Acute Effects of Concussion in Adolescent Athletes With High Preseason Anxiety

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 (β = 0.12, P <0 .001) and greater number of days to symptom evaluation (β = 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.

Postconcussion Moderate to Vigorous Physical Activity Predicts Anxiety Severity among Adolescent Athletes

PURPOSE

This study aimed to examine how moderate-to-vigorous physical activity (MVPA) during concussion recovery influences self-reported anxiety symptoms at follow-up assessment. We hypothesized that more MVPA after concussion would be associated with lower anxiety rating at follow-up.

METHODS

We performed a prospective study of participants aged 13-18 yr initially assessed within 14 d of diagnosed concussion. Participants rated concussion symptoms using the Post-Concussion Symptom Inventory and were provided a wrist-worn actigraphy device to track activity for 1 wk after assessment. At follow-up assessment, participants rated anxiety symptoms using the four-question Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety subscale. Each question ranged from 1 (never) to 5 (almost always), with an overall score range of 4-20. For univariable analysis, we calculated correlation coefficients between MVPA and PROMIS anxiety subscale scores. We then created a multiple linear regression model with follow-up PROMIS anxiety subscale score as the outcome and MVPA, sex, initial symptom severity, and preconcussion anxiety as predictors.

RESULTS

We enrolled and initially tested 55 participants, and 48 were included in the final analysis (age, 14.6±2.7 yr; 56% female; initial assessment, 7.3± 3.1 d; follow-up assessment, 42.0±29.7 d). We observed an inverse and low correlation between MVPA and follow-up PROMIS anxiety subscale T-scores ( r = -0.30, P = 0.04). Multivariable regression results indicated that MVPA ( β = -5.30; 95% confidence interval (CI), -10.58 to -0.01), initial Post-Concussion Symptom Inventory score ( β = 0.11; 95% CI, 0.03 to 0.19), and preconcussion anxiety ( β = 5.56; 95% CI, 0.12 to 11.0), but not sex ( β = -2.60; 95% CI, -7.14, to 1.94), were associated with follow-up PROMIS anxiety subscale T-scores.

CONCLUSIONS

After adjusting for covariates, more MVPA early after concussion predicted lower PROMIS anxiety subscale scores at follow-up. Although initial concussion symptom severity and preconcussion anxiety were also associated with follow-up PROMIS anxiety subscale score, MVPA represents a modifiable factor that may contribute to lower anxiety symptoms.

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

OBJECTIVE

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

DESIGN

Prospective cross-sectional study.

SETTING

York University in Toronto, Canada.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Anxiety Disorders in Athletes

Athletes and non-athletes experience many anxiety-related symptoms and disorders at comparable rates. Contributory factors may include pressure to perform, public scrutiny, sporting career dissatisfaction, injury, and harassment and abuse in sport. Anxiety may negatively impact sport performance. Specific types of anxiety may have unique presentations in athletes. It is important to rule out general medical and substance-related causes of anxiety symptoms. Psychotherapy and pharmacology treatment options should be considered, bearing in mind athletes' environmental circumstances and physiologies.

Characterizing the Network Structure of Post-Concussion Symptoms

OBJECTIVE

Assessment of post-concussion symptoms is implemented at secondary, post-secondary, and professional levels of athletics. Network theory suggests that disorders can be viewed as a set of interacting symptoms that amplify, reinforce, and maintain one another. Examining the network structure of post-concussion symptoms may provide new insights into symptom comorbidity and may inform targeted treatment. We used network analysis to examine the topology of post-concussion symptoms using the Post-Concussion Symptom Scale (PCSS) in high school athletes with recent suspected sport-related concussion.

METHOD

Using a cross-sectional design, the network was estimated from Post Concussion Symptom Scale scores from 3,292 high school athletes, where nodes represented symptoms and edges represented the association between symptoms. Node centrality was calculated to determine the relative importance of each symptom in the network.

RESULTS

The network consisted of edges within and across symptom domains. "Difficulty concentrating" and "dizziness" were the most central symptoms in the network. Although not highly central in the network, headaches were the highest rated symptom.

CONCLUSIONS

The interconnectedness among symptoms supports the notion that post-concussion symptoms are interrelated and mutually reinforcing. Given their central role in the network, "difficulty concentrating" and "dizziness" are expected to affect the activation and persistence of other post-concussion symptoms. Interventions targeting difficulties with concentration and dizziness may help alleviate other symptoms. Our findings could inform the development of targeted treatment with the aim of reducing overall symptom burden. Future research should examine the trajectory of post-concussion symptom networks to advance the clinical understanding of post-concussive recovery.

Relationship between anxiety and concussion symptoms among adolescents enrolled in a randomized controlled trial of aerobic exercise

BACKGROUND

Affective symptoms, specifically, anxiety, are often overlooked after sport-related concussion (SRC), and may contribute to prolonged recovery.

OBJECTIVE

To examine the impact of anxiety during clinical recovery among adolescents (13-18y) enrolled in a randomized trial of aerobic exercise for SRC.

METHODS

Patients at three sites were randomized into aerobic exercise or stretching arms, and enrolled in the 4-week intervention. The relationship between PROMIS Anxiety score at initial visit and time to symptom resolution was evaluated with survival analysis. The relationship between weekly PROMIS Anxiety score and Post-concussion Symptom Inventory (PCSI) score was evaluated with Linear Mixed Models. Analyses adjusted for study arm and baseline covariates.

RESULTS

Among 54 adolescents (median age = 15.8y, initial visit PCSI score = 32, pre-injury PROMIS Anxiety score = 2), median time to symptom resolution was 10 days (25th-75th percentiles: 6-24) in the Low-PROMIS Anxiety group and 12 days (25th-75th percentiles: 5-21) in the High-PROMIS Anxiety group (p = 0.62). Each additional unit of PROMIS Anxiety score corresponded to a 1.52-unit higher PCSI total score (p <  0.01). Neither effect varied by aerobic exercise/stretching group.

CONCLUSION

Higher initial PROMIS Anxiety score was not significantly associated with delayed symptom resolution. However, over time, PROMIS Anxiety score was significantly associated with elevated PCSI score, regardless of exercise/stretching group.

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

Introduction

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

Methods

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

Results

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

Discussion

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