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Predictors of Post-Concussion Syndrome After
Sports-Related Concussion in Youth Athletes:
A Matched Case-Control Study
Morgan CD, Zuckerman SL, Lee YM, King L,
Beaird S, Sills AK, Solomon GS
Disclosures
•
•
•
•
•
Gary S. Solomon, PhD: member of ImPACT Scientific Advisory Board
(uncompensated); consulting fees from the Tennessee Titans (NFL), the Nashville
Predators (NHL), and the athletic departments for several universities.
Allen K. Sills, MD: member of the 2012 Concussion In Sport Group
(uncompensated); consulting physician to the Nashville Predators (uncompensated)
and serves as an unaffiliated neurotrauma consultant for the NFL.
Christopher M. Bonfield, MD: unaffiliated neurotrauma consultant for the NFL
(uncompensated).
Scott L. Zuckerman, MD: board member of MomsTeam youth sports resource
(uncompensated).
Accepted to upcoming JNS Neurosurgical Focus
Sports-Related Concussion
Acute Recovery
• 80-85% of athletes
• Transient
• Symptoms 10-14 days
Post-Concussion Syndrome
• 10-15% athletes
• Chronic and prolonged
• Symptoms months to years
Terminology
Source
Post-Concussion Syndrome Definition
International Classification ≥3 symptoms for >1 month
of Diseases, 10th Edition
DSM IV
≥3 symptoms for >3 months with significant social
decline
Concussion in Sport Group
(CISG, 2012)
Symptomatic for > 10 days
DSM V
Not listed
Heterogenous, confusing set of definitions
McCrory et al. Br J Sports Med. 2013. 47:250-258.
WHO. International Classification of Disease-10 (ICD). Volume 2. 2010.
Diagnostic and Statistical Manual of Mental Disorders IV, V. APA. 2013.
Post-Concussion Symptom Clusters
Somatic
Cognitive
Sleep
Emotional
Headaches
Fatigue
Difficulty sleeping
More emotional
Visual problems
Fogginess
Sleeping less than
usual
Sadness
Dizziness
Drowsiness
Sleeping more than
usual
Nervousness
Photophobia/Phonophobia Difficulty
Concentrating/Remembering
Nausea/Vomiting
Balance Problems
Numbness/Tingling
Cognitive Slowing
Irritability
• 138 athletes
• Def: >1 month
• Avg age = 22.8 years
• Avg # symptoms = 7.6
• Median time = 6 months
• 80% previous concussion
Tator et al. Neurosurgery. 2014. 75:4. S106-S112.
Literature review of pediatric studies evaluating risk factors for PCS
Citation,
year
PCS /
Control
Age
Population
PCS Time
Definition
Key PCS Risk Factors
119 / 287
5-18
General
≥ 3 months
·
·
·
58/50
M: 16
Sports
≥ 2 weeks
·
Migraine symptom cluster
36/62
M: 16
Sports
≥ 3 weeks
·
Dizziness
57 / 513
14-22
Sports
≥ 1 week
McNally et.
al, 2013
186/99
8-15
General
≥ 1 month
Meehan
et. al, 2013
182
7-26
Sports
≥ 4 weeks
·
·
·
·
·
·
Olsson
et. al, 2013
150 / --
6-16
General
≥ 1 week
·
·
LOC and amnesia
More severe acute symptoms
Female gender
Younger age
Non-Caucasian
Total symptom score at
initial visit
Pre-injury parent anxiety
Children’s pre-injury
hyper-arousal symptoms
Higher-functioning family
with more financial
resources
Female Gender
Babcock et.
al, 2013
Lau et. al,
2011
Lau et. al,
2011
McCrea
et. al, 2013
Yeates
et. al, 2012
186/99
8-15
Pediatric ED
≥ 1 month
·
·
Adolescent age
Headache on presentation
Hospital admission
Age
Migraine
Race
Symptoms
Anxiety
Gender
Objective
Goal: To investigate potential predictive factors
of post-concussion syndrome (PCS) in an
exclusively pediatric and sports concussion
population.
Methods
• Retrospective, case-control, 2:1 design  age 9-18yo
 Cases: symptoms lasting ≥ 3 months
 Controls: symptoms resolved ≤ 14 days
• Matched between age and gender
• Possible predictive factors
1.
2.
3.
4.
