Sleep insufficiency and baseline preseason concussion-like symptom reporting in youth athletes

Terry D, Jurick, S, Huebschmann N, Silverberg N, Maxwell B, Zafonte R, Berkner P,  Iverson G. Clinical Journal of Sport Medicine: January 2022;32(1):46 55.

Take-Home Message

An athlete with insufficient sleep is more likely to have greater signs and symptoms scores during preseason testing than their peers who slept 7-8.5 hours.


The post-concussion signs and symptoms score is a key component that dictates diagnosis and care following a concussion. However, many factors could contribute to signs and symptoms before and after a concussion (e.g., sleep, caffeine, diet). Unfortunately, it remains unclear how insufficient sleep affects the signs and symptoms score.

Study Goal

Terry and colleagues conducted a cross-sectional study of healthy study-athletes to examine the association between insufficient sleep and their reporting of baseline concussion signs and symptoms.


The researchers analyzed preseason testing data from 19,529 student-athletes (~15 years of age, 49% girls) from 90 middle and high schools in Maine. Athletes underwent a preseason evaluation with a computerized cognitive assessment, which included a demographic section (e.g., age, sex, sport, hours of sleep), signs and symptoms inventory (0-6 Likert scale, 3 = mild, 6 = severe), and 6 test modules. The researchers excluded an athlete if they reported a concussion in the past 6 months, learning disability, ADHD, speech therapy, special education, repeated grade, neurological condition (e.g., migraine, meningitis, epilepsy), substance abuse, or 2 or more concussions. Researchers grouped athletes into 4 sleep groups based on responses: <5 hours, 5.5-6.5 hours, 7-8.5 hours, and >9 hours. Additionally, signs and symptoms scores  (excluding sleep-related items) were assessed to determine if otherwise healthy students met the criteria for ICD-10 post-concussion syndrome diagnosis.


Most student-athletes (60%) reported 7-8.5 hours of sleep, followed by 9 or more hours (24%), 5.5-6.5 hours (13%), or less than 5 hours (3%). Few athletes reported a previous concussion (12%). Overall, an athlete who reported less than 6.5 hours of sleep typically had higher signs and symptoms scores than those sleeping 7-8.5 hours. Furthermore, an athlete who reported at least 9 hours often reported fewer signs and symptoms than those sleeping 7-8.5 hours. Lastly, in athletes who slept <5 hours, 46% of the girls and 31% of the boys met the criteria for a post-concussion syndrome diagnosis compared with 16% and 11% who slept at least 9 hours, respectively. The authors found no relationship between sleep and neurocognitive test results.


Generally, the authors demonstrated that most student-athletes report obtaining enough sleep the night before a baseline concussion test. However, athletes who do not receive optimal sleep are more likely to report greater signs and symptoms scores, especially for girls. The increase in reported signs and symptoms related to insufficient sleep is potentially clinically meaningful because it could almost triple the number of student-athletes that qualify for a post-concussion syndrome diagnosis. However, it remains unclear how much overlap there was between the 16% with insufficient sleep at 12% with a history of a concussion. If these groups overlap a lot, then the diagnosis could be appropriate, but if the two groups are independent, it could highlight the seriousness of insufficient sleep on symptom reporting. Regardless, sleep seemed to have no relationship to how an athlete performed on neurocognitive testing.

Clinical Implications

The authors suggest clinicians consider someone’s sleep the night before when interpreting baseline and post-concussion symptom reporting. It may be beneficial to remind athletes and their parents of the importance of getting a whole night’s rest before their preseason testing session.

Questions for Discussion

Do you evaluate reported sleep time in their baseline report? Do you consider sleep schedules when you choose the timing of concussion baseline testing? What types and how many symptoms are your athletes reporting at baseline?

Related Posts

  1. Factors to Consider When Assessing Concussion Signs and Symptoms
  2. Females at Risk of Protracted Concussion
  3. 9-Point Survey to Determine Risk of Persistent Post-concussion Symptoms in Pediatric Population
  4. Comprehensive Services Improve. Care for Adolescents with Persistent Postconcussive Symptoms  

Written by: Jane McDevitt and Wendy Wheeler
Reviewed by: Jeffrey Driban

Evidence-Based Assessment of Concussion Course - 5 EBP CEUs