Investigating the Range of Symptom Endorsement at Initiation of a Graduated Return-to-Play Protocol After Concussion and Duration of the Protocol: A Study From the National Collegiate Athletic Association–Department of Defense Concussion, Assessment, Research, and Education (CARE) Consortium

2020 ◽  
Vol 48 (6) ◽  
pp. 1476-1484 ◽  
Author(s):  
Benjamin L. Brett ◽  
Katherine Breedlove ◽  
Thomas W. McAllister ◽  
Steven P. Broglio ◽  
Michael A. McCrea ◽  
...  
Keyword(s):  
Medical History ◽  
Symptom Severity ◽  
National Collegiate Athletic Association ◽  
Assessment Tool ◽  
Cox Regression ◽  
Hazard Ratio ◽  
Return To Play ◽  
Active Recovery ◽  
Level Of Evidence ◽  
Severity Scores

Background: Organizations recommend that athletes should be asymptomatic or symptom-limited before initiating a graduated return-to-play (GRTP) protocol after sports-related concussion, although asymptomatic or symptom-limited is not well-defined. Hypotheses: (1) There will be a range (ie, beyond zero as indicator of “symptom-free”) in symptom severity endorsement when athletes are deemed ready to initiate a GRTP protocol. (2) Baseline symptom severity scores and demographic/preinjury medical history factors influence symptom severity scores at the commencement of the GRTP protocol. (3) Greater symptom severity scores at GRTP protocol initiation will result in longer protocol duration. (4) Symptom severity scores will not differ between those who did and did not sustain a repeat injury within 90 days of their initial injury. Study Design: Cohort study; Level of evidence, 2. Methods: Across 30 universities, athletes (N = 1531) completed assessments at baseline and before beginning the GRTP protocol, as determined by local medical staff. Symptom severity scores were recorded with the symptom checklist of the Sport Concussion Assessment Tool–3rd Edition. Nonparametric comparisons were used to examine the effect of medical, demographic, and injury factors on symptom endorsement at GRTP protocol initiation, as well as differences in symptom severity scores between those who did and did not sustain a repeat injury within 90 days. A Cox regression was used to examine the association between symptom severity scores at GRTP protocol initiation and protocol duration. Results: Symptom severity scores at the time when the GRTP protocol was initiated were as follows: 0 to 5 (n = 1378; 90.0%), 6 to 10 (n = 76; 5.0%), 11 to 20 (n = 42; 3.0%), and ≥21 (n = 35; 2.0%). Demographic (sex and age), medical (psychiatric disorders, attention-deficit/hyperactivity disorder, learning disorder), and other factors (baseline symptom endorsement and sleep) were significantly associated with higher symptom severity scores at the GRTP initiation ( P < .05). The 4 GRTP initiation time point symptom severity score groups did not significantly differ in total time to unrestricted RTP, χ2(3) = 1.4; P = .73. When days until the initiation of the GRTP protocol was included as a covariate, symptom severity scores between 11 and 20 ( P = .02; hazard ratio = 1.44; 95% CI, 1.06-1.96) and ≥21 ( P < .001; hazard ratio = 1.88; 95% CI, 1.34-2.63) were significantly associated with a longer GRTP protocol duration as compared with symptom severity scores between 0 and 5. Symptom severity scores at GRTP initiation did not significantly differ between those who sustained a repeat injury within 90 days and those who did not ( U = 29,893.5; P = .75). Conclusion: A range of symptom severity endorsement was observed at GRTP protocol initiation, with higher endorsement among those with higher baseline symptom endorsement and select demographic and medical history factors. Findings suggest that initiation of a GRTP protocol before an absolute absence of all symptoms is not associated with longer progression of the GRTP protocol, although symptom severity scores >10 were associated with longer duration of a GRTP protocol. Results can be utilized to guide clinicians toward optimal GRTP initiation (ie, balancing active recovery with avoidance of premature return to activity).

scholarly journals Effect of Head Impact Exposures on Changes in Cognitive Testing

