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Depression and concussion are highly prevalent neuropsychological disorders that often occur simultaneously. However, due to the high degree of symptom overlap between the two events, including but not limited to headache, sleep disturbances, appetite changes, fatigue, and difficulty concentrating, they may be treated in isolation. Thus, clinical awareness of additive symptom load may be missed. This study measures neuropsychological and electroencephalography (EEG) alpha band coherence differences in collegiate student-athletes with history of comorbid depression and concussion, in comparison to those with a single morbidity and healthy controls (HC). 35 collegiate athletes completed neuropsychological screenings and EEG measures. Participants were grouped by concussion and depression history. Differences in alpha band coherence were calculated using two-way ANOVA with post hoc correction for multiple comparisons. Comorbid participants scored significantly worse on neuropsychological screening, BDI-FS, and PCSS than those with a single morbidity and HC. Two-way ANOVA by group revealed significant main effects of alpha band coherence for concussion, depression, and their interaction term. Post-hoc analysis showed that comorbid participants had more abnormal alpha band coherence than single morbidity, when compared to HC. Comorbidity of concussion and depression increased symptom reporting and revealed more altered alpha band coherence than single morbidity, compared to HC. The abnormalities of the comorbid group exclusively showed decreased alpha band coherence in comparison to healthy controls. The comorbidity of depression and SRC has a compounding effect on depression symptoms, post-concussion symptoms, and brain functional connectivity. This research demonstrates a promising objective measure in comorbid individuals, previously only measured via subjective symptom reporting., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: Little is known about the relationship between neuropsychological test performance, cognitive symptom reporting, and depressive symptoms after sport-related concussion. Accordingly, this cross-sectional study examined these relationships in collegiate athletes. It was hypothesized that depressive symptoms would moderate and mediate the relationship between performance-based and self-reported cognitive functioning after concussion., Methods: After sustaining a sport-related concussion, 110 collegiate athletes completed a neuropsychological battery, the Post-Concussion Symptoms Scale, and the Beck Depression Inventory-Fast Screen. Neuropsychological test performance, depressive symptoms, and their interactions were entered into distinct hierarchical linear regression analyses with self-reported cognition as the dependent variable to assess moderation. Mediation was analyzed using the PROCESS macro with 5000 bootstrap samples and a 95% confidence interval., Results: There was a significant interaction between the mean memory composite and depressive symptoms when predicting cognitive symptom reporting, p = 0.047. Simple effects tests revealed that for athletes who had a lower memory composite score, an increase in depressive symptoms led to an increase in self-reported cognitive dysfunction, p < 0.001, ηp2 = 0.11. Depressive symptoms partially mediated the relationship between the memory composite and cognitive symptom reporting, indirect effect = -0.26, 95%CI[-0.58,0.001], but this relationship was not found for any other neurocognitive domain., Conclusions: For tests of memory, depressive symptoms moderated and partially mediated the relationship between performance-based and self-reported cognitive functioning after sport-related concussion. Athletes reporting high depressive symptoms and cognitive dysfunction may need more comprehensive evaluations to inform return-to-play decisions, and depression could be a treatment target for athletes who report high levels of cognitive dysfunction after concussion., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Determine how a) masculinity, b) optimism bias, and c) perceived pressure from stakeholders predict concussion reporting intentions and behavior. Participants: Collegiate student-athletes ( n  = 369). Methods: Student-athletes completed surveys of Conformity to Masculine Norms Inventory-46 (nine sections), optimism bias (optimist, neutral, pessimist), perceived pressure from stakeholders (six stakeholder sections), reporting intentions (symptom and concussion), and behavior (symptom and concussion). Four separate stepwise multivariate regression analyses were conducted. Results: A one-point increase in playboy, heterosexual self-preservation, being neutral or optimist compared to a pessimist symptom reporting intention decreased. A one-point increase in sport primacy, perceived pressure from athletic administration, being neutral or optimist compared to pessimist concussion reporting intentions increased 0.05, and decreased 0.23, 0.35, and 0.32, respectively. A one-point increase in violence and playboy increased the odds of being a "non-reporter" by 30% and 40%. Conclusions: Pessimistic views regarding concussion risks may result in greater concussion reporting intentions, however these findings did not influence behavior.

Context: Underreporting of concussion symptoms in college athletics presents a challenge for sports medicine clinicians in evaluating and diagnosing such injuries. Some athletes do not report concussion symptoms because they do not recognize that they have a brain injury; however, many athletes intentionally withhold symptoms to avoid removal from sport participation., Objective: To examine individual factors that influence college athletes' intentions to report concussion symptoms., Design: Cross-sectional study., Setting: Collegiate athletics., Patients or Other Participants: Participants were 2649 student-athletes from 23 sports, across 22 colleges and universities., Main Outcome Measure(s): The primary outcome was intention to report concussion symptoms. Predictor variables included demographics (age, race/ethnicity, sex, sport type, number of years in sport, number of previous concussions, and perceived concussion symptom knowledge), athletic identity, attitudes toward symptom reporting, perceived social pressure (injunctive and descriptive norms), and perceived behavioral control (capacity and autonomy)., Results: Hierarchical ordinary least-squares regression revealed positive effects of attitude (b = 0.063, P = .005), descriptive norms (b = 0.131, P < .001), injunctive norms (b = 0.107, P < .001), and capacity (b = 0.196, P < .001) on intention to report symptoms. Athletic identity and participation in collision sports had small negative indirect effects on intention, and perceived concussion knowledge had a small positive indirect effect. The full regression model explained 14.24% of the variance in concussion-reporting intention., Conclusions: These findings may help clinicians develop more focused interventions that address key social and individual determinants of underreporting, including attitude, injunctive and descriptive norms, and capacity to report. Athletic identity, sport type, and perceived understanding of concussion symptoms also influence reporting intention to a lesser extent. Previous research in this area has often failed to address a diverse population of college-age athletes from different sports and National Collegiate Athletic Association divisions., (© by the National Athletic Trainers’ Association, Inc.)

Objective: The evaluation of self-reported symptoms is a standard component of concussion assessment and management. Clinicians typically evaluate a total symptom severity score rather than scores corresponding to specific symptom domains (i.e., cognitive, sleep-arousal, physical, and affective symptoms). This study examined (i) whether elevations in specific symptom domains would be missed when interpreting only the total symptom severity score and (ii) if a single symptom domain elevation was more common than having elevated symptoms across multiple domains., Method: Adolescent student-athletes (N = 1,008) with concussion history (i.e., ≥6 months since last concussion) completed the Post-Concussion Symptom Scale (PCSS). The PCSS total score and cognitive, sleep-arousal, physical, and affective domain scores were calculated. To determine if symptoms were elevated, scores were compared to normative data matched on gender and pre-existing conditions, with scores considered elevated if they were ≥84th percentile. The frequency of total and domain score elevations were calculated and stratified by gender and number of prior concussions (i.e., 1 or ≥2 prior concussions)., Results: Overall, 26% of student-athletes had an elevated symptom domain score without being elevated on the total score. The most common symptom presentation was to have a single elevated symptom domain (21%), followed by two (11%), three (8%), or four elevated domains (6%)., Conclusions: Interpreting PCSS symptom domains may be beneficial in detecting student-athletes with elevated symptoms following a remote concussion. Roughly a quarter of student-athletes have domain-specific symptom elevations that would be missed by interpreting the total score alone., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To identify (1) university educators' perceptions of academic adjustments (AA), and (2) if teaching experience correlated with AA perceptions following concussion. Participants: Two hundred twenty educators. Methods: University educators were invited to complete a survey containing four subsections; this manuscript focuses on AA following concussion. Objective 1 was descriptive; we conducted spearman's rho correlations between years of teaching experience and AA perceptions to address objective 2. Results: Educators were moderately familiar with AA but were not confident in their knowledge about AA following concussion. Participants who provided AA following concussion most often allowed excused absences and extra time for exams/assignments. There were no significant relationships between teaching experience and perceptions of AA. Conclusions: University educators largely feel unprepared to provide or recommend AA following concussion but had favorable AA perceptions following concussion. Standardized policies or referral sites within the university system may be warranted to improve post-concussion AA.

Nondisclosed sport-related concussion symptoms pose a significant risk to athletes' health and well-being. Many researchers have focused on understanding the factors affecting athletes' concussion disclosure behaviors. One of the most robust predictors of the likelihood that an athlete will disclose concussion symptoms to their coaches, athletic trainers, parents, or peers is what researchers term social norms. The extant literature regarding social norms influencing concussion disclosure behaviors is inconsistent on how the construct should be defined, conceptualized, or measured, often failing to distinguish between descriptive and injunctive social norms and their sources (direct and indirect). In this technical note, we provide an overview of these critical distinctions, their importance in assessments, and examples from the literature in which scholars have correctly operationalized these constructs in athletic populations. We conclude with a brief set of suggestions for researchers seeking to measure social norms in future research., (© by the National Athletic Trainers’ Association, Inc.)

