Mulligan, I, Boland, M, Payette,J. J Orthop Sports Phys Ther. 2012;42(7):625-32. Epub 2012 Apr 24.
Post-injury management of sports-related concussion has become increasingly dependent on the results from neurocognitive assessments, which rely on both subjective and objective data, including Balance Error Scoring System (BESS), the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT), and the Postconcussion Symptom Scale. A recent study examining high school athletes 2 days following a concussion found that even in the non-concussion control group, 30% of the athletes had significant changes in symptom scores or neurocognitive testing. Little research exists examining the prevalence of neurocognitive or balance deficits in athletes who do not report concussion-like symptoms to a healthcare provider. In this prospective cohort study by Mulligan, et. al., the authors tried to identify the prevalence of neurocognitive and balance deficits in 45 Division IA collegiate football athletes 48 hours following competition. Athletes between the ages of 18 and 25 years who traveled with the team for the final game of the season were included in the study. Excluded from the study were athletes who sustained a concussion during the season, were not on the traveling team, reported signs and symptoms associated with a concussion and were evaluated at the time of the game or prior to data collection, as well as athletes currently being treated for a lower extremity musculoskeletal injury. The athletes completed ImPACT (Version 2.1), the Postconcussion Symptom Scale, and BESS testing prior to the football season and approximately 48 hours after the last game. The authors reported the prevalence of scores exceeding reliable change from baseline (“detectable change”), as well as the number of deficits noted for each athlete. Results showed that 71% of those tested had neurocognitive impairments and/or balance deficits that may be associated with concussion despite no report of concussion-related symptoms. Of that 71%, 19 of the 32 (59.4%) had detectable change in at least 2 of the 3 screening tools or had at least 2 subcategories with detectable change during ImPACT testing.
The findings of this study suggest that despite having no reported symptoms associated with concussion 48 hours following a game, a significant number of football athletes had deficits on neurocognitive testing. These results also imply that reported symptoms alone may not be sensitive enough to rule out a concussion, and additional assessments may be necessary to evaluate athletes who may have suffered a concussion but do not recognize their deficits or report them to medical professionals. Consequently, further research in the area of improving recognition of an athlete’s potential neurocognitive deficits is needed. The results of this study should be viewed with caution as the study was conducted on athletes from a single football team and thus may have limited ability to be generalized to all collegiate-level athletes and replication studies with larger samples are needed for validation. Do you include a standardized balance assessment as part of the pre-participation physical examination for baseline purposes? Is it possible that athletes develop neurocognitive impairments and/or balance deficits over the course of a season as a result of “sub-concussive” hits sustained as part of regular season play?
Written By: Stephen Stache, MD
Reviewed By: Marc Harwood, MD & Jeffrey Driban