Demographic variables
Past medical, psychiatric, and family history
Acute post-injury phase (0-24 hours)
Sub-acute post-injury phase (0-2 weeks)
• Symptom clusters  somatic, cognitive, sleep, emotional
• Chi-squared, t-tests, logistic regression model
Results
Characteristic
Post-Concussion
Syndrome (N=40)
Control
(N=80)
P-value
Age, mean (SD)
14.9 (2.1)
14.8 (2.0)
0.722
Male, n (%)
19 (48%)
40 (50%)
0.848
Race
Black
Caucasian
Other
4 (10%)
36 (90%)
0 (0%)
18 (23%)
60 (75%)
2 (2%)
0.134
Prior Concussion,
mean (SD)
0.9 (0.7)
0.4 (0.7)
0.041***
Mood/Psych
Disorder, n (%)
7 (18%)
1 (1%)
0.002***
Family History
Mood/Psych
Disorder, n (%)
14 (35%)
9
(11.3%)
0.003***
Significant Stressor
3 (7.5%)
0 (0%)
0.036***
Helmeted sport, n (%)
11 (28%)
25 (31%)
0.833
LOC, n (%)
9 (23%)
17 (21%)
>0.999
Acute symptoms,
mean (SD)
Sub-acute syptoms,
mean (SD)
0.4 (1.1)
0.6 (1.2)
0.122
3.0 (1.7)
2.8 (2.3)
0.426
PCS group:
• Concussion history
• Mood/psych history
• Family history mood/psych/migraine
• Significant stressors
No Difference:
• Race
• Loss of consciousness
• Amnesia
• Acute symptoms
• Sub-acute symptoms
• Sport
Results
Predicted PCS in regression
model:
• Concussion history
• Mood/psych disorder
• Family history mood/psych
disorder
• Delayed symptoms
Conclusions
• Real-world study, youth and sports PCS population
• Who is at risk for prolonged recovery?
• Results highlight importance of previous concussions and
behavioral/psychiatric history
• New findings of family history may be significant
_____________________________________
PCS is a debilitating problem – important population that
needs more study
Predictors of post-concussion syndrome
in collegiate student-athletes
Scott L. Zuckerman MD, Aaron M. Yengo-Kahn BS, Thomas A.
Buckley EdD, Gary S. Solomon PhD, Allen K. Sills MD,
Christopher M. Bonfield MD, and Zachary Y. Kerr PhD MPH
The situation in college sports?
2009/10
57% returned to
play by 1 week
2013/14
30% returned to
play by 1 week
(p<0.001)
Collegiate athletes
taking longer to
return to play
Wasserman, Kerr, Zuckerman, Covassin. AJSM. 44(1). 2015.
Objective
To elucidate predictive factors of PCS among collegiate
student-athletes from 2009-10 to 2014-15.
Methods
• NCAA Injury Surveillance System – national and prospective
• Sample of ~150 schools across all divisions
• Reported by certified athletic trainers
– Detailed event reports  activity, mechanism, symptoms
• PCS dichotomized into 2 groups:
– Symptom resolution ≤2 weeks vs. ≥ 4 weeks
– Excluded intermediate resolution times between 2 and 4 weeks
• Statistics:
– Unit of analysis concussed individuals  most recent concussion
– Univariate and multivariable logistic regression
Kerr et al, JAT, 2013.
Kerr et al, JAT, 2013.
Predictive Factors
Variable
Values
Gender
Male vs. female
Contact level
Collision vs. high-contact vs. low-contact
Helmet status
Helmeted vs. unhelmeted
Recurrent concussion
Yes vs. no
LOC
Yes vs. no
Number of symptoms
Range 1-17
Symptoms endorsed
Posttraumatic amnesia, Retrograde amnesia, Difficulty
concentrating, Disorientation, Dizziness, Headache,
Excess excitability, Excess irritability, Loss of
consciousness, Nausea/vomiting, Tinnitus, Loss of
balance, Visual disturbance, Sensitivity to light,
Sensitivity to noise, Insomnia, Excess drowsiness
Demographics
•
1507 total athletes
•
112 PCS vs. 1395 non-PCS
•
Men’s hockey most PCS
•
Men’s football most non-PCS
•
Majority men’s football
•
PCS group with more:
•
Recurrent concussions
•
Number of symptoms
Significant
Predictors
of PCS
•
Recurrent concussion
•
Symptoms:
• Retrograde
amnesia
•
Difficulty
concentrating
•
Sensitivity to light
•
Insomnia
Discussion
• Identified PCS risk factors in sample of collegiate student-athletes
• Significant predictors
– Recurrent concussion
– Symptoms: retrograde amnesia, difficulty
concentrating, sensitivity to light, insomnia
• No significance
– Gender, helmet status, contact level, LOC
– No sport-specific factors
• Importance of scholastic requirements
• Limited by access to medical histories
Conclusions
• Who is at risk for PCS?
• Collegiate student-athletes
• Importance of previous concussions
• Symptoms: retrograde amnesia, difficulty concentrating, sensitivity to
light, insomnia
• No effect: gender, helmet status, contact level, LOC
_____________________________________
PCS is a debilitating problem – important population that
needs more study
What Next?
• Sport specific populations  gender, age and sport
• Outcome continuous
• Prognostic scores
• Intervention studies needed
Tator et al. JNS. 2016; Corwin et al. J of Pediatrics. 2014.
Thank You
• Zack Kerr
• Director of Sports
Injury Research
• Datalys Research
Center
V-SCoRe
Vanderbilt Sports COncussion REsearch