Objective: To examine baseline neurocognitive functioning among adolescent athletes on the autism spectrum based on self-reported level of academic performance., Method: Participants in this cross-sectional, observational study were 6,441 adolescent athletes with a self-reported diagnosis of autism who completed pre-season neurocognitive testing using Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT); 4,742 reported a co-occurring learning disorder (LD), and 6,612 individuals without autism or LD were included as a control group. The majority (57%) self-reported Average Academic Performance, 39% Above Average, and 4% Below Average performance., Results: Athletes with self-reported autism (with or without LD; 12.2%) were 2.74x (95% CI: 2.17-2.82) more likely to fall below cutoffs for ImPACT Embedded Invalidity Indicators (EVIs), with a significant interaction between self-reported Diagnosis and Academic Performance; individuals with co-occurring autism and LD who reported Below Average Academic Performance had the greatest likelihood of scoring below cutoffs (22%), followed by ASD without LD (14.8%) and Controls (14.6%) with Below Average Academic Performance. Analyses of variance (ANOVAs) revealed main effects of Diagnosis and Academic Performance on neurocognitive performance, with interactions on all ImPACT Composite Scores except Processing Speed., Conclusion: Athletes with self-reported ASD are more likely to fall below ImPACT EVIs and score worse on ImPACT, with greater likelihood/worse performance related to level of academic functioning. Academic performance should be considered when interpreting neurocognitive testing data, to best index neuropsychological functioning associated with concussion in this population. The current findings highlight the importance of individual participant baseline neuropsychological testing for individuals on the autism spectrum., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The first objective was to establish the respective factor structures of a concussion perceptions inventory that was adapted for youth athletes (ages 8-14 years) and their parents from the Perceptions of Concussion Inventory for Athletes. The second objective was to understand the associations between the concussion perceptions of youth athlete-parent dyads., Method: In this cross-sectional study, 329 parent-youth athlete dyads completed a respective concussion perception inventory. Mean age of youth respondents was 10.9 ± 1.8 years (70.1% male) and mean age of parent respondents was 40.5 ± 13.6 years (60.9% female)., Results: Exploratory factor analyses revealed unique 7-factor structures for both the youth athlete and parent inventories (youth athlete: anxiety, clarity, treatment, permanent injury, symptom variability, long-term outcomes, and personal control; parent: anxiety, clarity, treatment, permanent injury, symptom variability, and long-term outcomes, and affect others). Weak associations were found between dyads on the 5 factors that were composed of identical items (anxiety, clarity, treatment, permanent injury, and symptom variability)., Conclusions: Findings suggest that this adapted inventory has adequate psychometric properties to be used in the study of the concussion perceptions of youth athletes and their parents. Weak correlations across the concussion perceptions in the dyads suggest that parents and children hold different concussion perceptions and this should be considered in instrument selection of future studies., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: In adolescent and collegiate athletes with sport-related concussion (SRC), we sought to evaluate the prevalence and predictors of long-term psychological symptoms., Methods: A cohort study was conducted of athletes 12-24-year-old diagnosed with SRC between November 2017 and April 2022. Athletes/proxies were interviewed on psychological symptoms (i.e. anger, anxiety, depression, and stress). Participants who scored ≥75th percentile on one or more PROMIS (Patient-Reported Outcomes Measurement System) measures were operationalized to have subclinical, long-term psychological symptoms. Uni/multivariable regressions were used., Results: Of 96 participants (60.4% male), the average age was 16.6 ± 2.6 years. The median time from concussion to interview was 286 days (IQR: 247-420). A total of 36.5% athletes demonstrated subclinical, long-term psychological symptoms. Univariate logistic regression revealed significant predictors of these symptoms: history of psychiatric disorder (OR = 7.42 95% CI 1.37,40.09), substance use (OR = 4.65 95% CI 1.15,18.81), new medical diagnosis since concussion (OR = 3.43 95% CI 1.27,9.26), amnesia (OR = 3.42 95% CI 1.02,11.41), other orthopedic injuries since concussion (OR = 3.11 95% CI 1.18,8.21), age (OR = 1.24 95% CI 1.03,1.48), days to return-to-play (OR = 1.02 95% CI 1.00,1.03), and psychiatric medication use (OR = 0.19 95% CI 0.05,0.74). Multivariable model revealed significant predictors: orthopedic injuries (OR = 5.17 95% CI 1.12,24.00) and return-to-play (OR = 1.02 95% CI 1.00,1.04)., Conclusions: Approximately one in three athletes endorsed long-term psychological symptoms. Predictors of these symptoms included orthopedic injuries and delayed RTP.

Background: Sport-related concussions leave youth vulnerable to significant health, physical, social, and educational disruptions. Many youth athletes under-report concussions, but the scope of the issue for this population is not well understood, nor are the underlying motivations for (under)reporting. It is necessary to examine the relationship between sport-related concussion knowledge and reporting and invite athletes to share their decision-making processes. The purpose of the research was to understand how athletes' attitudes, experiences and beliefs regarding concussions influence their under-reporting decisions and behaviours., Methods: We conducted semi-structured interviews with 17 elite athletes, aged 16-18 years, from individual and team sports. Data were analyzed using constructivist grounded theory and a substantive theoretical model of sport-related concussion under-reporting was developed., Results: The model demonstrates personal, social, cultural, and biophysical processes that contribute to under-reporting decisions and identifies multiple interconnected processes that contribute to 'high-risk' situations of under-reporting. Youth athletes navigate various barriers and facilitators to under-reporting, including their own desire to play, perceived stigma, concussion sense-making, and social influences. Results suggest that under-reporting by youth athletes implicates a collective, rather than individual, responsibility., Conclusions: A theoretical grounded model for youth sport-related concussion under-reporting highlights the complexity of the decision-making process. This study offers a new framework for understanding why youth athletes may hide concussion symptoms. The model offers potential to be used to develop concussion interventions and tools for improved decision-making, and to address issues of risk and responsibility concerning concussion reporting., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Psychological symptoms following a sport-related concussion may affect recovery in adolescent athletes. Therefore, the aims of this study were to 1) describe the proportion of athletes with acute psychological symptoms, 2) identify potential predictors of higher initial psychological symptoms, and 3) determine whether psychological symptoms affect recovery in a cohort of concussed high school athletes., Methods: A retrospective cohort study of high school athletes (14-18 years of age) who sustained a sport-related concussion from November 2017 to April 2022 and presented to a multidisciplinary concussion center was performed. The main independent variable was psychological symptom cluster score, calculated by summing the four affective symptoms on the initial Post-Concussion Symptom Scale (PCSS) (i.e., irritability, sadness, nervousness, feeling more emotional). The psychological symptom ratio was defined as the ratio of the psychological symptom cluster score divided by the total initial PCSS score. The outcomes included time to return to learn (RTL), symptom resolution, and time to return to play (RTP). Univariable and multivariable regressions were performed to adjust for demographic factors and health history., Results: A total of 431 athletes (58.0% female, mean age 16.2 ± 1.3 years) were included. Nearly half of the sample (45%) reported at least one psychological symptom, with a mean psychological symptom cluster score of 4.2 ± 5.2 and psychological symptom cluster ratio of 0.10 ± 0.11. Irritability was the most commonly endorsed psychological symptom (38.1%), followed by feeling more emotional (30.2%), nervousness (25.3%), and sadness (22.0%). Multivariable regression showed that female sex (B = 2.15, 95% CI 0.91-3.39; p < 0.001), loss of consciousness (B = 1.91, 95% CI 0.11-3.72; p = 0.037), retrograde/anterograde amnesia (B = 1.66, 95% CI 0.20-3.11; p = 0.026), and psychological history (B = 2.96, 95% CI 1.25-4.70; p < 0.001) predicted an increased psychological symptom cluster score. Female sex (B = 0.03, 95% CI 0.00-0.06; p = 0.031) and psychological history (B = 0.06, 95% CI 0.02-0.10; p = 0.002) predicted an increased psychological symptom ratio. Multivariable linear regression showed that both higher psychological symptom cluster score and ratio were associated with longer times to RTL, symptom resolution, and RTP., Conclusions: In a cohort of high school athletes, 45% reported at least one psychological symptom, with irritability being most common. Female sex, loss of consciousness, amnesia, and a psychological history were significantly associated with an increased psychological symptom cluster score. Higher psychological symptom cluster score and psychological symptom ratio independently predicted longer recovery. These results reinforce the notion that psychological symptoms after concussion are common and may negatively impact recovery.

Background: Concussion is a pathophysiological process that occurs due to a traumatic biomechanical force. Concussions are an "invisible" and common traumatic brain injury with symptoms that may be underestimated. This necessitates fundamental improvements in public knowledge specifically addressing young university athletes and different genders. This cross-sectional study aimed to explore the possibility of gender differences with respect to university student athletes' concussion knowledge, attitude and reporting behaviors. We hypothesized that there should be no significant difference in concussion knowledge among male and female student athletes; however, females would show a more positive attitude and more reporting behaviors than male student athletes., Methods: Overall, 115 university athlete students completed a survey questionnaire; we eliminated some participants based on required inclusion criteria of Rosenbaum Concussion Knowledge and Attitude Survey-student version (RoCKAS-ST). Our final analysis consisted of 96 participants: 20 males (mean age 21.15 years) and 75 females (mean age 22.36 years). This study included questions about the athletes' given reasons for reporting or not reporting a concussion. Additionally, 33 RoCKAS-ST questions on Concussion Knowledge Index (CKI) with fair test-retest reliability (r=0.67) and 15 items on Concussion Attitude Index (CAI) with satisfactory test-retest reliability (r=0.79) were provided., Results: Males reported more sources for learning about concussions and more sport-related reasons for reporting a concussion than females (P<0.05). Both genders provided equal numbers of reasons for neglecting a concussion report or not disclosing a concussion for the sake of others (i.e., family, teammates or the coach). Out of 16 given reasons for not reporting a concussion, males significantly chose sport-related reasons over female athletes (P<0.05). Additionally, by looking at the two components of RoCKAS-ST, the independent t-test results showed no significant gender-based differences in concussion knowledge and attitude indices (P>0.05). Nevertheless, females were less optimistic about evaluating other athletes' attitude over concussion reporting (P<0.05)., Conclusions: Our study indicated that concussion knowledge is not gender biased among Canadian university athletes; however, more investigation is required to learn how safe environments for concussion disclosure could encourage reporting the symptoms in varsity athletes, especially in males who are more susceptible to not reporting a concussion to not miss their sport-related goals.