2018 ◽  
Vol 6 (3) ◽  
pp. 232596711876103 ◽  
Author(s):  
Eleni Diakogeorgiou ◽  
Theresa L. Miyashita
Keyword(s):  
Reaction Time ◽  
National Collegiate Athletic Association ◽  
Assessment Tool ◽  
Vital Signs ◽  
Head Impact ◽  
Cognitive Testing ◽  
Repeated Impact ◽  
Level Of Evidence ◽  
Head Impacts ◽  
Significant Difference

Background: Gaining a better understanding of head impact exposures may lead to better comprehension of the possible effects of repeated impact exposures not associated with clinical concussion. Purpose: To assess the correlation between head impacts and any differences associated with cognitive testing measurements pre- and postseason. Study Design: Case-control study; Level of evidence, 3. Methods: A total of 34 National Collegiate Athletic Association Division I men’s lacrosse players wore lacrosse helmets instrumented with an accelerometer during the 2014 competitive season and were tested pre- and postseason with the Sport Concussion Assessment Tool (SCAT 3) and Concussion Vital Signs (CVS) computer-based neurocognitive tests. The number of head impacts >20 g and results from the 2 cognitive tests were analyzed for differences and correlation. Results: There was no significant difference between pre- and postseason SCAT 3 scores, although a significant correlation between pre- and postseason cognitive scores on the SCAT 3 and total number of impacts sustained was noted ( r = –0.362, P = .035). Statistically significant improvements on half of the CVS testing components included visual reaction time ( P = .037, d = 0.37), reaction time ( P = .001, d = 0.65), and simple reaction time ( P = .043, d = 0.37), but no correlation with head impacts was noted. Conclusion: This study did not find declines in SCAT 3 or CVS scores over the course of a season among athletes who sustained multiple head impacts but no clinical concussion. Thus, it could not be determined whether there was no cognitive decline among these athletes or whether there may have been subtle declines that could not be measured by the SCAT 3 or CVS.

Concussion symptomology and recovery in children and adolescents with pre-existing anxiety

2020 ◽  
Vol 91 (10) ◽  
pp. 1060-1066 ◽  
Author(s):  
Alexia K Martin ◽  
Ashley J Petersen ◽  
Heather W Sesma ◽  
Mary B Koolmo ◽  
Katherine M Ingram ◽  
...  
Keyword(s):  
Anxiety Disorders ◽  
Children And Adolescents ◽  
Symptom Severity ◽  
Cox Regression ◽  
Symptom Trajectories ◽  
Severity Scores ◽  
Symptom Load ◽  
Prolonged Recovery ◽  
Symptom Recovery ◽  
Age And Sex

ObjectiveTo examine pre-existing anxiety disorders as a risk factor for increased concussion symptomology and prolonged recovery in children and adolescents.MethodsIn this retrospective cohort study, we abstracted medical record data for 637 children/adolescents (5–17 years) presenting to three tertiary concussion clinics between April 2018 and March 2019. Primary outcomes were mean concussion symptom and vision symptom severity scores measured at clinic visits. Linear mixed-effects regression models were employed to investigate differences in average symptom load, vision symptom score and symptom recovery trajectories across anxiety strata, adjusted for random effects (time), age and sex. Secondary outcomes, time to concussion symptom recovery and time to return to academics and sports, respectively, were examined via log-rank tests and multivariable Cox regression.ResultsAmong 637 eligible concussion patients, 155 (24%) reported pre-existing anxiety. On average, patients with anxiety reported an additional 2.64 (95% CI 1.84 to 3.44) concussion symptoms and 7.45 (95% CI 5.22 to 9.68) higher vision symptom severity scores throughout recovery versus those without, after adjusting for age and sex. There was no evidence that concussion or vision symptom trajectories varied over time between those with/without anxiety after accounting for baseline dissimilarities in symptom scores (all pinteraction >0.05). Anxiety was significantly associated with delayed symptom recovery (adjusted HR 3.34, 95% CI 2.18 to 5.12), return to school (adjusted HR 2.01, 95% CI 1.59 to 2.53) and return to physical activity (adjusted HR 1.88, 95% CI 1.49 to 2.37).ConclusionsPre-existing anxiety disorders were associated with more severe symptomology and prolonged recovery after concussion in children and adolescents. These results can be referenced by providers to manage patients’ recovery expectations.

