Cutoff Scores in Neurocognitive Testing and Symptom Clusters That Predict Protracted Recovery From Concussions in High School Athletes

University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
Neurosurgery (Impact Factor: 3.62). 08/2011; 70(2):371-9; discussion 379. DOI: 10.1227/NEU.0b013e31823150f0
Source: PubMed


Many studies address diagnosing concussions, but few look at predicting prognosis. A previous discriminant function analysis showed that symptom clusters derived from the Post-Concussion Symptom Scale and Immediate Postconcussion Assessment and Cognitive Testing composite scores used together improved predictions of protracted recovery after a sports-related concussion.
To determine cutoff scores in neurocognitive and Post-Concussion Symptom Scale symptom cluster scores when classifying protracted recovery in concussed athletes.
108 male high school football athletes completed a computer-based neurocognitive test battery (Immediate Postconcussion Assessment and Cognitive Testing) within a median of 2 days after injury. Patients completed graded exertional protocols requiring athletes to be symptom free at rest and during increasing levels of activity and had recovery of neurocognitive scores before return to play. After return to play, athletes were classified as protracted recovery (>14 days, n = 58) or short-recovery (≤14 days, n = 50). Receiver-operating characteristic curves analyzed each of the neurocognitive (verbal, visual, processing speed, and reaction time) and symptom cluster (migraine, cognitive, sleep, and neuropsychiatric) scores.
Cutoffs for migraine cluster, cognitive cluster, visual memory, and processing speed were statistically significant. Cutoffs at 75%, 80%, and 85% sensitivity to predict protracted recovery for the migraine symptom cluster were 15 or greater, 18, 20; cognitive symptom cluster 18 or greater, 19, 22; visual memory 48 or less, 46, 44.5; and processing speed 24.5 or less, 23.46, 22.5, respectively. Eighty-percent sensitivity indicates that the corresponding cutoff correctly identify 80% of concussed athletes requiring protracted recovery.
Specific cutoffs may help to set numerical thresholds for clinicians to predict which concussed athletes will have a protracted recovery.