Privilege and marginalization associated with racial background have been posited as contributors to why Black athletes face disparities within their care, treatment, and recovery from sport-related concussion (SRC). However, empirical findings have limited exploration on how disparate outcomes have emerged, and the interaction with systems of biases, power and disenfranchisement. To understand concussion care disparities, a qualitative content analysis was conducted in three phases: [I] identifying salient literature on racial differences for Black athletes with SRC ( N  = 29), [II] qualitative analysis of literature to determine salient topics, themes and patterns within the literature, and [III] constructing a novel ecological-systems framework that encapsulates the 'why' and 'how' related to psychosocial and sociocultural experiences of power, access, and biases for Black athletes. The content analysis yielded two patterns, where concussion care decisions are influenced by (1) biased, unconscious beliefs that posit Black athletes as uniquely invincible to injury and pain, and (2) inadequate access to concussion knowledge and resources, which both moderate SRC injury risk, diagnosis, recovery and outcomes. Ultimately, our novel framework provides a clear thread on how historical, macro-level policy and perceptions can impact micro-level clinical care and decision-making for Black athletes with SRC.

This study measured the relationship between head-injury exposure and later-in-life cognitive and emotional symptoms in aging collegiate football players who participated in the College Level Aging Athlete Study. Linear regressions examined the relationship between various head-injury exposure variables (head-injury exposure estimate [HIEE], number of diagnosed concussions, and symptomatic hits to the head) and subjective cognitive function, objective cognitive function, and emotional/mood symptoms. Additional regressions evaluated the impact of emotional symptoms on subjective cognitive decline and objective cognitive function. Participants (n = 216) were 50-87 years old (M = 63.4 [8.5]), 91% White, and well-educated (bachelor's/graduate degree = 92%). HIEE did not predict scores on cognitive or emotional/mood symptom measures ( p's > .169). Diagnosed concussions had a small effect on depression symptoms ( p = .002, b  = 0.501, R2 = .052) and subjective cognitive symptoms ( p = .002, b  = 0.383, R2 = .051). An emotional symptom index had a stronger relationship ( p < .001, b  = 0.693, R2 = .362) with subjective cognitive functioning but no significant relationship with objective cognitive function ( p = .052, b = -0.211, R2 = .020). Controlling for emotional symptoms, the relationship between concussions and subjective cognitive symptoms was attenuated ( p = .078, R2 = .011). Findings suggested that head-injury exposure was not significantly related to cognitive or emotional/mood outcomes in former collegiate football players and highlighted the importance of current emotional/mood symptoms on subjective cognitive function.

Objective: To determine if a peer-led concussion reporting worksheet activity could elucidate barriers to reporting in collegiate athletes. Participants: Five hundred and three athletes from 7 universities across all three NCAA divisions. Methods: A supplementary qualitative analysis of responses to a concussion reporting worksheet completed during an RCT of a novel peer concussion education program. The first column of the worksheet required participants to list thoughts that prevent reporting and the second column required replacement thoughts that facilitate reporting. Results: A qualitative phenomenological thematic analysis of responses to the first column of the worksheets identified themes that coalesced into three areas: 1) missing out on athletic and social events, 2) losing one's competitive edge, and 3) negative interpersonal interaction/self-perception. Conclusions: Barriers to concussion reporting from several areas central to the collegiate athlete experience were identified. These barriers should be considered during clinical assessment and when developing concussion education programs.

Context: Neurocognitive testing is a critical tool in the management of sport-related concussions. Adversity during childhood and adolescence affects cognitive tasks, behavioral outcomes, and academic performance. Adversity may be important in baseline concussion test validity as well; however, the influence of these experiences is not well understood., Objective: To examine the relationship between individual-level experiences of adversity and baseline test validity of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). We hypothesized that experiences of poverty, maltreatment, or extreme neighborhood deprivation would be associated with lower odds of baseline test validity., Design: Case-control study., Setting: Cuyahoga County, Ohio., Patients or Other Participants: A total of 6495 student-athletes born from 1995 through 2005 who completed a baseline ImPACT test between 10 and 18 years old and were identified in the Child-Household Integrated Longitudinal Data system, a comprehensive data system with demographic and social service usage outcomes for children in Cuyahoga County, Ohio., Main Outcome Measure(s): Baseline concussion test validity was determined using the ImPACT built-in validity measure. Experiences of adversity during the sensitive developmental periods of early childhood and adolescence were key independent variables., Results: Our findings suggested that social mobility may play an important role in baseline validity. Youth with upward social mobility (ie, poverty or neighborhood deprivation in early childhood only) were not different from youth without such experiences (odds ratio [OR] = 0.91, P = .74). Youth with persistent adversity across childhood or downward social mobility (ie, poverty or high neighborhood deprivation in adolescence only) had 50% to 72% lower odds of achieving a valid baseline test (persistent poverty, OR = 0.59, P = .05; adolescent poverty only, OR = 0.50, P = .004; adolescent neighborhood deprivation only, OR = 0.28, P < .001). Maltreatment had no significant effect on test validity., Conclusions: These findings indicated that certain patterns of adversity may predispose youth to invalid baseline testing scores, potentially increasing their risk of inappropriate injury management and poor outcomes., (© by the National Athletic Trainers’ Association, Inc.)

Cognitive dysfunction, especially memory impairment, is a typical clinical feature of long-term symptoms caused by repetitive mild traumatic brain injury (rmTBI). The current study aims to investigate the relationship between regional brain atrophy and cognitive impairments in retired athletes with a long history of rmTBI. Overall, 27 retired athletes with a history of rmTBI (18 boxers, 3 kickboxers, 2 wrestlers, and 4 others; rmTBI group) and 23 age/sex-matched healthy participants (control group) were enrolled. MPRAGE on 3 T MRI was acquired and segmented. The TBV and TBV-adjusted regional brain volumes were compared between groups, and the relationship between the neuropsychological test scores and the regional brain volumes were evaluated. Total brain volume (TBV) and regional brain volumes of the mammillary bodies (MBs), hippocampi, amygdalae, thalami, caudate nuclei, and corpus callosum (CC) were estimated using the SPM12 and ITK-SNAP tools. In the rmTBI group, the regional brain volume/TBV ratio (rmTBI vs. control group, Mann-Whitney U test, p < 0.05) underwent partial correlation analysis, adjusting for age and sex, to assess its connection with neuropsychological test results. Compared with the control group, the rmTBI group showed significantly lower the MBs volume/TBV ratio (0.13 ± 0.05 vs. 0.19 ± 0.03 × 10 -3 , p < 0.001). The MBs volume/TBV ratio correlated with visual memory, as assessed, respectively, by the Rey-Osterrieth Complex Figure test delayed recall (ρ = 0.62, p < 0.001). In conclusion, retired athletes with rmTBI have MB atrophy, potentially contributing to memory impairment linked to the Papez circuit disconnection., (© 2024. The Author(s).)

Concussion baseline testing has been advocated for the assessment of pre-morbid function. When individual baseline scores are unavailable, utilizing normative values is recommended. However, the validity of generalizing normative data across multiple socioeconomic environments is unknown., Objective: mimic the normative data creation of ImPACT™ to examine the effect of socioeconomic status (SES) on ImPACT™ composite scores., Methods: A retrospective cross-sectional design analyzed completed computerized neuropsychological test data (ImPACT™) obtained to establish the baseline scores of cognitive function from males aged 13-15 years ( n = 300) and 16-18 years ( n = 331) from an urban high school system. Comparisons between baseline scores and normative ImPACT™ values were calculated utilizing t -tests with ImPACT™ composite scores serving as dependent variables., Results: significant differences between age-dependent urban composite scores and ImPACT™ normative values for 13-15- and 16-18-year-olds were found for Composite Verbal Memory, Composite Visual Memory, Composite Motor and Composite Reaction Time ( p < 0.01)., Conclusions: Significant differences exist between urban high school athletes and ImPACT™-provided age-dependent normative scores, with urban participants performing below age-dependent normative values. These findings support establishing SES appropriate normative values when baseline test scores are not available for direct comparison in order to provide better evaluation and post-concussion management across diverse populations.