scholarly journals Symptoms and Vestibular Screening in Pediatric Concussion

2019 ◽  
Vol 34 (5) ◽  
pp. 763-763
Author(s):  
V Fazio Sumrok ◽  
N Kegel ◽  
N Blaney ◽  
A Colorito ◽  
K Viggiano ◽  
...  
Keyword(s):  
Symptom Severity ◽  
Assessment Tool ◽  
Descriptive Statistics ◽  
Population Characteristics ◽  
Return To Play ◽  
Ocular Motor ◽  
Clinical Assessments ◽  
Pediatric Concussion ◽  
Sport Concussion ◽  
Symptom Ratings

Abstract Purpose Purpose: Children under age 11 participate in sports with a risk of concussion. Tools are limited for assessment. Clinicians rely on exam for management and return to play. Researchers have started assessment adaptation: Sport Concussion Assessment Tool-5 Child (SCAT-5 Child) (Davis et al., 2017) and Vestibular/Ocular Motor Screening (VOMS) (Mucha et al., 2014). The purpose of this study was to compare scores on components of the SCAT-5 Child, Pediatric VOMS, and SCAT-5 Parent. Methods Method: Participants included 59 children (M-33/26-F) aged 5-10 (7.50±1.17) within 30 days from concussion. Participants completed the SCAT-5 Child, SCAT-5 parent, and Pediatric VOMS at all visits. Descriptive statistics were used to calculate population characteristics. Paired t-tests were used to compare measures. Results Results: 42.6% (n=25) reported symptoms on VOMS at first visit. Only 10.0% reported symptom on VOMS (p=.003) at second visit. VOMS scores were improved across visits (p=.003). Participants reported decreases in symptom severity (p<.001) and number (p<.001) on the SCAT-5 Child across visits. Parents reported decreases in symptom severity (p=.009) and number (p=.005). Both children (p=.001) and parents (p=.001) reported significant increases in BTN% across visits. Participants and parent reported similar scores in number of symptoms, severity, and BTN% on the SCAT-5 at both visits. Conclusion Conclusions: Results demonstrate the Pediatric VOMS assessment is useful to evaluate vestibular/ocular impairment. The SCAT-5 Child and Parent do not evaluate these areas. Symptom ratings decrease and are similar between parent and child, indicating this measure remains consistent across reporters. Findings highlight needed expansion of clinical assessments and research in pediatrics.

scholarly journals Influence of Self-reported Fatigue and Sex on Baseline Concussion Assessment Scores

2019 ◽  
Vol 7 (1) ◽  
pp. 232596711881751 ◽  
Author(s):  
Patricia R. Combs ◽  
Cassie B. Ford ◽  
Kody R. Campbell ◽  
Kevin A. Carneiro ◽  
Jason P. Mihalik
Keyword(s):  
Symptom Severity ◽  
Female Athletes ◽  
Vital Signs ◽  
Current Data ◽  
Neurological Deficits ◽  
Test Accuracy ◽  
Level Of Evidence ◽  
Cross Sectional ◽  
Assessment Scores ◽  
Severity Scores

