Optimizing Order of Administration for Concussion Baseline Assessment Among NCAA Student-Athletes and Military Cadets

Sports Med. 2021 Jul;

Lempke, L. B., Lynall, R. C., Anderson, M. N., McCrea, M. A., McAllister, T. W., Broglio, S. P., . . . Investigators, C. C..



BACKGROUND: Concussion pre-injury (i.e., baseline) assessments serve as a benchmark comparison point in the event an individual sustains a concussion and allows clinicians to compare to post-injury measures. However, baseline assessments must reflect the individual’s true and most optimized performance to serve as a useful comparison. Mental fatigue and motivation throughout baseline testing may alter individual assessment performance, indicating an order of administration (OoA) may play an influential role in assessment outcomes. OBJECTIVE: To examine the influence concussion baseline battery OoA has on symptom, postural stability, cognitive screening, and computerized neurocognitive test outcomes. METHODS: We employed a retrospective observational cohort study to examine healthy collegiate student-athletes and military cadets (n = 2898, 19.0 +/- 1.4 years, 66.1% male, 75.6% white, 54.4% Division-I) baseline assessment performance on the Sport Concussion Assessment Tool (SCAT; total symptom number and severity), Balance Error Scoring System (BESS; total error scores), Standardized Assessment of Concussion (SAC; total score), and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) domain scores (verbal and visual memory, visual-motor speed, reaction time). Assessments were binned to beginning, middle, or end tertiles based upon OoA. We used one-way ANOVAs with Tukey post-hoc t tests, 95% confidence intervals (CI), and Cohen’s d effect sizes for significant models (alpha = 0.05). RESULTS: SCAT total symptom number (mean difference = 2.23; 95% CI 1.76-2.70; d = 0.49, p < 0.001) and severity (mean difference = 5.58; 95% CI 4.42-6.74; d = 0.50; p < 0.001) were lower when completed at the end of baseline testing compared to the middle. Total BESS errors were 1.06 lower when completed at the middle relative to the end (95% CI 0.43-1.69; d = 0.17; p = 0.001). Total SAC scores were better at the beginning relative to middle (mean difference = 0.58; 95% CI 0.25-0.90; d = 0.33; p < 0.001) and end (mean difference = 0.44; 95% CI 0.16-0.73; d = 0.24; p = 0.001). Verbal memory, visual memory, and reaction time performance were highest at the beginning (p

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