Addressing the ``Replication Crisis'' in Sports Neuropsychology: Validation of the Two-Factor Theory of ImPACT

Abstract Purpose The "replication crisis" in psychology and across the broader field of social sciences raises criticism due to a lack of data to show that esoteric research findings can be replicated. The present study replicated and validated the two-factor “memory” and “speed” structure of ImPACT (Schatz & Maerlender, 2013). Methods High school aged athletes (N=18,918, Mean age=15.4, SD=1.2) who completed pre-season baseline ImPACT testing were randomly assigned to one of 5 independent samples of approximately 3,780 athletes. Exploratory factor analyses (FA) for a two-factor solution were conducted with ImPACT composite scores within each of the five groups. Post-Concussion Symptom Scale (PCSS) scores were included, with the expectation they would load on a third, unique factor. Results All five samples met assumptions for FA (KMO Measure of Sampling Adequacy above .600), and all five analyses yielded the same “memory” and “speed” two-factor structure. Visual Motor Speed and Reaction Time loaded on the first "Speed" factor and Verbal and Visual Memory loaded on a second "Memory" factor. The PCSS scores loaded on a third, unique “symptom” factor. Conclusion Replication of the two-factor structure for ImPACT in a five large high school sample further validates the model. Given that both visual and verbal memory involve encoding of information presented visually, use of a “memory” factor may improve interpretation of ImPACT scores. Similarly, similarities between constructs measuring speed of responding (Reaction Time) and speed of processing (Visual Motor Processing Speed) may be best explained using a “speed” factor.

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The Effect of Test Setting Upon Test-Retest Reliability of ImPACT Baseline Tests in High School Athletes

Neurology ◽

10.1212/01.wnl.0000801956.01474.ba ◽

2021 ◽

Vol 98 (1 Supplement 1) ◽

pp. S23.2-S23

Author(s):

Mark Thomas William Roberts ◽

Jonathan Danield Lichtenstein

Keyword(s):

High School ◽

Reaction Time ◽

Verbal Memory ◽

Visual Memory ◽

Motor Speed ◽

High School Athletes ◽

Retest Reliability ◽

Concussion Management ◽

Visual Motor ◽

Test Retest Reliability

ObjectiveTo determine the test-retest reliability of ImPACT baseline tests across different schools within the same larger concussion management program.BackgroundImPACT is the most widely used concussion management cognitive testing tool. Baseline testing is often required for high school sports participation. Typically, testing occurs every 2 years based on test-retest reliability statistics in previous studies. Demographic and environmental factors, such as age, sex, number of participants, and supervision, all impact baseline performance. Studies to date have not examined test-retest differences across testing sites, such as between school differences.Design/MethodsCross-sectional retrospective design. Valid baseline tests from high school athletes over a 2-year interval were included. Participants who experienced concussions prior to or between tests were excluded. A total of 979 student athletes from 5 schools were included. The Intra-class correlations were determined over a 2-year period for each ImPACT composite score and school.ResultsICC estimates averaged between schools reflected good reliability for visual-motor speed (0.833), visual memory (0.673) and reaction time (0.615) over the two-year period. Verbal memory (0.586) and impulse control (0.556) were less reliable. Between schools a greater range of composite reliability was observed for reaction time (0.484–0.730) and impulse control (0.461–0.655) compared to verbal memory (0.534–0.637), visual memory (0.61–0.719), and visual-motor speed (0.769–914).ConclusionsAs previously established, reliability of ImPACT baselines vary by composite. This study revealed that reliability also varies by setting, as different schools yielded different ICCs. Consistent with the literature, the most reliable measure was visual-motor speed. The greatest difference in reliability between schools was for reaction time. These results suggest that test setting and environment affect reliability of ImPACT baseline scores, with varying effects per composite. Attention must be paid to environmental setting to improve reliability of baseline cognitive test performance to maximize athlete safety.

