Post-Injury Item Endorsement And Correlation Between Symptom Severity And Days Post-Concussion For The Graded Symptom Scale In Concussed Adolescent Athletes

Journal of Athletic Training. -


Shepherd, L. I., R. C. Bay and T. C. Valovich McLeod.



Context: Symptoms are an important self-report indicator of athlete recovery and are often used to determine when return-to-play progressions can begin. Recent work has begun to examine individual symptoms and symptom clusters as predictors of prolonged recovery; however there are few studies that have investigated post-injury individual symptom patterns in adolescent athletes. Objective: To tabulate the frequency with which the 22 items of the Graded Symptom Scale are endorsed by concussed adolescent athletes during weeks 1, 2 and 3 post-concussion and to estimate the relationship between severity of item symptomatology and days since concussion. Design: Prospective cohort. Setting: High school athletic training facilities. Patients or Other Participants: Adolescent athletes (n = 437, males = 326, females = 111, age = 16.0 ± 1.2) participating in interscholastic contact sports, who suffered a sport-related concussion diagnosed by an athletic trainer. Intervention(s): All subjects completed the Immediate Post Concussion Assessment and Cognitive Testing (ImPACT) test within 21 days post-concussion. The primary independent variable was days post-concussion. Main Outcome Measure(s): Dependent variables included the 22 individual symptom items from the ImPACT symptom inventory; whether each item was endorsed (any score > 0) and severity score (7-point Likert scale). Percentages of subjects who endorsed each item during weeks 1 (n=266), 2 (n=125) and 3 (n=46) post-concussion were calculated. Spearman correlation coefficients (rs) were used to estimate the monotonic relationship between symptom severity and number of days post-concussion for each item. Results: Headache was the most commonly endorsed symptom during week 1 (71.1%), week 2 (37.6%) and week 3 (32.6%), for a weighted average of 57.4% across the 3 weeks. Weighted average endorsements for the remaining 5 most commonly endorsed symptoms, in descending order, were: difficulty concentrating (44.9%), drowsiness (34.1%), dizziness (33.2%) and sensitivity to light (33.0%). Numbness/ tingling and vomiting were endorsed by only 8.0% and 4.4% of participants, respectively. The severity scores for all items were negatively correlated with days post-concussion, p<.001, except sleeping less (p=.006). Headache (rs = -.50), dizziness (rs = -.40), diffculty concentrating (rs = -.39), slowed down (rs = -.39) and sensitivity to light (rs = -.39) were most highly correlated with days post-concussion. Conclusions: Headache is one of the most commonly reported symptoms following concussion, and while its prevalence decreases with time, it was still endorsed by one-third of subjects up to three weeks post-injury. Along with headache, the other prevalent symptoms should be monitored closely following injury. While important as on-field red flags, numbness/tingling and vomiting are rarely reported. Modi cation of the graded symptom scale to reflect this should be considered. Athletes’ symptom severity scores routinely decrease monotonically as time passes; however, in some, symptoms may linger. Clinicians must be aware that lingering symptomatology may indicate a longer recovery and take steps to address these persistent symptoms. Funded by a grant from the National Operating Committee on Standards for Athletic Equipment (NOCSAE)

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