Objective: Evaluate the independent effect of age on baseline neurocognitive performance., Study Design: Baseline ImPACT scores from tests taken by 7454 athletes aged 12-22 from 2009 to 2019 were split into three age cohorts: 12-14 years (3244), 15-17 years (3732), and 18-22 years (477). Linear regression analyses were used to evaluate the effect of age on ImPACT composite scores while controlling for demographic differences, medication-use, and symptom burden. Significance values have been set at p  < 0.05., Results: Linear regression analyses demonstrated that increased age does not significantly affect symptom score (β = 0.06, p  = 0.54) but does improve impulse control (β = -0.45, p  < 0.0001), verbal memory (β = 0.23, p  = 0.03), visualmotor (β = 0.77, p  < 0.0001), and reaction time (β = -0.008, p  < 0.0001) scores.  However, age did not have an effect on visual memory scores (β = -0.25, p  = 0.07)., Conclusions: Age was shown to be an independent modifier of impulse control, verbal memory, visual motor, and reaction time scores but not visual memory or symptom scores.  This underscores the previous literature showing developmental differences as age increases among the adolescent athlete population.  This data also indicates the need for repeat neurocognitive baseline testing every other year as baseline scoring is likely to change as athletes become older.

Aim: This study was designed to explore experiences of high school athletes in order to understand their occupational engagement after sustaining a sports-related concussion. The study explored the role occupational therapists (OTs) can play in post-concussion care while supporting adolescents in returning to meaningful occupations., Methods: The study utilized a qualitative, phenomenological approach by conducting interviews with high school athletes to understand their participation in occupations during recovery. Six student-athletes from 14-18 years of age were interviewed., Results: The five identified themes from the study included impacts on ADL performance, school performance, sleep, mental health, and driver safety. Student-athletes reported feelings of loneliness and loss of identity. Dressing, showering, grooming, and driving were disturbed due to balance deficits, headaches, and nausea. Participants reported decreased participation in social, sports, and leisure occupations due to heightened symptoms., Conclusions: Due to the considerable variability of disturbance in occupational participation post-concussion, occupational therapists can assist in creating and implementing individualized treatment plans to support high school athletes while recovering from a sports-related concussion.

ADHD is common among the general population and may be slightly more common among athletes. Diagnosis requires six or more DSM-5-TR symptoms to have been present prior to age 12 and to have an effect on functioning in multiple settings. Different sporting organizations have varying requirements for documentation when making a diagnosis. Stimulant medications are the mainstay of treatment; psychosocial interventions, exercise, and non-stimulant medications can serve as adjuncts. Future directions in research on ADHD in sports include determining whether ADHD is overrepresented among the population of elite athletes and parsing out the relationship between ADHD and concussion risk and recovery., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: Research on the neurocognitive effects of comorbid mood/anxiety disturbance in college athletes is limited. Previous research found that athletes with comorbid depression/anxiety performed worse on measures of attention/processing speed (A/PS) at baseline compared to healthy controls. However, this work solely examined mean performance. The current study expands upon this work by examining intraindividual variability (IIV) in relation to affective disturbance., Method: 835 (M = 624, F = 211) collegiate athletes completed baseline neuropsychological testing. Athletes were separated into four groups (Healthy Mood [n = 582], Depression Alone [n = 137], Anxiety Alone [n = 54], and Co-Occurring Depression/Anxiety [n = 62]) based on self-reported anxiety and depression. IIV was examined globally and within composites of A/PS and memory via intraindividual standard deviation, with higher scores indicating greater variability., Results: Linear regression results revealed that the Co-Occurring Depression/Anxiety group exhibited greater variability within the memory composite compared to the Healthy Mood group, as well as the Depression Alone and Anxiety Alone groups. The Depression Alone and Anxiety Alone groups did not differ from the Healthy Mood group on memory IIV. None of the groups differed on A/PS or global IIV., Conclusions: Athletes with co-occurring depression/anxiety demonstrated greater variability in performance on memory tasks. Greater dispersion is predictive of greater cognitive decline following concussion; therefore, it is important that neuropsychological performance is interpreted beyond measures of central tendency. These findings also highlight the importance of having baseline data available for athletes with affective disturbance, as these factors may influence performance, place athlete at risk for poorer outcomes, and skew future post-concussion comparisons., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Objective: To examine baseline neurocognitive functioning and symptom reporting among adolescents with self-reported autism., Method: Participants in this cross-sectional, observational study were 60,751 adolescents who completed preseason testing. There were 425 students (0.7%) who self-reported an autism spectrum disorder (ASD) diagnosis. Cognitive functioning was measured by Immediate Post-Concussion Assessment and Cognitive Testing and symptom ratings were obtained from the Post-Concussion Symptom Scale., Results: Groups differed significantly across all neurocognitive composites (p values <.002); effect size magnitudes for most differences were small, though among boys a noteworthy difference on visual memory and among girls differences on verbal memory and visual motor speed composites were noted. Among boys, the ASD group endorsed 21 of the 22 symptoms at a greater rate. Among girls, the ASD group endorsed 11 of the 22 symptoms at a greater rate. Some examples of symptoms that were endorsed at a higher rate among adolescents with self-reported autism were sensitivity to noise (girls: odds ratio, OR = 4.38; boys: OR = 4.99), numbness or tingling (girls: OR = 3.67; boys: OR = 3.25), difficulty remembering (girls: OR = 2.01; boys: OR = 2.49), difficulty concentrating (girls: OR = 1.82; boys: OR = 2.40), sensitivity to light (girls: OR = 1.82; boys: OR = 1.76), sadness (girls: OR = 1.72; boys: OR = 2.56), nervousness (girls: OR = 1.80; boys: OR = 2.27), and feeling more emotional (girls: OR = 1.79; boys: OR = 2.84)., Conclusion: Students with self-reported autism participating in organized sports likely experience a low degree of functional impairment, on average. If they sustain a concussion, their clinical management should be more intensive to maximize the likelihood of swift and favorable recovery., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Context: Collegiate club-sport athletes participate in a variety of competitive sports and have been understudied in the concussion literature. Baseline performance measures are warranted to better understand assessment and management., Objective: To quantify normative values and the effects of modifying factors sex, concussion history, diagnosed attention disabilities (attention-deficit/hyperactivity disorder [ADHD]), and sport type on baseline symptom evaluation among collegiate club-sport athletes., Design: Cross-sectional study., Setting: Retrospective chart review., Patients or Other Participants: A total of 1034 collegiate club-sport athletes (N = 649 males, 62.7%) from 29 sports at a single institution., Main Outcome Measure(s): Chart reviews were conducted for club-sport athletes who completed athlete background and symptom information on the Sport Concussion Assessment Tool-5th edition as a baseline concussion assessment during a single academic year. Demographics (eg, age, sex, sport), background medical information (eg, concussion history, ADHD), and symptom evaluation, consisting of individual 22-item symptom reports, the total number of symptoms, symptom severity scores, and symptom factors (eg, physical, cognitive, insomnia, and emotional), were analyzed., Results: On baseline symptom reporting, 68% of club-sport athletes were asymptomatic, with mild symptoms described by 3% to 12% and moderate or severe symptoms by ≤4%. Modifier groups differed with a higher total number of symptoms and symptom severity in females (P < .001), individuals reporting a history of concussion (P < .001), and those with ADHD (total number P = .04, symptom severity P = .02). Similar significant findings were noted for females and the history of concussion group on all 4 symptom factors; however, those in collision or contact sports also indicated greater cognitive (P = .03) and insomnia (P = .02) factors. Those with ADHD endorsed more cognitive (P < .001) factors., Conclusions: Normative symptoms for a collegiate club-sport sample revealed approximately 70% were asymptomatic. Higher total number of symptoms and symptom severity were demonstrated by females and those with a history of concussion. Cognitive-specific symptoms were greater in those diagnosed with ADHD and those who participated in collision or contact sports., (© by the National Athletic Trainers’ Association, Inc.)

Context: Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) is one of the most widely used computerized neurocognitive assessment batteries in athletics and serves as both a baseline and postinjury assessment. It has become increasingly popular to administer the ImPACT baseline test in an unsupervised remote environment; however, whether the lack of supervision affects the test-retest reliability is unknown., Objective: To establish the minimal detectable change (MDC) of composite scores from the ImPACT test when administered to National Collegiate Athletic Association Division I student-athletes in an unsupervised remote environment before 2 consecutive athletic seasons., Design: Cross-sectional study., Setting: Participants were provided with a unique link and detailed written instructions on how to complete the ImPACT test at home., Patients or Other Participants: Division I student-athletes., Main Outcome Measure(s): Remote baseline ImPACT results from the 2020-2021 and 2021-2022 athletic seasons were analyzed. The MDC was calculated at the 95%, 90%, and 80% CIs for each of the ImPACT composite scores as well as the average and SD., Results: The MDC at the 95% CI was 18.6 for the verbal memory composite score, 24.44 for visual memory, 8.76 for visual motor, 0.14 for reaction time, and 6.13 for impulse control. One-way repeated-measures multivariate analysis of variance, repeated-measures analysis of variance, and Wilcoxon signed ranks tests suggested no difference in the composite scores and impulse control between time points., Conclusions: The ImPACT composite scores and impulse control did not change between the 2 remote testing time points when administered approximately 1 year apart. Our study suggests that the MDC serves as a clinician's guide for evaluating changes in ImPACT baseline scores and in making clinical judgments on sport-related concussion when the test is administered at home., (© by the National Athletic Trainers’ Association, Inc.)