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B-44 An Examination of Balance Measurements in Predicting Post-Concussion Neurocognitive Dysfunction

Archives of Clinical Neuropsychology ◽

10.1093/arclin/acz034.127 ◽

2019 ◽

Vol 34 (6) ◽

pp. 990-990

Author(s):

A DaCosta ◽

A Crane ◽

M Fasciana ◽

A LoGalbo

Keyword(s):

Reaction Time ◽

Verbal Memory ◽

Visual Memory ◽

Clinical Utility ◽

Collegiate Athletes ◽

Motor Speed ◽

Balance Performance ◽

Neurocognitive Dysfunction ◽

Balance Deficits ◽

Visual Motor

Abstract Objective Previous research indicates that athletes experiencing concussions demonstrate acute balance deficits (Guskiewicz, 2011). Although it is hypothesized that balance performance is related to neurocognitive function in athletes experiencing a concussion (Guskiewicz, Ross, & Marshall, 2001; Broglio, Sosnoff, Ferrara, 2009), limited research exists regarding the clinical utility of baseline measures. Method 68 collegiate athletes (ages 18-23; M = 19.62, SD = 1.44) were evaluated using the Balance error scoring system (BESS) and ImPACT at baseline and post-concussion. Multiple linear regressions were used to determine how BESS performance change across evaluations predicted post-concussion neurocognitive dysfunction compared to post-concussion performance alone. Results BESS performance changes from baseline to post-concussion significantly predicted post-concussion Verbal Memory (R² = .06, p = .05), Visual Memory (R² = .135, p = .002), Visual-Motor Speed (R² = .146, p = .001), Reaction Time (R² = .156, p = .001), and Total Symptom Scores (R² = .112, p = .005); while post-concussion BESS scores predicted Visual Memory (R² = .138, p = .002), Visual-Motor Speed (R² = .137, p = .002), and Reaction Time (R² = .145, p = .001). Therefore, assessing change in BESS performance is a more comprehensive predictor of neurocognitive dysfunction than solely post-concussion BESS performance. Conclusions Changes in BESS performance from baseline to post-concussion was found to be a more comprehensive predictor of neurocognitive dysfunction than post-concussion BESS scores alone. Therefore, our results support the clinical utility of evaluating balance at pre-participation to better understand neurocognitive risk factors.

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THE RELATIONSHIP BETWEEN ACUTE MOOD, SLEEP, AND SEX ON NEUROCOGNITIVE PERFORMANCE POST-CONCUSSION IN ADOLESCENTS

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967120s00191 ◽

2020 ◽

Vol 8 (4_suppl3) ◽

pp. 2325967120S0019

Author(s):

Sara Stremlau ◽

Richard Cameron Allred ◽

Richard Gerkin ◽

Steven Erickson ◽

Jamie Pardini

Keyword(s):

Reaction Time ◽

Verbal Memory ◽

Visual Memory ◽

Cognitive Testing ◽

Motor Speed ◽

Neurocognitive Performance ◽

Symptom Report ◽

Mood Symptoms ◽

Visual Motor ◽

And Performance

Background: Both sleep disturbance and mood changes are common symptoms post-concussion (Sell & Rubeor, 2017). Studies have found these symptoms are correlated with poorer performance on neurocognitive testing (Kontos et al., 2012 and Kostyun et al., 2015). In addition, Brown et al., (2015) showed that females report more symptoms at both baseline and post-concussion compared to males on the Post-Concussion Scale and the Sport Concussion Assessment Tool 2. Hypothesis/Purpose: The purpose of this study is to investigate how a patient’s sex, as well as self-reported acute mood and sleep symptoms are related to neurocognitive performance in individuals with concussion. Methods: Data were acquired through IRB-approved retrospective chart review. Composite scores from the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) computerized evaluation and self-reported symptom scores on the Post-Concussion Symptom Scale were gathered for 1619 adolescents age 12-18 (49.3% female) who presented to a large metropolitan outpatient clinic for treatment of concussion. Results: Females endorsed higher overall symptoms (x=19.52, SD 19.37, median 13.0 for females; x=12.88, SD 15.89, median 7.0 for males; Mann-Whitney U Test p<0.001). This same pattern emerged for the mood and sleep symptom clusters (female mood mean=2.92, SD 4.51; male mood mean=1.64, SD 3.34; female sleep mean=1.59, SD 2.0; male sleep mean=1.11, SD 1.84; both Independent Samples Mann-Whitney U Tests ps<0.001). There were significant but modest negative correlations between mood symptoms and performance on verbal memory (r=-0.174), visual memory (r=-0.213), and visual motor speed (r=-0.146) composites (all ps<0.01). There was positive correlation between reaction time composite and mood symptoms (r=0.191). There were significant but modest negative correlations between sleep symptoms and performance on verbal memory (r=-0.171), visual memory (r=-0.184), and visual motor speed (r=-0.161) composites (all ps<0.01). There was a positive correlation between reaction time composite and sleep symptoms (r=0.196, p<0.01). Conclusion: Consistent with prior research, adolescent females reported more symptoms post-concussion, including total symptom score, mood symptoms, and sleep symptoms. Adolescents presenting with more mood and sleep symptoms demonstrated poorer performance on neurocognitive testing. However, given the modest nature of the correlation, a significant amount of variation in test performance is not explained by symptom report. Results from this study underscore the importance of a multidimensional concussion assessment that includes both symptom report and cognitive testing when working with pediatric athletes. This study also reinforces the importance of understanding potential effects of sleep, mood, and sex on concussion.

