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Leggett B, Eliason P, Sick S, Burma JS, Wong SK, Laperrière D, Goulet C, Fremont P, Russell K, Schneider KJ, Emery CA. Youth Preseason Performance on the Sport Concussion Assessment Tool 5 Across Multiple Sports. Clin J Sport Med 2024; 34:288-296. [PMID: 38149828 DOI: 10.1097/jsm.0000000000001201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/07/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE To examine preseason Sport Concussion Assessment Tool 5 (SCAT5) performance of adolescent sport participants by environment (in-person/virtual), sex, age, concussion history, collision/noncollision sport participation, and self-reported medical diagnoses. DESIGN Cross-sectional. SETTING Canadian community and high-school sport settings. PARTICIPANTS Three thousand eight hundred five adolescent (2493 male, 1275 female, and 37 did not disclose; 11- to 19-year-old) sport participants. ASSESSMENT OF RISK FACTORS Sport Concussion Assessment Tool 5 administration method (in-person/virtual), sex (male/female/unreported), age (years), concussion history (0/1/2/3+), collision/noncollision sport participant, and self-reported medical diagnoses [attention deficit disorder or attention-deficit/hyperactivity disorder, headache/migraine, learning disability, and psychiatric disorder (ie, anxiety/depression/other)]. OUTCOME MEASURES Preseason SCAT5 outcomes including total number of symptoms (TNS; /22), symptom severity score (SSS; /132), Standardized Assessment of Concussion (SAC; /50), and modified Balance Error Scoring System (mBESS; /30). RESULTS Multiple multilevel linear or Poisson regression complete case analyses adjusting for clustering and robust standard errors, with β-coefficients (95% CI) back-transformed to indicate an increase/decrease in SCAT5 subdomains when relevant for clinical interpretation. Virtual (V) performance was associated with fewer symptoms reported [TNS Difference V-IP = -1.53 (95% CI, -2.22 to -0.85)], lower SSS [-2.49 (95% CI, -4.41 to -0.58)], and fewer mBESS errors (IP) [-0.52 (95% CI, -0.77 to -0.27)] compared with in-person. For every one-year increase in age, more symptoms [TNS = 0.22 (95% CI, 0.01-0.44)], higher SSS [0.52 (95% CI, 0.01-1.06)], higher SAC [0.27 (95% CI, 0.15-0.38), and poorer balance [mBESS = -0.19 (-0.28 to -0.09)] were observed. Differences between males and females were also seen across all SCAT5 outcomes. Individuals reporting any medical diagnosis or 3+ concussion history also reported more symptoms (TNS) and higher SSS than those who did not. CONCLUSIONS Administration environment, sex, age, concussion history, and medical diagnoses were associated with SCAT5 subdomains and are important considerations when interpreting the SCAT5 results.
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Affiliation(s)
- Benjamin Leggett
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
| | - Paul Eliason
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Stacy Sick
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Joel S Burma
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- Cerebrovascular Concussion Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Sophie K Wong
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - David Laperrière
- Pavillon de l'Éducation physique et des sports, Université Laval, Québec City, QC, Canada
- Pediatrics and Child Health, University of Manitoba, Winnipeg, MN, Canada
- Department of Physical Education, Faculty of Education, Université Laval, Québec City, QC, Canada
| | - Claude Goulet
- Department of Physical Education, Faculty of Education, Université Laval, Québec City, QC, Canada
| | - Pierre Fremont
- Pavillon de l'Éducation physique et des sports, Université Laval, Québec City, QC, Canada
| | - Kelly Russell
- Pediatrics and Child Health, University of Manitoba, Winnipeg, MN, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, MB, Canada
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Sport Medicine Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- Evidence Sport and Spine, Calgary, AB, Canada
| | - Carolyn A Emery
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, AB, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; and
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Echemendia RJ, Burma JS, Bruce JM, Davis GA, Giza CC, Guskiewicz KM, Naidu D, Black AM, Broglio S, Kemp S, Patricios JS, Putukian M, Zemek R, Arango-Lasprilla JC, Bailey CM, Brett BL, Didehbani N, Gioia G, Herring SA, Howell D, Master CL, Valovich McLeod TC, Meehan WP, Premji Z, Salmon D, van Ierssel J, Bhathela N, Makdissi M, Walton SR, Kissick J, Pardini J, Schneider KJ. Acute evaluation of sport-related concussion and implications for the Sport Concussion Assessment Tool (SCAT6) for adults, adolescents and children: a systematic review. Br J Sports Med 2023; 57:722-735. [PMID: 37316213 DOI: 10.1136/bjsports-2022-106661] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/16/2023]
Abstract