Context: Data on the early to midlife effects of repetitive neurotrauma on patient-reported outcomes have been delimited to homogeneous samples of male athletes without comparison groups or accounting for modifying factors such as physical activity., Objective: To determine the effect of contact or collision sport participation and repetitive neurotrauma on patient-reported outcomes among early to middle-aged adults., Design: Cross-sectional study., Setting: Research laboratory., Patients or Other Participants: A total of 113 adults (53 [46.9%] men, 60 [53.1%] women; age = 34.88 ± 11.80 years) in 4 groups: (1) physically inactive individuals with no repetitive head impact (RHI) exposure (NON); (2) noncontact sport athletes and nonathletes with no RHI exposure who were currently physically active (NCA); (3) former high-risk sport athletes with an RHI history who were physically active (HRS); and (4) former rugby players with prolonged RHI exposure who remained physically active., Main Outcome Measure(s): The 12-Item Short-Form Health Survey (SF-12), Apathy Evaluation Scale-self-rated version (AES-S), Satisfaction With Life Scale (SWLS), and Sport Concussion Assessment Tool-5th Edition (SCAT5) Symptom and Symptom Severity Checklist., Results: The NON group had worse self-rated physical function than the NCA group as assessed by the SF-12 physical component summary (P = .03) and worse self-rated apathy (AES-S) and satisfaction with life (SWLS) than the NCA (P = .03 for both) and HRS groups (P = .03 and P = .040, respectively). We observed no group differences for self-rated mental health (SF-12 mental component summary; P = .26) or symptoms (SCAT5; P = .42). Career duration was not associated with any patient-reported outcomes., Conclusions: A history of contact or collision sport participation and career duration did not negatively affect patient-reported outcomes in physically active, early to middle-aged adults. However, physical inactivity status was negatively associated with patient-reported outcomes in these individuals in the absence of an RHI history., (© by the National Athletic Trainers’ Association, Inc.)

Risk factors associated with depression in athletes include biological sex, physical pain, and history of sport-related concussion (SRC). Due to the well-documented benefits of sport and physical activity on mental health, athletes and non-athletes were recruited to assess any differences. Beyond this, athletes were also grouped by sport-type (contact/non-contact sports) due to the increased prevalence of pain and SRC in contact sports. To our knowledge, there has been no research on how these factors influence the likelihood of depression. In the current study, 144 participants completed a short survey on the above factors and the Center for Epidemiological Studies Depression Scale. Sixty-two of these reported a history of concussion. Logistic regression revealed all the above predictors to be significantly associated with the depression scale. Individuals that had previously sustained SRC, were experiencing greater physical pain and females were more likely to display poor mental health. However, we provide further evidence for the benefits of engaging in sport and physical activity as those that took part in sport were less likely to report depression. Therefore, this study provides a simple risk metric whereby sportspeople can make a better informed choice of their sporting participation, making their own cost/reward judgement., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Walker et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: The comparison of baseline neuropsychological test results with post-concussion neuropsychological test results is a common practice to assess the aftermath of a sport-related concussion. The effectiveness of this approach is compromised when invalid baseline test performances occur. The present study was designed to assess the prevalence of invalid baseline test results of high school athletes, using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). Method: A large sample of 8938 high school athletes' baseline test data were examined, including the four ImPACT Composite scores and three sets of embedded invalid indices: five ImPACT Invalidity Indicators, four ImPACT sandbagging red flags, and two ImPACT sandbagging subtest flags. Results: There were 8394 (93.91%) Valid scorers, who failed no Invalidity Indicators; 544 (6.09%) Invalid scorers, who failed at least one Invalidity Indicator, 2718 (30.41%) Red Flag scorers, who had at least one Red Flag score; and 4154 (46.47%) Subtest Flag scorers, who had at least one Subtest Flag score. Of the entire sample, 4485 (54.65%) failed at least one of the invalid indices. Conclusions: As in prior studies of high school athletes, the Invalidity Indicators identified a low portion (6.09%) of the athletes with invalid baseline test results, while other invalidity measures found 30.41% to 46.48% of the athletes producing questionable test results. The high rate of invalid test findings suggested in this research calls for greater efforts to improve the accuracy of baseline test results.

Objectives: Sports-Related Concussion (SRCs) are of relevant risk and burden for female athletes. The following study aimed to explore potential barriers to return to play (RTP) best practice in coaches of amateur female athletes, and medical professionals who may treat and manage SRCs in amateur female athletes., Design: Qualitative, semi-structured, virtual interviews following a critical analysis framework., Methods: Twenty-five coaches, allied healthcare professionals (AHPs), and general practitioners (GPs) were recruited and interviewed using a convenience snowball sample. Data were transcribed verbatim and thematically analysed., Results: Three themes were identified following reflexive thematic analysis; biopsychosocial norms, stakeholder inaction, and practitioner effectiveness. The findings identify numerous factors which limit the uptake of best practice guidelines as endorsed by Irish national governing bodies (NGBs). Education, training, and implementation of these guidelines are lacking, with sub-standard or non-existent medical support and poor general injury and/or SRC attitudes providing further resistance to these measures., Conclusion: Existence of SRC-RTP protocols does not equal adherence to such. Greater efforts are required to translate knowledge provided by the 6th Concussion Consensus statement. NGBs, league and club administrators, and educators need to better support coaches, practitioners and athletes in the implementation of these protocols in amateur female sport., Competing Interests: Declaration of competing interest ., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: Neurocognitive testing and oculomotor assessment have been an integral component to provide objective measures for sport-related concussion (SRC) detection and management. Hormonal contraceptive (HC) use is common among collegiate female athletes and may modify baseline SRC performance. The purpose was to examine the effects of HC use on baseline computerized neurocognitive testing (CNT) and oculomotor testing in college-aged individuals., Method: A total of 63 participants (22 HC using females, 22 non-HC using females, 19 males) completed a baseline SRC battery consisting of CNT, near point of convergence (NPC), and the King-Devick (KD) test. CNT measures were composite scores of verbal and visual memory, visual motor processing speed and reaction time, impulse control, and cognitive efficiency index (CEI). NPC was measured as the average convergence distance across three trials. KD time was recorded as total time for each of the two trials and best trial marked as baseline., Results: There were no group differences between HC, non-HC, and male control groups on all baseline CNT composite scores (p = .13-.98), impulse control (p = .47), and CEI (p = .49). NPC distance was similar between groups (p = .41), as well as KD time by trial (Trial 1 p = .65; 2 p = .48) and best time (p = .49)., Conclusions: HC use does not appear to influence baseline SRC measures of neurocognition and oculomotor assessment. Clinicians should continue to consider the effects of modifying factors at baseline and post-concussion. Additional research is needed to better understand sex hormone levels and SRC performance measures., (© The Author(s) 2023. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Concussions are associated with a variety of physical, cognitive, and mental health impairments. If sustained during adolescence, a time when the brain is undergoing development, the risk of long-term impairments becomes heightened. This is a notable subject for investigation as many concussions are sustained among adolescents during high school sports and other physical activities., Methods: We used data from the 2019 United States Youth Risk Behavior Survey to investigate the association between concussions and suicidality (i.e., suicide ideation, planning, and attempts), suicide capability (i.e., physical fighting and weapon carrying), and hopelessness, a risk factor for suicide. We utilized a cross-sectional design and used multivariate regression models and t tests for analysis., Results: Participants were 1754 adolescent students who sustained a concussion during the prior year (54.61% male; M age = 15.94) and 9795 adolescent students who did not sustain a concussion during the prior year (47.27% male; M age = 15.95). Females were less likely (13.23%) than males (17.12%) to report at least one concussion in the past 12 months. Both male and female students who had experienced a concussion were more likely to report physical fighting, weapon carrying, and hopelessness. Male students with a concussion history were also more likely to report suicide attempts than male students without a concussion history., Conclusion: Findings indicate that concussions are associated with an increased risk of suicide attempts, suicide capability, and hopelessness among male adolescents and suicide capability and hopelessness among female adolescents. They further suggest a need for additional mental health support and safety policies for student-athletes and other at-risk adolescents., (© 2023 Foundation for Professionals in Services to Adolescents.)

Context: A mobile application neurocognitive assessment has been used in place of equipment intensive computerized neurocognitive assessment protocol. A previous study reported high to very high test-retest reliability of neurocognitive assessment using the mobile application in healthy adults, but no studies have examined test-retest reliability, reliable change indices (RCIs), and sex effect in middle school and high school populations when conducted 1 year apart., Objective: The purpose of this study was to examine the test-retest reliability and RCIs of baseline data collected at 2-time points approximately 1 year apart using a mobile application neurocognitive rest in middle school and high school athletes. The secondary purpose of the study was to investigate the sex difference in neurocognitive measures., Design: Cross-sectional study., Setting: Institutional., Patients or Other Participants: 172 middle school and high school healthy student-athletes (mean age=13.78±1.59 years old)., Main Outcome Measure(s): Mobile application neurocognitive rest scores (reaction time, impulse control, inspection, and memory)., Results: The result from the study demonstrated that neurocognitive measures had low test-retest reliability across a 1-year time period in middle and high school settings. Upon retesting, reaction time and inspection time improved significantly in both middle and high school athletes, and impulse control showed significant improvement in middle school athletes. More athletes in middle school showed more RCI improvements compared to high school athletes. While both males and females demonstrated improvements in neurocognitive measures throughout adolescence, males outperformed females on reaction time and impulse control., Conclusions: Findings from the study indicate unacceptably low test-retest reliability of a mobile application neurocognitive test most likely due to cognitive development occurring throughout adolescence. Additionally, significant RCIs were noted. These naturally occurring improvements due to cognitive development could mask the post-concussion deficits. The findings warrant consideration of age and sex on the neurocognitive performance of middle and high school athletes.