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Baseline neurocognitive scores in athletes with attention deficit–spectrum disorders and/or learning disability

Journal of Neurosurgery Pediatrics ◽

10.3171/2013.5.peds12524 ◽

2013 ◽

Vol 12 (2) ◽

pp. 103-109 ◽

Cited By ~ 73

Author(s):

Scott L. Zuckerman ◽

Young M. Lee ◽

Mitchell J. Odom ◽

Gary S. Solomon ◽

Allen K. Sills

Keyword(s):

Reaction Time ◽

Attention Deficit ◽

Processing Speed ◽

Verbal Memory ◽

Impulse Control ◽

Visual Memory ◽

Special Populations ◽

Motor Processing ◽

Visual Motor ◽

Visual Motor Processing

Object Up to 16% of children in the US between the ages of 3 and 17 years have either attention deficit–spectrum disorder or a learning disability (LD). Sports-related concussions among youth athletes represent a significant public health concern, and neurocognitive testing is a method to evaluate the severity of cognitive impairment and recovery after a sports-related concussion. The goal of this study was to assess baseline neurocognitive differences between athletes with attention deficit hyperactivity disorder (ADHD) and/or LD versus those with neither disorder and to establish normative data for these special populations. Methods Between August 2007 and March 2012, 6636 young athletes underwent baseline neurocognitive testing performed using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) battery. Of these participants, 90 had self-reported LD only, 262 had self-reported ADHD only, and 55 reported both. Those with ADHD and/or LD were matched with 407 participants with no history of ADHD or LD by age, sex, and number of prior concussions. The mean scores and SDs were calculated for each group to obtain normative values. A pairwise comparison between each diagnostic group was done to assess whether LD and/or ADHD diagnostic status predicted participants' baseline neurocognitive scores. Results Participants with ADHD had significantly lower verbal memory, visual memory, and visual motor processing speed scores, along with significantly higher reaction time, impulse control, and symptom scores compared with those without LD or ADHD. Participants with LD had similar results, with significantly lower verbal memory, visual memory, and visual motor processing speed scores, higher reaction time and symptom score, but did not differ in their impulse control score compared with those without LD or ADHD. Participants with both LD and ADHD had a significantly lower visual motor speed score and a significantly higher reaction time and symptom score than those without LD or ADHD, but did not differ with regard to the other composite scores. Conclusions Athletes with ADHD and/or LD have lower baseline ImPACT neurocognitive scores compared with athletes without ADHD and LD. Preliminary normative neurocognitive data for these special populations are provided.

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An Examination of Adolescent Athletes and Nonathletes on Baseline Neuropsychological Test Scores

Journal of Athletic Training ◽

10.4085/1062-6050-84-17 ◽

2018 ◽

Vol 53 (4) ◽

pp. 404-409 ◽

Cited By ~ 2

Author(s):

Christopher P. Tomczyk ◽

Megan Mormile ◽

Megan S. Wittenberg; ◽

Jody L. Langdon ◽

Tamerah N. Hunt

Keyword(s):

