Greater Acute Concussion Symptoms Linked to Longer Recovery Times in Adolescents
Nathan E. Cook, PhD, Grant L. Iverson, PhD, and colleagues presented novel findings that adolescents with high symptom burden in the first 72 hours after a sport-related concussion likely take longer to return to school and sports than those with lower acute symptom burden.
This prospective observational study examined the association between acute post-concussion symptom burden and the time required for adolescent student–athletes to return to school and sports.
From a Maine concussion surveillance database, 345 students were identified, ages 14 to 19, the Sport Concussion Assessment Tool, Fifth Edition (SCAT 5) symptom questionnaire acutely following a concussion, and were followed by school officials.
Total symptom severity was strongly associated with functional recovery; for example, 68% of adolescents with the lowest burden of acute symptoms returned to school within seven days compared to 45% of those with the highest burden (P=0.001).
Respective figures for return to sports within seven days were 21% vs. 7% (P=0.001).
Early identification of student–athletes who are at high risk will help physicians and other healthcare providers counsel patients and their families and better direct management and rehabilitation.
It's logical to think that after a sports-related concussion, adolescents with a low burden of acute symptoms will return to sports more quickly than those with a high burden. Surprisingly, though, that issue has not been well studied. Furthermore, the time to return to school isn't typically measured.
Researchers at Mass General Brigham have advanced the literature by studying adolescents who played diverse sports, sustained concussions, had their acute symptom burden assessed within the first 72 hours following injury, and had their recovery monitored prospectively. Nathan E. Cook, PhD, a neuropsychologist in the Sports Concussion Clinic at Massachusetts General Hospital, and an assistant professor in the Department of Physical Medicine and Rehabilitation at Harvard Medical School and Spaulding Rehabilitation Hospital, Grant L. Iverson, PhD, neuropsychologist and director of the Sports Concussion Program at Mass General, and a professor in the Department of Physical Medicine and Rehabilitation at Harvard Medical School and Spaulding Rehabilitation Hospital, and colleagues published the results in the Journal of Child Neurology. They document that adolescents with high acute symptom burden had the slowest return to school and sports, and adolescents with low acute burden had the fastest return.
The Maine Concussion Management Initiative maintains an online concussion injury surveillance resource called the Head Injury Tracker. Athletic trainers, school nurses, and other school officials prospectively monitored the recovery of high school student-athletes who sustained a sports-related concussion or suspected concussion.
This study included 375 adolescents, ages 14 to 19 (56% male), who completed the Sport Concussion Assessment Tool, Fifth Edition (SCAT 5) symptom questionnaire acutely following a concussion sustained between September 2014 and January 2020. Adolescents completed the self-report symptom questionnaire within three days of injury.
Total symptom severity scores were used to divide the study subjects into three groups:
- Lowest acute symptoms (n=134)—score 0–20 for girls and 0–19 for boys
- Middle acute symptoms (n=112)—score 21–38 for girls and 20–33 for boys
- Highest acute symptoms (n=119)—score ≥39 for girls and ≥34 for boys
Return to School
For the first ten days after injury, adolescents with a low symptom burden were significantly more likely to return to school full-time, without accommodation, than those with a middle or high burden:
- By day 3—43% lowest burden vs. 30% middle burden vs. 23% highest burden (P=0.003)
- By day 5—54% vs. 40% vs. 33% (P=0.003), respectively
- By day 7—68% vs. 62% vs. 45% (P=0.001), respectively
- By day 10—78% vs. 74% vs. 61% (P=0.008), respectively
The odds of remaining out of school on days 3, 5, 7, and 10 were twice as high for adolescents with the highest acute symptom burden compared with the lowest acute symptom burden.
Return to Sports
Return to sports was also significantly slower for adolescents with the highest acute symptom burden through the first ten days:
- By day 7—21% lowest burden vs. 8% middle burden vs. 7% highest burden (P=0.001)
- By day 10—43% vs. 30% vs. 20% (P<0.001), respectively
The odds of remaining out of sports on days 7 and 10 were three times higher for adolescents with the highest acute symptom burden.
Early Risk Stratification Needed
Early identification of high-risk young patients will help physicians and other health care providers direct management and rehabilitation efforts. In addition, clinicians have a responsibility to help bridge the gap between student-athletes and school administrators to minimize the adverse effects of missed classroom time. The data presented here may guide the counseling of patients and their families.
This study also indicates evidence-based guidelines for return to school should take into account the considerable interindividual variability in acute symptom burden following concussion.