OBJECTIVES To systematically review the scientific literature regarding the acute assessment of sport-related concussion (SRC) and provide recommendations for improving the Sport Concussion Assessment Tool (SCAT6). DATA SOURCES Systematic searches of seven databases from 2001 to 2022 using key words and controlled vocabulary relevant to concussion, sports, SCAT, and acute evaluation. ELIGIBILITY CRITERIA (1) Original research articles, cohort studies, case-control studies, and case series with a sample of >10; (2) ≥80% SRC; and (3) studies using a screening tool/technology to assess SRC acutely (<7 days), and/or studies containing psychometric/normative data for common tools used to assess SRC. DATA EXTRACTION Separate reviews were conducted involving six subdomains: Cognition, Balance/Postural Stability, Oculomotor/Cervical/Vestibular, Emerging Technologies, and Neurological Examination/Autonomic Dysfunction. Paediatric/Child studies were included in each subdomain. Risk of Bias and study quality were rated by coauthors using a modified SIGN (Scottish Intercollegiate Guidelines Network) tool. RESULTS Out of 12 192 articles screened, 612 were included (189 normative data and 423 SRC assessment studies). Of these, 183 focused on cognition, 126 balance/postural stability, 76 oculomotor/cervical/vestibular, 142 emerging technologies, 13 neurological examination/autonomic dysfunction, and 23 paediatric/child SCAT. The SCAT discriminates between concussed and non-concussed athletes within 72 hours of injury with diminishing utility up to 7 days post injury. Ceiling effects were apparent on the 5-word list learning and concentration subtests. More challenging tests, including the 10-word list, were recommended. Test-retest data revealed limitations in temporal stability. Studies primarily originated in North America with scant data on children. CONCLUSION Support exists for using the SCAT within the acute phase of injury. Maximal utility occurs within the first 72 hours and then diminishes up to 7 days after injury. The SCAT has limited utility as a return to play tool beyond 7 days. Empirical data are limited in pre-adolescents, women, sport type, geographical and culturally diverse populations and para athletes. PROSPERO REGISTRATION NUMBER CRD42020154787.
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Affiliation(s)
- Ruben J Echemendia
- Concussion Care Clinic, University Orthopedics, State College, Pennsylvania, USA
- University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Joel S Burma
- Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
| | - Jared M Bruce
- Biomedical and Health Informatics, University of Missouri - Kansas City, Kansas City, Missouri, USA
| | - Gavin A Davis
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Cabrini Health, Malvern, Victoria, Australia
| | - Christopher C Giza
- Neurosurgery, UCLA Steve Tisch BrainSPORT Program, Los Angeles, California, USA
- Pediatrics/Pediatric Neurology, Mattel Children's Hospital UCLA, Los Angeles, California, USA
| | - Kevin M Guskiewicz
- Matthew Gfeller Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dhiren Naidu
- Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Steven Broglio
- Michigan Concussion Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Simon Kemp
- Sports Medicine, Rugby Football Union, London, UK
| | - Jon S Patricios
- Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa
| | | | - Roger Zemek
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Christopher M Bailey
- Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Benjamin L Brett
- Neurosurgery/ Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Gerry Gioia
- Depts of Pediatrics and Psychiatry & Behavioral Sciences, Children's National Health System, Washington, District of Columbia, USA
| | - Stanley A Herring
- Department of Rehabilitation Medicine, Orthopaedics and Sports Medicine, and Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - David Howell
- Orthopedics, Sports Medicine Center, Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Tamara C Valovich McLeod
- Department of Athletic Training and School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa, Arizona, USA
| | - William P Meehan
- Sports Medicine, Children's Hospital Boston, Boston, Massachusetts, USA
- Emergency Medicine, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Zahra Premji
- Libraries, University of Victoria, Victoria, British Columbia, Canada
| | | | | | - Neil Bhathela
- UCLA Health Steve Tisch BrainSPORT Program, Los Angeles, California, USA
| | - Michael Makdissi
- Florey Institute of Neuroscience and Mental Health - Austin Campus, Heidelberg, Victoria, Australia
- La Trobe Sport and Exercise Medicine Research Centre, Melbourne, Victoria, Australia
| | - Samuel R Walton
- Department of Physical Medicine and Rehabilitation, School of Medicine, Richmond, Virginia, USA
| | - James Kissick
- Dept of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jamie Pardini
- Departments of Internal Medicine and Neurology, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Kathryn J Schneider
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
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Magliato SN, Wingerson MJ, Seehusen CN, Smulligan KL, Simon SL, Wilson JC, Howell DR. Sleep Problems After Concussion Are Associated With Poor Balance and Persistent Postconcussion Symptoms. J Child Neurol 2023; 38:198-205. [PMID: 37122172 DOI: 10.1177/08830738231170721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