Abstract Concussions can impact cognitive processes necessary for driving. Young adults, a group who are more likely to engage in risky behaviors, have limited driving experience and a higher rate of motor vehicle collisions; they may be at higher risk for driving impairment after concussion. There are no clear guidelines for return-to-driving following a concussion. We sought to examine the simulated driving performance of young drivers after receiving medical care following a concussion, compared with a similar control population, to examine the association of driving performance with performance on neuropsychological tests. We evaluated 47 drivers, 16- to 25-year-old, within 3 weeks of sustaining a concussion and 50 drivers with similar characteristics who had not sustained concussions. Participants completed demographic questionnaires, the Sport Concussion Assessment Tool-5 (SCAT-5), and a brief set of neurocognitive tests, including the National Institutes of Health (NIH) Toolbox Cognition Battery and the Trail Making Test, and a simulated driving assessment. At various times during simulated driving, participants were asked to respond to tactile stimuli using the tactile detection response task (TDRT), a validated method of testing cognitive load during simulated driving. The concussion group reported significantly higher symptoms on the SCAT-5 than the comparison group. Performance on crystallized neurocognitive skills was similar between groups. Performance on fluid neurocognitive skills was significantly lower in the concussion than comparison group, although scores were in the normal range for both groups. Simulated driving was similar between groups, although there was a small but significant difference in variation in speed as well as TDRT miss rate, with worse performance by the concussion group. Symptom report on the SCAT-5 was significantly associated with TDRT miss rate. In addition, neurocognitive test scores significantly predicted TDRT reaction time and miss count with medium to large effect sizes. Results suggest that neurocognitive screening may be a useful tool for predicting capacity to return to drive. However, further research is needed to determine guidelines for how neuropsychological tests can be used to make return to driving recommendations and to evaluate effects of concussion on real world driving.

Objective: Professional jockeys experience high rates of concussion, workplace stress, and poor mental health. The present cross-sectional study, for the first time, concurrently assessed the potential interplay between concussion history and workplace stress with current depression symptoms., Method: Seventy-two professional flat-track jockeys (male = 49, female = 23) were grouped based on self-reported concussion history (CG; n = 56) and those who did not report a concussion history (NCG; total n = 16). Analyses featured both between (CG vs NCG) and within group (CG only) assessment on self-reported measures of workplace stress and depression symptoms (affect, daily functioning)., Results: Jockeys in the CG had more symptoms of negative affect than the NCG. This association, however, was nonsignificant after covarying for age, gender, and workplace stress. Higher workplace stress (p = .005) and gender (p = .001) were associated with poorer daily functioning after controlling for concussion history (CG vs. NCG) and age. Gender moderated the association between concussion group and poorer daily functioning (β = -18.739, t (71) = -2.924, p = .005), with the difference between CG and NCG significant for females, but not males (β = 33.648, t (71) = 3.420, p = .001)., Conclusions: The findings provide preliminary evidence that previously concussed females may be more likely to report poorer daily functioning than males with a history of concussion, and that workplace stress may reduce the association between a history of concussion and depression symptoms. Prospective studies are required to validate and extend these findings., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com.)

Context: The rate of lower extremity musculoskeletal injury (LE MSK) is elevated after concussion; however, the underlying mechanism has not been elucidated. Physical characteristics have been investigated despite poorer mental health being a common postconcussion complaint and linked to MSKs., Objective: To evaluate the role of mental health as a predictor of postconcussion LE MSK., Design: Case-control study., Setting: Intercollegiate athletic training facility., Patients or Other Participants: A total of 67 National Collegiate Athletic Association Division I student-athletes (n = 39 females) who had been diagnosed with a sport-related concussion., Main Outcome Measure(s): The Brief Symptom Inventory-18, Hospital Anxiety and Depression Scale, and Satisfaction With Life Scale (SWLS) measures were completed at baseline (preseason) and on the day participants were cleared for unrestricted return to play (RTP) after a concussion. Two binary logistic regressions were used to predict postconcussion LE MSK within a year, one for the baseline time point and the second for the RTP time point. A 2 (group: LE MSK, no LE MSK)-by-2 (time: baseline, RTP) repeated-measures analysis of variance compared performance between baseline and RTP., Results: Subsequent LE MSKs were sustained by 44 participants (65.7%). The only significant predictor of postconcussion LE MSK was the SWLS score at RTP, with Exp(B) = 0.64, indicating that an increased (improved) SWLS score was associated with a lower LE MSK rate. No significant interactions were present between mental health measures and subsequent MSK (P values = .105-.885)., Conclusions: Limited associations were evident between postconcussion LE MSK and scores on commonly used measures of anxiety, depression, and satisfaction with life. Reported increased satisfaction with life was associated with a decreased injury risk, which warrants further attention. Our results suggest that these measures of anxiety, depression, and satisfaction with life have limited value in assisting sports medicine clinicians with determining which student-athletes are at elevated risk of postconcussion LE MSK., (© by the National Athletic Trainers' Association, Inc.)

Objective: Studies have observed variable associations of prior contact sport participation with subjective and objective measures of cognitive function. This study directly investigated the association between subjective self-report and objective performance-based cognition among former collegiate football players, as well as its relationship to self-reported concussion history., Methods: Former collegiate football players (N = 57; mean age = 37.9 years [ SD  = 1.49]) retired from sport 15-years prior were enrolled. Linear regression models examined associations between subjective cognition (Quality of Life in Neurological Disorders Cognitive Functioning-Short Form), and performance on a neuropsychological battery. Domain specific (executive function) metrics of subjective (Behavior Rating Inventory of Executive Function-Adult) and objective cognition were also exclusively examined. Associations between self-reported concussion history with subjective and objective measures were tested. Potential influential factors (sleep quality and distress) were included as covariates., Results: Subjective cognition was not significantly associated with any objective measures of cognitive functioning ( p 's > .05). Greater self-reported concussion history was inversely associated with subjective cognition (B = -2.49, p = .004), but not objective performance-based cognition ( p 's > .05). Distress was significantly related to all metrics of subjective cognition ( p 's < .001) as well as performance on delayed recall and verbal fluency ( p 's < .05). Sleep quality was only significantly related to timed visuospatial sequencing ( p = .033)., Conclusions: Reliance on self-reported measures of cognitive functioning alone is insufficient when assessing cognition in former contact sport athletes. Assessment of other factors known to influence subjective cognitive complaints should also be examined in determining the presence of cognitive deficits.

