptoms. Anxiety can mimic the ICD-10 postconcussional syndrome in adolescent student athletes at baseline, when they have not been injured.

Network Structure of Physical, Cognitive, and Emotional Symptoms at Preseason Baseline in Student Athletes with Attention-Deficit/ Hyperactivity Disorder.

OBJECTIVE: Preexisting attention-deficit/hyperactivity disorder (ADHD) may be a risk factor for worse outcome following sport-related concussion. We used a statistical and psychometric approach known as network analysis to examine the architecture of physical, cognitive, and emotional symptoms at preseason baseline among student athletes with ADHD. METHOD: A cohort of 44,527 adolescent student athletes completed baseline preseason testing with ImPACT® between 2009 and 2015. A subsample of athletes reporting a diagnosis of ADHD and at least one symptom were included in this study (N = 3,074; 14-18 years old, 32.7% girls). All participants completed the 22-item Post-Concussion Symptom Scale at preseason baseline. RESULTS: Student athletes reported high frequencies of difficulty concentrating (boys/girls = 50.7%/59.4%), emotional symptoms (nervousness: boys/girls = 30.2%/51.0%; irritability: boys/girls = 23.6%/34.8%; sadness: boys/girls = 21.4%/39.7%), sleep/arousal-related symptoms (trouble falling asleep: boys/girls = 39.5%/49.4%; sleeping less than usual: boys/girls = 36.2%/43.4%; and fatigue: boys/girls = 29.8%/36.4%), and headaches (boys/girls = 27.6%/39.0%) during preseason baseline testing. The most central symptoms included dizziness, which was related to multiple somatic symptoms, and increased emotionality, which was related to a cluster of emotional symptoms. Girls reported symptoms at a greater frequency than boys, and there was evidence for variance in the global strength of the symptom network across gender, but not specific intersymptom relationships. CONCLUSION: In the absence of injury, symptoms that commonly occur after concussion interact and potentially reinforce each other among student athletes with ADHD at preseason. Symptoms common in ADHD (i.e., difficulty concentrating) are not necessarily the most central within the symptom network. These findings may inform more precise interventions for athletes with ADHD and prolonged recovery following concussion.

Architecture of Physical, Cognitive, and Emotional Symptoms at Preseason Baseline in Adolescent Student Athletes With a History of Mental Health Problems.

Objective: Pre-injury mental health problems are associated with greater symptom reporting following sport-related concussion. We applied a statistical and psychometric approach known as network analysis to examine the interrelationships among symptoms at baseline in adolescent student athletes with a history of mental health problems. Design: Cross-sectional study. Setting: High schools in Maine, USA. Participants: A cohort of 44,527 adolescent student athletes completed baseline preseason testing with ImPACT® between 2009 and 2015, and those with a history of mental health problems reporting at least one symptom were included (N = 2,412; 14-18 years-old, 60.1% girls). Independent Variables: Self-reported history of treatment for a psychiatric condition. Main Outcome Measures: Physical, cognitive, and emotional symptoms from the Post-Concussion Symptom Scale. Results: Student athletes reported high frequencies of emotional symptoms (nervousness: boys = 46.6%, girls = 58.3%; irritability: boys = 37.9%, girls = 46.9%; sadness: boys = 38.7%, girls = 53.2%), sleep/arousal-related symptoms (trouble falling asleep: boys = 50.4%, girls = 55.1%; sleeping less than usual: boys = 43.8%, girls = 45.2%; and fatigue: boys = 40.3%, girls = 45.2%), headaches (boys = 27.5%, girls = 41.8%), and inattention (boys = 47.8%, girls = 46.9%) before the start of the season. Although uncommonly endorsed, dizziness was the most central symptom (i.e., the symptom with the highest aggregate connectedness with different symptoms in the network), followed by feeling more emotional and feeling slowed down. Dizziness was related to physical and somatic symptoms (e.g., balance, headache, nausea, numbness/tingling) whereas increased emotionality was related to sadness, nervousness, and irritability. Feeling slowed down was connected to cognitive (e.g., fogginess, forgetfulness), and sensory symptoms (e.g., numbness/tingling, light sensitivity). There were no gender differences in the symptom network structure. Conclusions: We examined the interconnections between symptoms reported by student athletes with mental health problems at preseason baseline, identifying how physical, cognitive, and emotional symptoms interact and potentially reinforce each other in the absence of injury. These findings are a step toward informing more precise interventions for this subgroup of athletes if they are slow to recover following concussion.