Background: Baseline concussion assessments are advocated to provide an objective preinjury point of comparison for determining the extent of postconcussion neurological deficits and to assist with return-to-activity decision making. Many factors, including testing environment, proctor availability, and testing group size, can influence test accuracy and validity; however, it is unknown how self-reported fatigue affects test scores. Purpose: To investigate the influence of self-reported fatigue and patient sex on baseline concussion assessment scores. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Participants included 494 healthy Division I college student-athletes (221 women, 273 men; mean ± SD age, 20.0 ± 1.3 years). During preseason baseline testing, participants were asked to rate their fatigue on a scale from 0 to 100 based on how they normally feel and function each day (0, completely exhausted; 100, completely awake and alert). Each participant then completed a multimodal baseline concussion assessment, including a graded symptom checklist (number of symptoms endorsed and total symptom severity score), Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), and CNS Vital Signs computerized neurocognitive testing. Multiple linear regressions tested whether self-reported fatigue and sex predicted baseline concussion examination scores. Results: Athletes with higher self-reported fatigue levels (ß = –0.014, P < .01) and female athletes (ß = –0.216, P < .01) reported more total symptoms. Being male (ß = 0.856, P < .01) increased the likelihood of endorsing zero symptoms versus any symptoms by a factor of 2.40. Women also had significantly higher SAC scores (ß = 0.569, P < .001), BESS scores (ß = –2.747, P < .001), and CNS Vital Signs summary scores (ß = 4.506, P < .001). SAC, BESS, and CNS Vital Signs scores were not predicted by fatigue level ( P > .05). Conclusion: Female athletes and fatigued athletes endorsed more symptoms and higher symptom severity at baseline. Using total symptom endorsement and total symptom severity scores as part of the postinjury management is a common practice. The current data suggest that levels of reported exhaustion can influence concussion assessment scores meant to represent a healthy baseline and likely would interfere with postinjury assessment scores.

scholarly journals Lower Reinjury Rate with a Coach-Controlled Rehabilitation Program in Amateur Male Soccer

2007 ◽  
Vol 35 (9) ◽  
pp. 1433-1442 ◽  
Author(s):  
Martin Hägglund ◽  
Markus Walden ◽  
Jan Ekstrand
Keyword(s):  
Cox Regression ◽  
Controlled Trial ◽  
Intervention Group ◽  
Rehabilitation Program ◽  
Return To Play ◽  
Control Group ◽  
Level Of Evidence ◽  
Cox Regression Analysis ◽  
Limb Injuries ◽  
Soccer Teams

Background Soccer injuries are common, and athletes returning to play after injury are especially at risk. Few studies have investigated how to prevent reinjury. Hypothesis The rate of reinjury is reduced using a coach-controlled rehabilitation program. Study Design Randomized controlled trial; Level of evidence, 1. Methods Twenty-four male amateur soccer teams were randomized into an intervention (n = 282) and control group (n = 300). The intervention was implemented by team coaches and consisted of information about risk factors for reinjury, rehabilitation principles, and a 10-step progressive rehabilitation program including return to play criteria. During the 2003 season, coaches reported individual exposure and all time loss injuries were evaluated by a doctor and a physiotherapist. Four teams (n = 100) withdrew from the study after randomization, leaving 10 teams with 241 players for analysis in both groups. Results There were 90 injured players (132 injuries) in the intervention group, and 10 of these (11%) suffered 14 reinjuries during the season. In the control group, 23 of 79 injured players (29%) had 40 recurrences (134 injuries). A Cox regression analysis showed a 66% reinjury risk reduction in the intervention group for all injury locations (hazard ratio [HR] 0.34, 95% confidence interval [CI] 0.16-0.72, P = .0047) and 75% for lower limb injuries (HR 0.25, 95% CI 0.11-0.57, P < .001). The preventive effect was greatest within the first week of return to play. Injured players in the intervention group complied with the intervention for 90 of 132 injuries (68%). Conclusion The reinjury rate in amateur male soccer players was reduced after a controlled rehabilitation program implemented by coaches.