Purpose: To perform a systematic review of the literature and evaluate the return to play (RTP) time frame after a concussion diagnosis. Our secondary purpose was to analyze and compare different prognostic variables affecting concussions, time to return to school, time to symptom resolution of concussive symptoms, and time each patient spent in the RTP protocol., Methods: A PubMed, Scopus, Medline, Embase, and Cochrane Library database literature review was performed in August 2022. The studies needed to report, in days, the length of time a patient/athlete was removed from play due to concussion management. The Risk of Bias in Non-Randomized Studies of Interventions tool was used for risk of bias for each study, and Methodological Index for Non-Randomized Studies criteria were used for quality assessment., Results: There were 65 studies included in the systematic review and a total of 21,966 patients evaluated. The RTP time intervals ranged from 1 to 1,820 days, with 80.7% of the median RTP time frames for each study within 21 days. Preconcussion risk factors for prolonged RTP included female sex, younger age, presence of psychiatric disorders, and history of previous concussion. Postconcussion risk factors included severe symptom scores at initial clinic visit, loss of consciousness, nonelite athletes, and delayed removal from competition. The most common sports resulting in concussion were contact sports, most commonly football and soccer. Median time to return to school was 3 to 23 days. Median time to symptom resolution ranged from 2 to 11 days. Median time in RTP protocol was 1 to 6 days., Conclusions: Median time to return to sports after concussion is within 21 days in 80% of published studies., Level of Evidence: IV, systematic review of Level I to IV studies., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background and Objective: Computer-based neurocognitive tests are widely used in sport-related concussion management, but the performance of these tests is not well understood in the participant population with attention-deficit/hyperactivity disorder (ADHD) and/or learning disorder (LD). This research estimates the sensitivity and specificity performance of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) computer-based neurocognitive test in identifying concussion in this population., Methods: Study participants consisted of collegiate university athletes and military service academy cadets from the National Collegiate Athletic Association-Department of Defense CARE Consortium who completed the ImPACT test between 2014 and 2021. Participants who self-identified as belonging to one of the subgroups of interest (ADHD with or without LD [ADHD:LD+/-], LD with or without ADHD [LD:ADHD+/-], ADHD and/or LD [ADHD a/o LD]) and completed a baseline (1874 ADHD:LD+/-, 779 LD:ADHD+/-, 2338 ADHD a/o LD) or 24-48 h post-concussion (175 ADHD:LD+/-, 77 LD:ADHD+/-, 216 ADHD a/o LD) ImPACT assessment were included. Sensitivity and specificity were calculated using a normative data method and three machine learning classification methods: logistic regression, classification and regression tree, and random forest., Results: Using the four methods, participants with ADHD:LD+/- had sensitivities that ranged from 0.474 to 0.697, and specificities that ranged from 0.538 to 0.686. Participants with LD:ADHD+/- had sensitivities that ranged from 0.455 to 0.688, and specificities that ranged from 0.456 to 0.588. For participants with ADHD a/o LD, sensitivities ranged from 0.542 to 0.755, and specificities ranged from 0.451 to 0.724., Conclusions: For all subgroups and analytical methods, the results illustrate sensitivity and specificity values below typically accepted levels indicative of clinical utility. These findings support that using ImPACT alone may be insufficient to inform concussion diagnoses and encourages the use of a multi-dimensional concussion assessment., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objective: Sport concussion is a common injury, and athletes with attention-deficit/hyperactivity disorder (ADHD) and/or learning disorder (LD) are at increased risk and require specialized attention in clinical settings. Although systematic reviews of the relationship between ADHD/LD and concussion are reported in the literature, these reviews do not include quantitative syntheses. Additionally, no reviews have focused on the most commonly utilized concussion assessment, Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). The current review provides an update of sport concussion assessment in athletes with ADHD and/or LD from 2000 to 2021 on these topics: baseline and postconcussion performance on ImPACT, baseline and postconcussion symptom reporting using the Postconcussion Symptom Scale, invalid baseline classification on ImPACT, and self-reported history of concussion., Method: Meta-analyses were conducted on baseline ImPACT performance, symptom reporting, invalid baseline classification, and concussion rates. Thirty-four studies were included in systematic review and 19 were included in meta-analyses., Results: Decreased baseline performance was found for athletes with ADHD (trivial to small effects), LD (small-to-medium effects), and ADHD/LD (small-to-medium effects). Increased baseline symptom reporting was found for athletes with ADHD (small effect). Increased odds of invalid baseline performance (trivial effect) and self-reported concussion history (small effect) were found in ADHD., Conclusions: These results provide the first quantitative synthesis of the literature in this area. It is recommended that future research further examines these topics in athletes with LD and co-occurring ADHD/LD (given the focus on ADHD), as well as the effects that all of these conditions may have on concussion recovery and return-to-play decision-making. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Context: Clinical reaction-time (RT) measures are frequently used when examining patients with concussion but do not correlate with functional movement RT. We developed the Standardized Assessment of RT (StART) to emulate the rapid cognitive demands and whole-body movement needed in sport., Objective: To assess StART differences across 6 cognitive-motor combinations, examine potential demographic and health history confounders, and provide preliminary reference data for healthy collegiate student-athletes., Design: Prospective, cross-sectional study., Setting: Clinical medicine facilities., Patients or Other Participants: A total of 89 student-athletes (56 [62.9%] men, 33 [37.1%] women; age = 19.5 ± 0.9 years, height = 178.2 ± 21.7 cm, mass = 80.4 ± 24 kg; no concussion history = 64 [71.9%])., Main Outcome Measure(s): Student-athletes completed health history questionnaires and StART during preseason testing. The StART consisted of 3 movements (standing, single-legged balance, and cutting) under 2 cognitive states (single task and dual task [subtracting by 6's or 7's]) for 3 trials under each condition. The StART trials were calculated as milliseconds between penlight illumination and initial movement. We used a 3 × 2 repeated-measures analysis of variance with post hoc t tests and 95% CIs to assess StART cognitive and movement differences, conducted univariable linear regressions to examine StART performance associations, and reported StART performance as percentiles., Results: All StART conditions differed (P ≤ .03), except single-task standing versus single-task single-legged balance (P = .36). Every 1-year age increase was associated with an 18-millisecond (95% CI = 8, 27 milliseconds) slower single-task cutting RT (P < .001). Female athletes had slower single-task (15 milliseconds; 95% CI = 2, 28 milliseconds; P = .02) and dual-task (28 milliseconds; 95% CI = 2, 55 milliseconds; P = .03) standing RT than male athletes. No other demographic or health history factors were associated with any StART condition (P ≥ .056)., Conclusions: The StART outcomes were unique across each cognitive-motor combination, suggesting minimal subtest redundancy. Only age and sex were associated with select outcomes. The StART composite scores may minimize confounding factors, but future researchers should consider age and sex when providing normative data., (© by the National Athletic Trainers' Association, Inc.)

Objective: This study examined neurocognitive performance and symptoms between concussed Black and White collegiate athletes at baseline, post-injury, and change from baseline to post-injury., Method: The Immediate Post-Concussion Assessment and Cognitive Test (ImPACT) was used to measure neurocognitive performance and four concussion symptom clusters for 235 concussed collegiate athletes. Between-groups differences were documented at baseline and post-injury, along with change in scores for sex/race, and sport/race groups, using ANOVAs. Baseline scores, and days-to-post-test were covariates in post-injury comparisons. Symptom endorsement by race was evaluated using chi-square analyses., Results: At baseline, group comparisons by race and sex showed that Black male/female athletes scored lower on reaction time (RT; p = .008), White females scored higher on verbal memory (VerbMem; p = .001), Black females scored lower on visual motor processing speed (VMS; p = .001), and Black football athletes scored slower/poorer on RT ( p = .001) and VMS ( p = .006). Post-injury, Black males scored lower on visual memory (VisMem; p = .005) and VMS ( p = .002), and Black football athletes scored slower on VMS ( p = .005), whereas White non-football athletes scored higher on VerbMem ( p = .002) and reported fewer symptoms. Significant time-by-sport/race interactions were found for VerbMem ( p < .001), VisMem ( p < .001) and reported symptoms. With respect to post-injury symptom scores/endorsement, Black athletes scored significantly higher for physical ( p = .01) and sleep ( p = .01) symptoms., Conclusion: These findings drive the conversation of how subjective measures of symptoms, and objective clinical concussion measures, may relate to the concussion recovery process and providing a culturally competent clinical management approach for diverse patients.

Context: Sex differences influence symptom presentations after sport-related concussion and may be a risk factor for certain concussion clinical profiles., Objective: To examine sex differences on the Concussion Clinical Profile Screen (CP Screen) in adolescents after sport-related concussion., Design: Cross-sectional study., Setting: A concussion specialty clinic., Patients or Other Participants: A total of 276 adolescent (age = 15.02 ± 1.43 years; girls = 152 [55%]) athletes with a recently diagnosed concussion (≤30 days)., Main Outcome Measure(s): The 5 CP Screen profiles (anxiety mood, cognitive fatigue, migraine, vestibular, ocular) and 2 modifiers (neck, sleep), symptom total, and symptom severity scores were compared using a series of Mann-Whitney U tests between boys and girls., Results: Girls (n = 152) scored higher than boys (n = 124) on the cognitive fatigue (U = 7160.50, z = -3.46, P = .001) and anxiety mood (U = 7059, z = -3.62, P < .001) factors but not on the migraine (U = 7768, z = -2.52, P = .01) factor. Girls also endorsed a greater number of symptoms (n = 124; U = 27233, z = -3.33, P = .001) and scored higher in symptom severity (U = 7049, z = -3.60, P < .001) than boys., Conclusions: Among adolescents, symptom endorsement on the CP Screen varied based on sex, and clinicians need to be aware of these differences, especially when evaluating postconcussion presentation in the absence of baseline data., (© by the National Athletic Trainers' Association, Inc.)