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    • "Based on the available data, recent consensus guidelines (from the 2012 International Conference on Concussion in Sport; McCrory et al. 2013) concluded that prolonged LOC (>1 min) and amnesia appear to be risk factors for prolonged recovery, although clinical features such as the nature and severity of postconcussive symptoms may be even more relevant than these other signs. For example, one study found dizziness to be particularly associated with prolonged recovery (with LOC, PTA, RGA, and other symptoms not predictive; Lau et al. 2011), and in another sample, the same group reported that other symptom clusters (migraine, cognitive) and post-injury cognitive impairments (visual memory, processing speed) were most predictive of prolonged recovery (although the magnitude of relationships between these variables and recovery group was rather small; Lau et al. 2012). A recent large-scale study evaluated the value of a wide variety of factors in predicting prolonged clinical (symptom) recovery following SRC (McCrea et al. 2013). "
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    ABSTRACT: Concussion is a highly prevalent injury in contact and collision sports that has historically been poorly understood. An influx of sport-concussion research in recent years has led to a dramatic improvement in our understanding of the injury's defining characteristics and natural history of recovery. In this review, we discuss the current state of knowledge regarding the characteristic features of concussion and typical acute course of recovery, with an emphasis on the aspects of functioning most commonly assessed by clinicians and researchers (e.g., symptoms, cognitive deficits, postural stability). While prototypical clinical recovery is becoming better understood, questions remain regarding what factors (e.g., injury severity, demographic variables, history of prior concussions, psychological factors) may explain individual variability in recovery. Although research concerning individual differences in response to concussion is relatively new, and in many cases limited methodologically, we discuss the evidence about several potential moderators of concussion recovery and point out areas for future research. Finally, we describe how increased knowledge about the negative effects of and recovery following concussion has been translated into clinical guidelines for managing concussed athletes.
    Full-text · Article · Nov 2013 · Neuropsychology Review
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    • "The precise frequency of athletes who do not follow the typical course of rapid, spontaneous recovery and instead exhibit prolonged postconcussive symptoms or other functional impairments after concussion remains unclear. While several studies have reported that the largest percentage of athletes achieve a complete recovery within one to two weeks (Belanger & Vanderploeg, 2005; Broglio & Puetz, 2008), limited research has suggested a lengthier recovery time in younger athletes (Field, Collins, Lovell, & Maroon, 2003), citing that roughly half of all high school athletes required more than 14 days to recover (Lau, Lovell, Collins, & Pardini, 2009; Lau, Collins, & Lovell, 2012). Unfortunately, these studies did not include controls, and applied criteria for ''recovery'' that may have resulted in high false positive rates due to criterion contamination that significantly complicate the interpretation of data from those studies. "
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    ABSTRACT: Sport-related concussion (SRC) is typically followed by clinical recovery within days, but reports of prolonged symptoms are common. We investigated the incidence of prolonged recovery in a large cohort (n = 18,531) of athlete seasons over a 10-year period. A total of 570 athletes with concussion (3.1%) and 166 controls who underwent pre-injury baseline assessments of symptoms, neurocognitive functioning and balance were re-assessed immediately, 3 hr, and 1, 2, 3, 5, 7, and 45 or 90 days after concussion. Concussed athletes were stratified into typical (within 7 days) or prolonged (> 7 days) recovery groups based on symptom recovery time. Ten percent of athletes (n = 57) had a prolonged symptom recovery, which was also associated with lengthier recovery on neurocognitive testing (p < .001). At 45-90 days post-injury, the prolonged recovery group reported elevated symptoms, without deficits on cognitive or balance testing. Prolonged recovery was associated with unconsciousness [odds ratio (OR), 4.15; 95% confidence interval (CI) 2.12-8.15], posttraumatic amnesia (OR, 1.81; 95% CI, 1.00-3.28), and more severe acute symptoms (p < .0001). These results suggest that a small percentage of athletes may experience symptoms and functional impairments beyond the typical window of recovery after SRC, and that prolonged recovery is associated with acute indicators of more severe injury. (JINS, 2012, 18, 1-12).
    Full-text · Article · Oct 2012 · Journal of the International Neuropsychological Society
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    ABSTRACT: Context Evolving concussion diagnosis/management tools and guidelines make Knowledge Transfer and Exchange (KTE) to practitioners challenging. Objective Identify sports concussion knowledge base and practise patterns in two family physician populations; explore current/preferred methods of KTE. Design A cross-sectional study. Setting Family physicians in Alberta, Canada (CAN) and North/South Dakota, USA. Participants CAN physicians were recruited by mail: 2.5% response rate (80/3154); US physicians through a database: 20% response rate (109/545). Intervention/instrument Online survey. Main and secondary outcome measures Diagnosis/management strategies for concussions, and current/preferred KTE. Results Main reported aetiologies: sports/recreation (52.5% CAN); organised sports (76.5% US). Most physicians used clinical examination (93.8% CAN, 88.1% US); far fewer used the Sport Concussion Assessment Tool (SCAT1/SCAT2) and balance testing. More US physicians initially used concussion-grading scales (26.7% vs 8.8% CAN, p=0.002); computerised neurocognitive testing (19.8% vs 1.3% CAN; p<0.001) and Standardised Assessment of Concussion (SAC) (21.8% vs 7.5% CAN; p=0.008). Most prescribed physical rest (83.8% CAN, 75.5% US), while fewer recommended cognitive rest (47.5% CAN, 28.4% US; p=0.008). Return-to-play decisions were based primarily on clinical examination (89.1% US, 73.8% CAN; p=0.007); US physicians relied more on neurocognitive testing (29.7% vs 5.0% CAN; p<0.001) and recognised guidelines (63.4% vs 23.8% CAN; p<0.001). One-third of Canadian physicians received KTE from colleagues, websites and medical school training. Leading KTE preferences included Continuing Medical Education (CME) courses and online CME. Conclusions Existing published recommendations regarding diagnosis/management of concussion are not always translated into practise, particularly the recommendation for cognitive rest; predicating enhanced, innovative CME initiatives.
    Full-text · Article · Nov 2012 · British Journal of Sports Medicine
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