Outcomes of NCAA Defensive Football Players Following Achilles Tendon Repair

2020 ◽  
Vol 41 (4) ◽  
pp. 398-402 ◽  
Author(s):  
Patrick M. Wise ◽  
Jesse L. King ◽  
Christopher M. Stauch ◽  
Kempland C. Walley ◽  
Michael C. Aynardi ◽  
...  
Keyword(s):  
Achilles Tendon ◽  
National Football League ◽  
National Collegiate Athletic Association ◽  
Tendon Repair ◽  
High Rate ◽  
Performance Criteria ◽  
Return To Play ◽  
Football Players ◽  
Level Of Evidence ◽  
Significant Drop

Background: The incidence of Achilles ruptures has been on the rise in National Collegiate Athletic Association (NCAA) football players, but the career impact of this injury is not fully understood. In this study, we analyzed a large series of Achilles tendon injuries in NCAA Football Bowl Subdivision (FBS) defensive football players who required repair in order to determine their return to play, performance, and career outcomes afterward. Methods: FBS defensive football players who required Achilles repair from 2010 to 2016 were identified. The return to play of the eligible underclassmen athletes was then determined and the preinjury and postoperative performances of players who met criteria were compared with matched controls. The number of underclassmen who went on to participate in the National Football League (NFL) Combine or play in at least 1 NFL game was also determined and compared with controls. Results: Fifty-seven total Achilles ruptures were identified, 40 of which occurred in underclassmen, who returned at a rate of 92.5%. Of the players who met performance criteria, only defensive backs differed from matched controls in terms of solo tackling ( P = .025) and total tackling (P = .038), while still increasing compared with preoperative performance. Only 5.0% of underclassmen performed at NFL Combine and only 7.5% competed in at least 1 NFL game (20.0% and 21.3%, respectively, for matched controls). Conclusion: Defensive FBS players returned at a high rate following Achilles rupture and did not seem to experience a significant drop-off in performance upon return. An Achilles rupture did appear to impact their chances of playing professionally in the future, however. Level of Evidence: Level III, retrospective comparative study.

Role of Postoperative Patient-Reported Outcomes to Predict Ankle Arthroplasty and Arthrodesis Revision

2019 ◽  
Vol 41 (1) ◽  
pp. 10-16 ◽  
Author(s):  
Sameer Desai ◽  
Jason M. Sutherland ◽  
Alastair Younger ◽  
Murray Penner ◽  
Andrea Veljkovic ◽  
...  
Keyword(s):  
Confidence Interval ◽  
Patient Reported Outcomes ◽  
Cox Regression ◽  
Ankle Arthrodesis ◽  
Hazard Ratio ◽  
Total Ankle Arthroplasty ◽  
Level Of Evidence ◽  
Ankle Arthroplasty ◽  
Patient Reported

Background: Patient-reported outcomes are becoming common for measuring patient-centric outcomes in surgery. However, there is little known about the relationship between postoperatively collected patient-reported outcomes and objective clinical outcomes. The objective of this study was to measure whether postoperative Ankle Osteoarthritis Scale (AOS) values were associated with risk of revision among patients having ankle arthrodesis or total ankle arthroplasty for treatment of symptomatic end-stage ankle arthritis. Methods: This is a retrospective analysis of a longitudinal cohort of ankle arthrodesis and total ankle arthroplasty patients. A single center recruited patients between 2003 and 2013 and follow-up was at least 4 years. Patients completed the AOS preoperatively and annually following surgery. An extended Cox regression model incorporating time-varying AOS values was used to model risk of failure. A total of 336 patients and 348 ankles were included, representing 139 ankle arthrodesis procedures and 209 total ankle arthroplasties. Results: The median follow-up time for revisions was 8.2 years and 46 patients had a revision. Higher values of patients’ AOS scores in the postoperative period were associated with a higher likelihood of revision (hazard ratio, 1.04 per 1-point increase; 95% confidence interval, 1.03-1.05). Ankle arthrodesis was associated with a reduced risk of revision compared with ankle fusion (hazard ratio, 0.12; 95% confidence interval, 0.03-0.49). Conclusion: This study showed that persistent pain and poor function after fusion or replacement surgery, as measured by elevated values of the AOS, were associated with higher risk of further surgery. Level of Evidence: Level III, retrospective cohort study.

