Sports Medicine Research: In the Lab & In the Field: Typical vs Prolonged Recovery Time and Predictors Following Concussion in High School and College Athletes (Sports Med Res)


Wednesday, December 5, 2012

Typical vs Prolonged Recovery Time and Predictors Following Concussion in High School and College Athletes

Incidence, Clinical Course, and Predictors of Prolonged Recovery Time Following Sport-Related Concussion in High School and College Athletes.

McCrea, M. Guskiewicz, K. Randolph, C. Barr, W. Hammeke, T. Marshall, S. Powell, M. Woo Ahn, K. Wang, Y. Kelly, J. J Int Neuropsychol Soc (2012), 18, 1–12.
The authors of this 10-year prospective-cohort study sought to build upon the growing body of evidence in post-concussion management by following high school and college athletes to determine the typical clinical course of concussion recovery, the frequency of athletes who do not follow the typical recovery course, and what risk factors may be associated with prolonged recovery time. Over 18,000 player seasons were monitored, with 345 high school and 225 collegiate athletes (total n = 570) sustaining a concussion. Among the athletes with a concussion (3.1% of cohort sample) 88.9% were male and American football accounted for 80.7% of concussions, followed by soccer, lacrosse, and ice hockey. The authors also observed a demographically-matched control group of 166 non-concussed high school (63.3%) and college (36.7%) athletes. Both groups were administered the same baseline and post-injury testing protocol which included testing with the Graded Symptom Checklist (GSC), Balance Error Scoring System (BESS), Standardized Assessment of Concussion (SAC), and a neuropsychological test battery. After assessment 513 (90%) concussed athletes were classified as typical recovery (TR) with symptoms returning to baseline by seven days post-concussion. Fifty seven (10%) athletes with concussions were stratified as prolonged recovery (PR). The TR group was then compared to the PR group at 1 to 2 days, 1 week, and 45 or 90 days post-injury. Both groups were also compared to the non-concussed control group. The TR and PR groups had different cognitive functioning (SAC) scores until day 7 but not at day 45/90 post-injury. In contrast, the TR and PR groups only had different balance (BESS) scores one day post-injury. Compared to the control group, the TR group had more symptoms until day 7, impaired cognitive functioning until day 3, and less balance only at the first day post-injury. Finally, unconsciousness at time of injury, posttraumatic or retrograde amnesia, and greater symptom severity (> 20 points from baseline on the GSC) within the first 24 hours of injury were significantly associated with PR. Furthermore, athletes withheld longer from competition and allowed a symptom-free waiting period had lower the risks of PR.

This study is significant because it is one of the first prospective studies that followed a large sample of athletes over a long period of time. This study reinforces on a larger scale, data that previously showed approximately 90% of athletes on the high school and college level who sustain a concussion functionally recover within seven to fourteen days. This study also shows new risk factors that predict PR not seen in previous research. These results can help clinicians better predict which athletes may experience a prolonged recovery. Additionally, the use of multi-dimensional assessment tools such as the BESS, GSC and SAC, as used in this study, can potentially help clinicians discriminate between athletes who will fall in the typical versus the prolonged recovery pattern. Finally, these findings emphasize the importance of complete brain rest as the main component of post-concussion symptom recovery. The authors showed that the longer an athlete was withheld from competition, the less risk the athlete had for PR. Future prospective studies will hopefully explore concussions sustained in sports other than football and the effects of gender on concussion recovery. What is the typical length of recovery for athletes who sustain concussion under your care? Have you developed any sort of feel for symptoms that may be predictors of PR in your clinical practice?

Written By: Stephen Stache, MD
Reviewed By: Marc Harwood, MD and Stephen Thomas

Related Readings:
On-field predictors of neuropsychological and symptom deficit following sports-related concussion.
The relation between post concussion symptoms and neurocognitive performance in concussed athletes

McCrea M, Guskiewicz K, Randolph C, Barr WB, Hammeke TA, Marshall SW, Powell MR, Woo Ahn K, Wang Y, & Kelly JP (2012). Incidence, Clinical Course, and Predictors of Prolonged Recovery Time Following Sport-Related Concussion in High School and College Athletes. Journal of the International Neuropsychological Society : JINS, 1-12 PMID: 23058235


William T. said...

Working as a graduate assistant AT with a D-I football program this past season I’ve encountered a number of concussions. I’m not 100% sure of the typical length of recovery for those who have experienced a concussion but I think the longest that someone was held from competition/practice was 10 days. The athletes who encountered prolonged recovery were starters. All of which did not face any returning S&S or reinjury that I’m aware of.

The protocol that we utilize aside from typical sideline assessment is SCAT2, depending on results the next step would be physical exertion followed by retesting using the CRI software. The results are printed and analyzed by our football AT staff along with the team docs. If everything appears to be okay the subject is cleared to gradually return to play but will continue to follow up following practice and especially weight lifting to see if any S&S return in which the GSC portion of the SCAT2 will be reassessed as well as the CRI. This year what I’ve seen is that following weight lifting is when most S&S have returned.

I think that personality, position, contribution to the team and motivation should be considered when addressing RTP following concussion. I am not saying or accusing an athlete of not wanting to RTP however I feel that through my experience sometimes towards the end of the week, closer to game day, S&S have shown improvements drastic at times. I think it’d be interesting to see a study addressing level of competition, motivation, contribution to the team (starter, back up, practice player) as well as position and see whether or not there are any common trends regarding test results over time.

Stephen Stache said...

Thank you for your comment William T. Your school's procedure for concussion management sounds like an example of the current typical management plan. While there are no true guidelines, many institutions have begun to formalize approaches to concussion management given things like new legislation and increased media coverage. As we move forward, the more we understand, the clearer management plans will hopefully become.

Your comment on athletes-reported symptoms rapidly improving as game day approaches is a common occurrence in sports and unfortunately is not unique to concussions. Knowing that athletes will potentially down-play symptoms only emphasizes the importance of using different modalities such as a thorough physical exam including vestibluar testing, BESS, and computer based neuropsych testing to guide clinical decision making for return to play.

Athletes education, regardless of level of competition, team role, or level of contribution is also essential to an effective concussion management program. I do think your idea about looking at different individual player factors would be interesting, particularly in the setting of concerns for repetitive "sub-concussive" head injuries that may be more common in starters and athletes that have participated in their sport for a longer period.

Chip W. said...

Working with track and field, I haven't(and likely won't) come across any concussions this year. However, previously working with soccer exposed me to a few athletes sustaining concussions. This article provided good objective data with regards to how severity and type of symptoms affected time for return to play, and will be a good reference when I work a contact sport again. I would be curious to see how BESS, SAC, and GSC scores differ in athletes with a history of previous concussion(s), and how recovery time is affected in these athletes compared to a first concussion. As for factors that I noticed in prolonged recovery, previous concussion was the main one. Also, working in undergrad and being peers with many athletes, I had an idea of who would take care of themselves and rest vs. who might not follow guidelines, further prolonging recovery.

Stephen Stache said...

Thanks for the comment Chip W. I agree that it would have been interesting if the authors of this article had looked as concussion history as a modifier. Previous research by authors from this research group found that history of a previous concussion may be associated with slower recovery of neurological function (

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