High School ◽

High School Students ◽

High Schools ◽

Reaction Time ◽

Verbal Memory ◽

Visual Memory ◽

Neuropsychological Test ◽

Test Battery ◽

Cognitive Test ◽

High School Athletes

Context: An estimated 15.3 million adolescent students are enrolled in US high schools, with approximately 7.8 million participating in athletics. Researchers have examined various demographics in high school athletes; however, athletic participation may play a larger role in test performance than previously thought. Currently, investigations of concussion assessment may rely on uninjured athletes as controls. However, due to the intense nature of athletics, this may not be an appropriate practice. Objective: To examine differences between athletes and nonathletes using a common computerized neuropsychological test. Design: Retrospective cross-sectional study. Setting: High schools from a school district in Columbus, Ohio. Patients or Other Participants: A total of 662 adolescent high school students (athletes: n = 383, female n = 18; nonathletes: n = 279, female n = 193). Main Outcome Measure(s): Participants were administered a computerized neuropsychological test battery (Immediate Post-Concussion Assessment and Cognitive Test [ImPACT]) during baseline concussion assessment. Differences between groups were established for output composite scores. Results: Differences were found between athletes and nonathletes in composite reaction time (F1,522 = 14.855, P < .001) and total symptom score (F1,427 = 33.770, P < .001). Nonathletes reported more symptoms, whereas athletes had faster reaction times. No differences were present in composite verbal memory, composite visual memory, composite visual motor speed, or composite impulse control (P > .05). Conclusions: Symptom reporting and reaction time differed between high school athletes and nonathletes. Participation in extracurricular activities may lead to cognitive differences in adolescents that can influence performance on the Immediate Post-Concussion Assessment and Cognitive Test battery. Researchers should account for these differences in baseline performance when making concussion diagnostic and management decisions.

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Signs of cognitive dysfunction in adult players of club level rugby

South African Journal of Psychology ◽

10.1177/0081246319826816 ◽

2019 ◽

Vol 50 (1) ◽

pp. 128-140 ◽

Cited By ~ 1

Author(s):

Diana Zoccola ◽

Ann B Shuttleworth-Edwards ◽

Sarah E Radloff

Keyword(s):

Reaction Time ◽

Cognitive Dysfunction ◽

Verbal Memory ◽

Visual Memory ◽

Rugby Union ◽

Motor Speed ◽

Visual Motor ◽

The Impact ◽

Rugby Players

The objective of this study was to investigate players of club level Rugby Union (hereafter rugby) over one rugby season, for signs of residual cognitive dysfunction due to repeated concussive events incurred during long-term participation in the sport. Adult male players of club level rugby, without a diagnosis of a concussion during the season ( n = 20), were compared with non-contact club level sports participants ( n = 22) of equivalent sex, age, education, and estimated IQ at pre-, mid-, and post-season intervals. Measures included the ImPACT Verbal Memory, Visual Memory, Visual Motor Speed and Reaction Time composites, and the Purdue Pegboard test. Statistical group comparisons revealed consistently poorer performance for rugby players compared with controls for ImPACT Visual Motor Speed and Reaction Time composites at all test intervals, and for the Purdue Pegboard tasks at the first two test intervals. Repeat measures comparisons across the three test intervals demonstrated differential learning patterns between groups on ImPACT Visual Memory, ImPACT Reaction Time, and Purdue Both tasks, suggestive of cognitive vulnerability in the rugby group. Overall, the results reveal deleterious cognitive performance in adult club level rugby players relative to equivalent non-contact sports controls. The finding serves to endorse indications from other studies that demonstrate persistent brain injury effects in association with long-term participation in a contact sport. Recommendations for further research and management of concussion in rugby players are discussed.

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A-38 A Different Approach for Examining Gender Differences on Computerized Neurocognitive Testing: Percentile Ranks Versus Composite Scores

Archives of Clinical Neuropsychology ◽

10.1093/arclin/acaa036.38 ◽

2020 ◽

Vol 35 (5) ◽

pp. 634-634

Author(s):

P Schatz ◽

K Slicer ◽

R J Elbin

Keyword(s):