scholarly journals Descriptive Values for Dancers on Baseline Concussion Tools

2017 ◽  
Vol 52 (11) ◽  
pp. 1035-1040 ◽  
Author(s):  
Lauren McIntyre ◽  
Marc Campo
Keyword(s):  
Symptom Severity ◽  
Scoring System ◽  
Assessment Tool ◽  
Standardized Assessment ◽  
Normative Values ◽  
Professional Status ◽  
Individualized Care ◽  
Severity Scores ◽  
Balance Error Scoring System ◽  
Balance Error

Context: Capturing baseline data before a concussion can be a valuable tool in individualized care. However, not all athletes, including dancers, have access to baseline testing. When baseline examinations were not performed, clinicians consult normative values. Dancers are unique athletes; therefore, describing values specific to dancers may assist those working with these athletes in making more informed decisions.Objective: To describe values for key concussion measures of dancers. Our secondary aim was to examine whether differences existed between sexes and professional status. Finally, we explored factors that may affect dancers' scores.Design: Cross-sectional study.Setting: Professional dance companies and a collegiate dance conservatory.Patients or Other Participants: A total of 238 dancers (university = 153, professional = 85; women = 171; men = 67; age = 21.1 ± 4.8 years).Main Outcome Measure(s): We calculated the total symptom severity from the Sport Concussion Assessment Tool–3rd edition; the Standardized Assessment of Concussion score; the modified Balance Error Scoring System score; and the King-Devick score for each participant. Group differences were analyzed with Mann-Whitney or t tests, depending on the data distribution. We used bivariate correlations to explore the effects of other potential influencing factors.Results: Participants demonstrated the following baseline outcomes: symptom severity = 16.6 ± 12.8; Standardized Assessment of Concussion = 27.5 ± 1.8; modified Balance Error Scoring System = 3.2 ± 3.1 errors; and King-Devick = 41.5 ± 8.2 seconds. A Mann-Whitney test revealed differences in King-Devick scores between female (40.8 ± 8.0 seconds) and male (43.4 ± 8.4 seconds) dancers (P = .04). An independent-samples t test also demonstrated a difference in modified Balance Error Scoring System scores between female (2.95 ± 3.1 errors) and male (3.8 ± 3.1 errors) dancers (P = .02). Age, hours of sleep, height, and history of concussion, depression, or injury did not display moderate or strong associations with any of the outcome measures.Conclusions: Dancers' symptom severity scores appeared to be higher than the values reported for other athletes. Additional studies are needed to establish normative values and develop a model for predicting baseline scores.

scholarly journals SCAT5 vs. SCAT3 Symptom Reporting Differences and Convergent Validity in Collegiate Athletes

2019 ◽  
Vol 35 (3) ◽  
pp. 291-301 ◽  
Author(s):  
Breton M Asken ◽  
Zachary M Houck ◽  
Russell M Bauer ◽  
James R Clugston
Keyword(s):  
Symptom Severity ◽  
Convergent Validity ◽  
Assessment Tool ◽  
Rank Order ◽  
Collegiate Athletes ◽  
Brief Symptom Inventory ◽  
Targeted Interventions ◽  
Adjustment Difficulties ◽  
Symptom Evaluation ◽  
Severity Scores