Objective: Patients who are fully recovered from a concussion may still be more vulnerable in the face of subsequent concussions. This study examines symptoms associated with repeated concussions in young and otherwise healthy adults., Design: Cross sectional., Setting: Institutional study at a university setting., Participants: University students with a history of concussion., Independent Variables: Participants were grouped based on numbers of concussions., Main Outcome Measures: The impact of incremental concussion on symptom clusters in Sport Concussion Assessment Tools 5 and Spearman ranking correlation coefficients between symptom clusters., Results: One hundred thirty-five participants reported having had 1 concussion, 63 reported 2 concussions, 50 reported 3 concussions, and 43 reported 4 to 6 concussions. Total severity scores over the range of concussion number (1, 2, 3, and greater than 3) did not show a clear incremental effect. However, average scores of cognitive symptoms rose with each subsequent concussion ( P ≤ 0.05). The largest incremental effect observed was that of second concussions on emotional symptom scores (t = 5.85, P < 0.01). Symptoms in the emotional and cognitive clusters were the most correlated regardless of the number of reported concussions; the correlations were lowest with symptoms associated with sensitivity to light or noise., Conclusions: The incremental rise of cognitive symptom scores with each concussion affirms the importance of cognitive impairment in concussion assessment and implies a cumulative brain vulnerability that persists even after symptom resolution. The cognitive-emotional symptom clusters may reflect underlying concussion-induced impairments in the corticostriatothalamocortical (CSTC) networks, although sensitivity symptoms are potentially attributable to different neural correlates., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: International consensus statements highlight the value of neuropsychological testing for sport-related concussion. Computerized measures are the most frequently administered assessments of pre-injury baseline and post-injury cognitive functioning, despite known measurement limitations. To our knowledge, no studies have explored the convergent validity of computerized Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and traditional, well-validated paper and pencil (P&P) neuropsychological tests in high school student athletes. This study aimed to assess a "hybrid" adolescent test battery composed of ImPACT and P&P measures to determine the extent of shared variance among ImPACT and P&P tests to inform comprehensive yet streamlined assessment., Method: Participants included male and female high school student athletes in the Southeastern United States participating in American football, hockey, and soccer who completed a battery of ImPACT and P&P tests (N = 69)., Results: We performed principal component analysis with ProMax rotation to determine components of the hybrid battery that maximally accounted for observed variance of the data (Kaiser-Meyer-Olkin factor adequacy = 0.71). Our analysis revealed four independent factors (Verbal Learning and Memory, ImPACT Memory and Speed, Verbal Processing Speed/Executive Functions, and Nonverbal Processing Speed/Executive Functions) explaining 75% of the variance., Conclusions: Findings of this study in adolescent student athletes support those from the adult literature demonstrating the independence of ImPACT and P&P tests. Providers should be aware of limitations in using standalone ImPACT or P&P measures to evaluate cognitive functioning after concussion. If confirmed in a larger, clinical sample, our findings suggest that a hybrid battery of computerized and P&P measures provides a broad scope of adolescent cognitive functioning to better inform recovery decisions, including return to play after concussion., (© The Author(s) 2022. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Traditional reliable change index (RCI) methods may be psychometrically limited due to their inability to account for particularly high or low baseline performance and regression to the mean following serial testing. The current study sought to examine differences between RCI and standardized regression-based (RBz) methods in a cohort of adolescent athletes engaged in sport-related concussion recovery., Methods: Consultation records and results of computerized testing data via the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery were retrospectively reviewed among 240 adolescent athletes involved in return-to-play protocols following a sport-related concussion., Results: High concordance rates were found between RCI and RBz metrics across ImPACT composites, consistent with previous literature. However, especially for those with lower baseline performance, RBz scores tended to suggest cognitive performance not meeting or exceeding baseline scores despite RCI metrics being appropriate across speed-based ImPACT composites. In contrast, results revealed high rates of RCI scores suggesting continued cognitive difficulties despite RBz metrics being within normal limits, especially for adolescents with higher baseline performance., Conclusions: Results suggest value in interpreting RBz values in addition to RCI values as these allow for clinical interpretation more sensitive to statistical confounds, including baseline performance and regression to the mean.

Objective: Performance validity assessment is an important component of concussion baseline testing and Immediate Post-Concussion and Cognitive Testing (ImPACT) is the most commonly used test in this setting. A review of invalid performance on ImPACT was published in 2017, focusing largely on the default embedded validity indicator (Default EVI) provided within the test. There has since been a proliferation in research evaluating the classification accuracy of the Default EVI against independently developed, alternative ImPACT-based EVIs, necessitating an updated review. The purpose of this study was to provide an up-to-date review of the prevalence of invalid performance on ImPACT and to examine the relative effectiveness of ImPACT-based EVIs. Method: Literature related to the prevalence of invalid performance on ImPACT and the effectiveness of ImPACT-based EVIs, published between January 2000 and May 2020, was critically reviewed. Results: A total of 23 studies reported prevalence of invalid performance at baseline testing using ImPACT. Six percent of baseline assessments were found to be invalid by the ImPACT's Default EVI, and between 22.31% and 34.99% were flagged by alternative EVIs. Six studies assessed the effectiveness of ImPACT-based EVIs, with the Default EVI correctly identifying experimental malingerers only 60% of the time. Alternative ImPACT-based EVIs identified between 73% and 100% of experimental malingerers. Conclusions: The ImPACT's Default EVI is not sufficiently sensitive, and clinicians should consider alternative indicators when assessing invalid performance. Accordingly, the base rate of invalid performance in athletes at baseline testing is likely well above the 6% previously reported.

Persistent concussion symptoms in adolescents are associated with lower health-related quality of life (HRQOL). The association between persistent emotional and behavioral-related concussion symptoms (EBS) and HRQOL is unknown, however. This study was a prospective cohort of adolescent athletes presenting to a concussion clinic within three days post-concussion and completing a one-month follow-up. The independent variable in these analyses was parent reported EBS symptom presence grouped as: (1) no EBS; (2) EBS present at pre-concussion levels; and (3) EBS worse than pre-concussion. The EBS included the following concussion symptoms: feeling irritable, depressed, frustrated/impatient, restless, reduced tolerance to stress/emotion, poor concentration, and fear of permanent symptoms. Dependent variables were parent reported psychosocial, physical, and total HRQOL. Separate multi-variable linear regression models controlling for age, sex, and concussion history were used to assess the association between EBS and HRQOL. Estimated adjusted mean differences (MD) and 95% confidence intervals (CI) were used to assess associations; MDs with a 95%CI excluding 0.0 were considered statistically significant. Overall, n  = 245 presented to the study clinic three days post-concussion and completed the one-month follow-up ( M age  = 14.28 ± 2.09 years, 59.02% male, 90.64% Caucasian, 31.84% with concussion history). At one-month post-concussion, adolescents with pre-concussion EBS levels had significantly lower psychosocial, physical, and total HRQOL than those with no EBS. In addition, those with EBS worse than pre-concussion had significantly lower psychosocial, physical, and total HRQOL than those with no EBS and EBS at pre-concussion levels. These findings highlight the importance of HRQOL assessments and that targeted interventions may be needed for those with EBS at one-month post-concussion to improve HRQOL.

Objective: This study examined factor models for the Post-Concussion Symptom Scale (PCSS) at baseline and after suspected sport-related concussion, and measurement invariance from pre-injury to post-injury assessments and across age, gender, and health history groups (e.g., attention-deficit/hyperactivity disorder, psychiatric history). Methods: Adolescent student athletes (ages 13-18) completed a baseline PCSS ( n  = 39,015; 54.3% boys) and a subsample within 21 days of a suspected concussion ( n  = 1,554; 56.7% boys) completed a post-injury PCSS. Five models were evaluated for fit and invariance. Results: Confirmatory factor analyses showed good baseline and post-injury model fit for a previously supported four-factor model (i.e., cognitive-sensory, sleep-arousal, vestibular-somatic, and affective), an alternative four-factor model (i.e., cognitive, sleep-arousal, physical, and affective), and an incomplete bifactor model with vestibular-somatic and affective specific factors, along with partial invariance from pre-injury to post-injury assessments. Partial-to-full invariance was established for each model at baseline across demographic and health history groups. Conclusions: Results showed empirical and conceptual support for both PCSS subscales (i.e., cognitive, sleep-arousal, physical, and affective) and a total score for use in pre-injury to post-injury assessments and across demographic and health history groups at baseline. Future normative data, stratified by demographics and health history, could provide more precise symptom assessments for concussion management.

Background: Continued participation after sport-related concussion (SRC) worsens outcomes, but it is unknown if duration of continued participation after SRC impacts recovery outcomes, and which athletes who continue to participate are at greatest risk for poor SRC outcomes. The purpose of this National Collegiate Athletic Association/Department of Defense (NCAA/DoD) Concussion Assessment, Research, and Education (CARE) Consortium study was to evaluate the association of estimated duration of continued participation after SRC with symptom severity and recovery time in collegiate athletes., Methods: Clinicians estimated if/how long athletes continued participation after SRC. Collegiate athletes who continued participation after suspected SRC (n = 195/373, 52.3%) completed the Graded Symptom Checklist to evaluate the severity of total symptoms and migraine/fatigue, cognitive/ocular, and affective symptom clusters. Linear regression analyzed the associations between estimated duration of continued participation, symptom severity, and recovery time. Binary logistic regression examined the association of estimated duration of continued participation with the odds of recovery ≥ 14 and ≥ 21 days. Statistical significance was p < 0.05., Results: Athletes who continued to participate did so for 27.9 ± 25.3 min (mean ± standard deviation; range 1-90 min). Longer estimated continued participation (1-90 min) was associated with greater symptom severity (β = 0.122, p = 0.02), affective (β = 0.171, p = 0.001) and migraine/fatigue symptoms (β = 0.104, p = 0.049), longer symptom duration (β = 0.193, p < 0.001), and longer time missed (β = 0.156, p = 0.003). Longer estimated continued participation positively interacted with female sex (cognitive/ocular: female R 2  = 0.03, male R 2  = 0.01, p = 0.02; affective: female R 2  = 0.06, male R 2  = 0.02, p = 0.006), migraine history (affective symptoms: no migraine R 2  = 0.02; migraine R 2  = 0.18; p = 0.04), and concussion history (affective: 2 + prior concussions [R 2  = 0.14] compared with those with 1 [R 2  = 0.07] or 0 [R 2  < 0.01] prior concussions [p = 0.003])., Conclusions: Longer estimated duration of continued participation after SRC was associated with higher symptom severity, particularly affective and migraine/fatigue; longer symptom duration; and more time missed from sport. SRC outcomes in those who continue to play may be especially severe for female athletes, athletes with migraine history, and athletes with prior concussion(s). The findings can help clinicians and administrators to educate athletes on the importance of immediate removal following a suspected SRC., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)