Gender Differences ◽

Reaction Time ◽

Verbal Memory ◽

Visual Memory ◽

Motor Speed ◽

Age And Gender ◽

Visual Motor ◽

Gender Based ◽

And Gender ◽

Composite Scores

Abstract Objective ImPACT is a popular tool used to assess neurocognitive function after concussion. Age- and gender-based percentile ranks are provided as part of the ImPACT clinical report, but only raw composite scores are provided for research. Percentile ranks may provide an alternate look at gender differences on neurocognitive testing. We sought to compare the use of percentile ranks versus composite scores when comparing neurocognitive performance between male and females. Method Pre-season baseline data from 3,238 collegiate athletes were exported from a larger multi-site database, 1,714 male (53%) and 1,524 female (47%), ages 18–22 (Mean = 19.3, SD = 1.2). ImPACT composite scores were extracted (Verbal Memory, Visual Memory, Visual Motor Speed, Reaction Time) and Percentile Ranks were calculated using age- and gender-based reference tables in the ImPACT 2017–2012 Technical Manual. One-way analyses of variance (ANOVA) were conducted with gender as the IV and the four composite scores and their associated percentile ranks as the DVs. Bonferroni correction for 8 comparisons set the alpha level to p < .006. Results ANOVAs revealed a significant effect of gender on ImPACT Verbal Memory [F(1,3236) = 16.32, p < .001], Visual Memory [F(1,3236) = 66.06, p < .001], Visual Motor Speed [F(1,3236) = 15.61,p < .001] but not Reaction Time [F(1,3236) = 2.59, p = .11]. When using percentile ranks, ANOVAs revealed a significant effect of gender on only Visual Motor Speed [F(1,3236) = 31.07, p < .001], but not Verbal Memory [F(1,3236) = 2.43, p = .12], Visual Memory [F(1,3236) = 0.48, p = .49], or Reaction Time [F(1,3236) = 0.61, p = .44]. Conclusions Use of ImPACT Composite Scores in concussion research may exaggerate or inappropriately promote gender differences on computerized neurocognitive testing. Given that age- and gender-based normative data are available, use of percentile ranks is recommended.

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Disparities on Baseline Performance Using Neurocognitive and Oculomotor Clinical Measures of Concussion

The American Journal of Sports Medicine ◽

10.1177/0363546520946753 ◽

2020 ◽

Vol 48 (11) ◽

pp. 2774-2782 ◽

Cited By ~ 1

Author(s):

Jessica Wallace ◽

Ryan Moran ◽

Erica Beidler ◽

Jamie McAllister Deitrick ◽

James Shina ◽

...

Keyword(s):

High School ◽

African American ◽

Reaction Time ◽

Title I ◽

Verbal Memory ◽

Visual Memory ◽

Title I Schools ◽

Black African ◽

Motor Processing ◽

Baseline Performance

Background: Given the high participation of Black/African American individuals in high school sports, especially high-risk sports for concussion, it is important to note if racial and socioeconomic status (SES) differences exist in baseline performance on clinical measures of concussion. Purpose: To explore the association between race and SES on baseline concussion assessments of neurocognitive performance and oculomotor function in adolescent athletes. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: A total of 564 high school athletes (mean ± SD age, 15.33 ± 1.1 years) completed the baseline Immediate Post-Concussion Assessment and Cognitive Test and King-Devick (KD) battery before the start of their competitive season. Race was defined as either White/non-Hispanic or Black/African American. SES status was determined by whether the individual’s participating high school was a Title I or non–Title I school. A series of multivariable linear regression analyses were conducted to evaluate the association of computerized neurocognitive test scores (verbal memory, visual memory, motor processing speed, and reaction time), symptom severity scores, and KD scores by race and SES. Results: White/non-Hispanic individuals performed significantly better than Black/African American individuals on verbal memory ( P < .01), visual memory ( P < .01), visual motor processing speed ( P < .01), and reaction time ( P < .01) and had a lower symptom score ( P < .01). Regarding SES, individuals from non–Title I schools performed better on visual memory ( P = .05) and reaction time ( P = .02) than individuals from Title I schools. Examination of cumulative KD test reading time revealed that there was no association between race on baseline reading times ( P = .12). There was a significant association between cumulative reading time and SES ( P = .02). Individuals from non–Title I schools performed significantly faster than individuals from Title I schools on KD test time. Conclusion: Overall, race and SES influence neurocognitive and oculomotor concussion baseline performance in high school athletes. These findings add to the growing literature on the influence of race and SES on neurocognitive and oculomotor function baseline concussion assessments; they highlight the necessity for individualized concussion baseline measurements or race-specific normative reference values.