Abstract Objective The Sport Concussion Assessment Tool (SCAT), fifth Edition, Symptom Evaluation (S5SE) differs from previous versions by having examinees report trait (i.e. “typical” feelings) as opposed to state (i.e., “how you feel right now”) concussion-like symptoms at baseline. This study assessed differences among, and convergent validity of, scores on the S5SE, SCAT3 Symptom Evaluation (S3SE), and the Brief Symptom Inventory (BSI-18). Methods A total of 113 University of Florida varsity athletes completed symptom questionnaires on the same day in a counterbalanced administration. The final sample consisted of 94 participants (mean age ± SD = 18.4 ± 0.8 years, 57% male, 65% white) from 17 sports. We assessed convergent validity using Spearman rank-order correlations. Within-participant differences were analyzed with Wilcoxon Signed-Rank tests. We qualitatively described free-response answers to the S5SE question that asks, “if not feeling 100%, why?”. Results S5SE total severity score demonstrated adequate convergent validity with both the S3SE (rho = .407, p &lt; .001) and BSI-18 (rho = .432, p &lt; .001). Domain-specific analyses indicated variable convergent validity (rho &lt; 0.4 to rho &gt; 0.6). Severity scores did not differ between the S3SE and S5SE (p = .500), but 24.5% of participants reported S3SE &gt; S5SE and 34.0% S5SE &gt; S3SE. Three themes emerged from qualitative examination of reasons for “not feeling 100%”: (1) tiredness/sleep, (2) adjustment difficulties, and (3) academic/athletic stress. Conclusions Adequate convergent validity exists between SCAT5 and SCAT3 symptom severity in collegiate athletes. However, most examinees report different baseline symptom severity when asked to describe their trait (S5SE) versus state symptoms (S3SE). Clinicians should consider using the new SCAT5 Symptom Evaluation as a screening tool for identifying otherwise healthy or “undiagnosed” individuals who would benefit from targeted interventions.

Multiple Concussions Increase Odds and Rate of Lower Extremity Injury in National Collegiate Athletic Association Athletes After Return to Play

2019 ◽  
Vol 47 (13) ◽  
pp. 3256-3262 ◽  
Author(s):  
Garrett K. Harada ◽  
Caitlin M. Rugg ◽  
Armin Arshi ◽  
Jeremy Vail ◽  
Sharon L. Hame
Keyword(s):  
Lower Extremity ◽  
National Collegiate Athletic Association ◽  
Collegiate Athletes ◽  
Neuromuscular Control ◽  
The United States ◽  
Return To Play ◽  
Lower Extremity Injury ◽  
Rank Test ◽  
Extremity Injury ◽  
Level Of Evidence

Background: Concussion in collegiate athletics is one of the most prevalent sport-related injuries in the United States, with recent studies suggesting persistent deficits in neuromuscular control after a concussion and an associated increase in risk of lower extremity injury. Purpose: To expand on the relationship between concussion and lower extremity injury by examining the effect of multiple concussions (MC) on rate and odds of future lower extremity injury in collegiate athletes after return to play (RTP) compared with matched controls. Study Design: Cohort study; Level of evidence, 3. Methods: From 2001 to 2016, 48 National Collegiate Athletic Association Division I athletes sustaining multiple concussions at a single institution were identified. Athletes with multiple concussions (MC) were matched directly to athletes with a single concussion (SC) and to athletes with no concussion history (NC) by sex, sport, position, and games played. Incidence of, time to, and location of lower extremity injury were recorded for each group after RTP from their first reported concussion until completion of their collegiate career. Logistic regression was used to analyze odds ratios (ORs) for sustaining lower extremity injury, whereas time to injury was summarized by use of Kaplan-Meier curves and log rank test analysis. Results: The incidence of lower extremity injury after RTP was significantly greater ( P = .049) in the MC cohort (36/48, 75%) than in SC athletes (25/48 = 52%) and NC athletes (27/48 = 56%). Similarly, odds of lower extremity injury were significantly greater in the MC cohort than in SC athletes (OR, 3.00; 95% CI, 1.26-7.12; P = .01) and NC athletes (OR, 1.66; 95% CI, 1.07-2.56; P = .02). Time to lower extremity injury was significantly shorter in the MC group compared with matched controls ( P = .01). No difference was found in odds of lower extremity injury or time to lower extremity injury between SC and NC athletes. Conclusion: Collegiate athletes with MC were more likely to sustain a lower extremity injury after RTP in a shorter time frame than were the matched SC and NC athletes. This may suggest the presence of a cohort more susceptible to neuromuscular deficits after concussion or more injury prone due to player behavior, and it may imply the need for more stringent RTP protocols for athletes experiencing MC.

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