We examined the association of self-reported sleep problems with clinical measures of postural stability, memory performance, symptom burden, and symptom duration following youth concussion. Patients 6-18 years of age presenting ≤21 days postconcussion underwent a clinical evaluation including modified Balance Error Scoring System, single- and dual-task tandem gait, immediate and delayed recall, and symptom severity. We calculated time from injury until symptom resolution and determined the proportion of patients who developed persistent postconcussion symptoms, defined as a symptom duration >28 days postconcussion. We grouped patients based on whether they reported sleep problems at their postconcussion clinical evaluation and compared symptom-based and functional outcomes between groups. Of the 207 patients included, n = 97 (14.3 ± 2.9 years; 49% female; initial visit 10.2 ± 5.8 days postconcussion) reported sleep problems postconcussion and n = 110 (14.3 ± 2.4 years; 46% female; initial visit 9.3 ± 5.4 days postinjury) did not. Those reporting sleep problems postconcussion had significantly more modified Balance Error Scoring System errors than those without (8.4 ± 5.5 vs 6.7 ± 4.7; P = .01), but similar tandem gait and memory performance. A significantly greater proportion of those who reported sleep problems postconcussion experienced persistent postconcussion symptoms than those who did not (53% vs 31%; P = .004). After adjusting for time from concussion to clinical visit and preconcussion sleep problems, postconcussion sleep problems were associated with a 2 times greater odds of developing persistent postconcussion symptoms (adjusted odds ratio = 2.02, 95% CI = 1.01, 4.06; P = .049). Identifying sleep problems early following concussion may allow clinicians to implement targeted treatment recommendations to improve sleep and provide an optimal recovery environment.
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Affiliation(s)
- Samantha N Magliato
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
- Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA
| | - Mathew J Wingerson
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
- Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA
| | - Corrine N Seehusen
- Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA
| | - Katherine L Smulligan
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
- Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA
| | - Stacey L Simon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
- Pediatric Sleep Center, Children's Hospital of Colorado, Aurora, CO, USA
| | - Julie C Wilson
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
- Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - David R Howell
- Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA
- Sports Medicine Center, Children's Hospital of Colorado, Aurora, CO, USA
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Brett BL, Nelson LD, Meier TB. The Association Between Concussion History and Increased Symptom Severity Reporting Is Independent of Common Medical Comorbidities, Personality Factors, and Sleep Quality in Collegiate Athletes. J Head Trauma Rehabil 2022; 37:E258-E267. [PMID: 34570026 PMCID: PMC8940748 DOI: 10.1097/htr.0000000000000724] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We investigated the degree to which the association between history of concussion with psychological distress and general symptom severity is independent of several factors commonly associated with elevated symptom severity. We also examined whether symptom severity endorsement was associated with concussion injury specifically or response to injury in general. SETTING Academic medical center. PARTICIPANTS Collegiate athletes ( N = 106; age: M = 21.37 ± 1.69 years; 33 female) were enrolled on the basis of strict medical/psychiatric exclusion criteria. DESIGN Cross-sectional single-visit study. Comprehensive assessment, including semistructured interviews to retrospectively diagnose the number of previous concussions, was completed. Single-predictor and stepwise regression models were fit to examine the predictive value of prior concussion and orthopedic injuries on symptom severity, both individually and controlling for confounding factors. MAIN OUTCOME MEASURES Psychological distress was operationalized as Brief Symptom Inventory-18 Global Severity Index (BSI-GSI) ratings; concussion-related symptom severity was measured using the Sport Concussion Assessment Tool. RESULTS Controlling for baseline factors associated with the symptom outcomes (agreeableness, neuroticism, negative emotionality, and sleep quality), concussion history was significantly associated with psychological distress ( B = 1.25 [0.55]; P = .025, Δ R2 = 0.034) and concussion-like symptom severity ( B = 0.22 [0.08]; P = .005, Δ R2 = 0.064) and accounted for a statistically significant amount of unique variance in symptom outcomes. Orthopedic injury history was not individually predictive of psychological distress ( B = -0.06 [0.53]; P = .905) or general symptom severity ( B = 0.06 [0.08]; P = .427) and did not explain the relationship between concussion history and symptom outcomes. CONCLUSIONS Concussion history is associated with subtle elevations in symptom severity in collegiate-aged athletes; this relationship is independent of medical, lifestyle (ie, sleep), and personality factors. Furthermore, this relationship is associated with brain injury (ie, concussion) and is not a general response to injury history.