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Concussion History and Cognitive Function in a Large Cohort of Adolescent Athletes

The American Journal of Sports Medicine ◽

10.1177/0363546518798801 ◽

2018 ◽

Vol 46 (13) ◽

pp. 3262-3270 ◽

Cited By ~ 4

Author(s):

Kathryn M. Taylor ◽

Marianthi-Anna Kioumourtzoglou ◽

Jim Clover ◽

Brent A. Coull ◽

Jack T. Dennerlein ◽

...

Keyword(s):

High School ◽

Cognitive Function ◽

Verbal Memory ◽

Impulse Control ◽

Visual Memory ◽

Test Battery ◽

Cognitive Test ◽

Effect Estimate ◽

Cognitive Score ◽

And Performance

Background: The incidence of reported concussions in the adolescent population is increasing, yet research on the effects of concussions in this population is minimal and inconclusive. Purpose: To assess the association between concussion and performance on a cognitive test battery. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Using multivariate models, the authors assessed the association between concussion and performance on a cognitive test battery among 5616 high school and junior high school athletes. The researchers utilized a global cognitive score and scores for 5 domains: verbal memory, visual memory, visual motor, reaction time, and impulse control. Each cognitive score was converted to a z score with the mean and SD of the nonconcussed population. Results from each model were then interpreted as change in the standardized unit score. In the models, concussion was evaluated as ever having a concussion, number of concussions, time since last concussion, and age at first concussion. Results: Ever having a concussion was associated with a mean decrease of 0.11 standardized units (95% CI, −0.20 to −0.01) on the global cognitive score and lower scores in all cognitive domains. Each additional concussion was associated with lower scores on global cognitive function (effect estimate, −0.06; 95% CI, −0.11 to −0.02), verbal memory, visual memory, and impulse control. Concussion in early childhood was associated with lower global cognition (effect estimate, −0.05; 95% CI, −0.08 to −0.01), visual memory, and motor visual scores as compared with concussions in later childhood. The associations between time since last concussion and cognitive test scores were nonlinear, and on all tests, lower scores were observed even ≥1 year after the concussion. Conclusion: On the basis of objective performance metrics for cognitive function, concussions had a more persistent effect on cognitive function than previously thought. The age at which an individual has his or her first concussion may be an important factor in determining long-lasting cognitive effects.

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A-120 Comparison of Baseline and Post-Concussion ImPACT Performance in Spanish-English Bilingual and English Monolingual Athletes

Archives of Clinical Neuropsychology ◽

10.1093/arclin/acab062.138 ◽

2021 ◽

Vol 36 (6) ◽

pp. 1170-1170

Author(s):

Erick Rogers ◽

Hana Kuwabara ◽

Grace Goodwin ◽

Sara Moore ◽

Nia Hopkins ◽

...

Keyword(s):

Reaction Time ◽

Visual Memory ◽

Cognitive Testing ◽

English Speakers ◽

Future Research ◽

Motor Speed ◽

Linear Modeling ◽

Impact Performance ◽

Sport Type ◽

Visual Motor

Abstract Objective Research comparing English and Spanish administrations of Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) have consistently found differences in performance on various cognitive composites. Few studies have examined the effect of bilingualism on baseline and post-concussion assessments. This study examined whether monolingual English-speakers (MO) and bilingual Spanish/English speakers (BI) differed in cognitive performance at baseline (BL) and post-concussion (PC). Methods Participants were selected from a larger database of high school athletes administered ImPACT in English at BL and PC. Participants included 86 BI athletes (Mage = 14.53; 65.10% male) and 86 MO athletes matched on age, gender, sport type, and probable concussion as defined by number of PC follow-up assessments (PCF; 0 vs. ≥1). To examine group differences and changes over time in cognitive composites, a general linear modeling approach was used with language and PCF as between-subjects factors and time as a within-subjects factor. Results There was a significant Language x Time x PCF interaction for Visual Memory (VM), Visual Motor Speed (VMS), and Reaction Time (RT). On VM and RT, MO with multiple PCF performed the worst at PC, while MO with 0 PCF performed the best at PC. On VMS, BI with 0 PCF performed the worst at BL. Conclusion Visual memory and reaction time were less affected in bilingual compared to monolingual athletes with probable concussion. However, at baseline, bilingual athletes had slower visual motor speed compared to monolingual athletes. Future research should focus on how bilingualism may serve as both a protective and risk factor for cognitive functioning after probable concussion.

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