Computerized neuropsychological testing was used to assess 25.7% of concussions and correlated with the timing of return to play. Although it is now recognized as one of “the cornerstones of concussion evaluation,”3,20
routine neuropsychological testing in the setting of sports-related concussion is a relatively new concept.1,9
This is the first study, of which we are aware, to query the use of computerized neuropsychological testing in high school athletes using a large, nationally representative sample. Interestingly, those injured athletes evaluated with computerized neuropsychological testing were less likely to return to play on the same day, and less likely to return to play within a week of their injury. There are several possible explanations for this finding. It is possible that, despite reporting symptom resolution, these athletes had deficits in their neurocognitive function, adding further evidence to the benefit of neuropsychological testing in the management of sport-related concussion. Several previous studies have shown such a benefit.4,10,17,29
However, athletes’ neuropsychological test scores were not collected. Thus, this analysis could not be performed with the current data. Another possibility is that clinicians who use computerized neuropsychological testing are more conservative in their management, and thus are less likely to return athletes to play on the same day or within the same week as their injury. It is also possible that athletes deemed to have more severe injuries were more likely to receive neuropsychological testing.
Injured football players were less likely to have computerized neuropsychological testing during their evaluation than those athletes injured in other sports. Again, this may be interpreted in several different ways. Perhaps schools with limited financial resources are more likely to have football programs, given its popularity, than they are to have other sports. Similarly, they may not have the resources to purchase computerized test programs. Another possibility is that football programs may be reluctant to use computerized neuropsychological testing in the assessment of a concussion for fear that athletes may miss more playing time.
As with other studies, we found that most sport-related concussions sustained by high school athletes occur during games as opposed to practice,16
and headache is the most common symptom of concussion.14,16
Loss of consciousness is uncommon, occurring in less than 5% of concussions in our study. This is lower than reported by other investigators who examined high school athletes. Field et al11
noted loss of consciousness in 11% of high school athletes sustaining a sport-related concussion. In a different study of high school athletes, Collins et al8
reported 10% of concussed athletes experienced a loss of consciousness. One possible explanation for this difference in the percentage of concussions involving a loss of consciousness is a change over time in the understanding of sport-related concussion. Significant misunderstandings of this injury have been documented in youth coaches as recently as 2007, with 42% of coaches believing a concussion only occurs when an athlete loses consciousness.28
However, in a later study of parents of young rugby players published in 2009, 95% reported that a player need not be “knocked out” to have been concussed.27
The percentage of diagnosed concussions associated with a loss of consciousness is likely decreasing, as the athletic community learns that loss of consciousness is not necessary for concussion diagnosis.
Although the mechanism of concussion has been recorded in various sports such as soccer2
and American football,15,18,30
this is the first study we are aware of to record the specific mechanisms of injury in a large, representative, national sample of American high school athletes in various sports. We found that contact between 2 players’ heads, or between the head of the injured athlete and a different body part of another athlete, accounted for a much greater number of injuries than contact between the injured athlete’s head and the playing surface. Of particular interest is that, of the 101 concussions that occurred during soccer, none were due to contact with the ball when the athlete was purposefully heading the ball.
It has been suggested that younger athletes have longer recovery times than older athletes. Studies performed in high school athletes have revealed longer recovery times than those of college or professional athletes.11,17
Guskiewicz et al14
described symptom duration in National Collegiate Athletic Association football players, reporting that 88% had resolution of their symptoms within 1 week. In our study, 15.1% of students remained symptomatic for longer than 7 days, while 1.5% had symptoms lasting longer than 1 month. Within the limited age range of the high school population, significant associations between age and duration of symptoms were not seen in these 544 injuries. Although those athletes younger than 15 years of age appeared to be more likely to have symptoms lasting longer than 1 month, this finding did not reach statistical significance (P
This study has limitations, in addition to those mentioned in the above discussion. First, data are entered by athletic trainers working in the field at their respective institutions. Athletic trainers have their own individual threshold for diagnosis, management strategies, and return-to-play protocols. Therefore, the definition of “concussion,” the determination of recovery, and the approach to assessment and management could not be standardized for study purposes. As a result, however, the data represent what is actually occurring on a national level in US high schools. Second, as noted above, the neuropsychological test scores were not collected; thus, associations between neuropsychological testing, sport played, and return to play cannot be definitively interpreted.