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Affiliation(s)
- Benjamin L Brett
- Departments of Neurosurgery and Neurology (Drs Brett and Nelson) and Neurosurgery, Biomedical Engineering, and Cell Biology, Neurobiology, and Anatomy (Dr Meier), Medical College of Wisconsin, Milwaukee
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Anzalone C, Bridges RM, Luedke JC, Decker SL. Neurocognitive correlates of persisting concussion symptoms in youth. APPLIED NEUROPSYCHOLOGY-CHILD 2021; 11:771-780. [PMID: 34392768 DOI: 10.1080/21622965.2021.1961260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Many patients that experience a concussion have impairing symptoms that persist beyond typical recovery timeframes. Concussion symptoms often remit within a month, but persisting impairments are difficult to characterize and attribute to concussion given the poorly defined diagnostic criteria of post-concussion syndrome and inadequate understanding of the cognitive symptoms associated with this condition. The current study aims to clarify the cognitive profiles of school-aged concussion patients (n = 21; N = 36; 64% male) that have persisting symptoms to improve the clinical identification methods for this condition. Logistic regression was used to explore the importance of cognitive processing speed and working memory for identifying patients with persisting concussion symptoms (PCS). Additional exploratory analyses were conducted to clarify cognitive domains that may be impacted by having PCS. Findings indicate processing speed and working memory abilities alone are not adequate to identify patients with PCS. Further, measures of processing speed, fluid reasoning, working memory, and long-term retrieval together were found to be necessary to identify those who had a prior concussion with PCS. These findings indicate clinical neuropsychological batteries must include measures of these four cognitive domains when assessing school-aged patients with chronic symptoms that extend beyond three months following injury.
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Affiliation(s)
- Christopher Anzalone
- Department of Psychology, University of South Carolina, Columbia, South Carolina, USA
| | - Rachel M Bridges
- Department of Psychology, University of South Carolina, Columbia, South Carolina, USA
| | - Jessica C Luedke
- Department of Psychology, University of South Carolina, Columbia, South Carolina, USA
| | - Scott L Decker
- Department of Psychology, University of South Carolina, Columbia, South Carolina, USA
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Moran RN, Ingargiola A. Self-reported prior night's sleep quantity on baseline symptom factors and computerized neurocognitive testing in high school athletes. APPLIED NEUROPSYCHOLOGY-CHILD 2020; 11:62-68. [PMID: 32301352 DOI: 10.1080/21622965.2020.1751163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Little is known regarding sleep and baseline concussion performance and symptoms in athletes. We explored the effects of self-reported prior night's sleep quantity on baseline symptoms and computerized neurocognitive testing in high school athletes. A retrospective analysis of 958 high school athletes between the ages of 13-19 years was completed on Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) performance. Participants were categorized into two groups based on self-reported prior night's sleep quantity: <8 h (n = 524; 55%) and ≥8 h (n = 434; 45%). Measures consisted of baseline total symptom score, symptom factors (vestibular-somatic, sleep-arousal, affective, and cognitive-sensory), and ImPACT composite scores (verbal and visual memory, visual-motor speed, reaction time, and impulse control). Significant differences were found on all baseline symptom factors (ps < .02) and total symptom scores (p < .001) with greater symptom reporting in the <8 h prior night's sleep group. No group differences were observed between duration and composite scores of verbal memory (p = .49), visual memory (p = .94), visual-motor speed (p = .38), reaction time (p = .50), or impulse control (p = .81). High school athletes who report <8 h of sleep the night prior to baseline concussion testing reported greater symptoms across all symptom factors. Clinicians should consider inadequate sleep the night prior to concussion testing to ensure accurate, valid assessments, especially on symptom reporting scales.
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Affiliation(s)
- Ryan N Moran
- Athletic Training Research Laboratory, Department of Health Science, The University of Alabama, Tuscaloosa, AL, USA
| | - Alicia Ingargiola
- Athletic Training Research Laboratory, Department of Health Science, The University of Alabama, Tuscaloosa, AL, USA
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