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Multiple Concussion History Linked to Continuing Symptoms

"Particular care" in management recommended

High school athletes with a history of two or more concussions consistently report more concussion-related symptoms such as headache, balance problems, and dizziness than peers with no concussion history, finds a study to be published in the journal Neurosurgery.

Active brain

The study is the first to report increased concussion-related symptoms in otherwise healthy high school athletes on the basis of multiple previous concussions.

The "current findings raise the possibility that the process of cognitive impairment and symptom destabilization related to post-concussion syndrome in adult athletes exposed to multiple concussions may start as early as the adolescent years," writes Philip Schatz, Ph. D., lead author of the study and a professor in the Department of Psychology at St. Joseph's University in Philadelphia. 


On the basis of their self-reported history of concussion, high school athletes from Michigan, New Jersey, and Pennsylvania were assigned by researchers to three groups (none, one previous concussion, two or more previous concussion) . Of the athletes in the "one previous" and "two or more previous" groups, none had sustained a concussion within the previous 4 months.

The athletes were then asked to report and rate any concussion-related symptoms they were currently experiencing based on the 22-item Post-Concussion Symptom Scale (PCSS) checklist, and to choose the number on a 0-6-point scale that best described the way they were feeling that day, with "0" denoting no symptoms and 1-6 denoting mild-to-severe symptoms and with symptoms further categorized into four "clusters" (physical, emotional, cognitive, and sleep).

The study found that high school athletes with a history of two or more concussions:

  • reported experiencing headaches, balance problems, and dizziness at higher rates than their peers with a history of one or no concussions;
  • reported higher rates of nausea and fatigue than those with no concussion history;  
  • were significantly more likely than athletes with one or no previous concussion to report symptoms in the:
    • physical symptom cluster (e.g. headache, nausea, vomiting, balance problems, dizziness, visual problems, fatigue, sensitivity to light, and sensitivity to noise);
    • cognitive symptom cluster (e.g. feeling mentally "foggy"; feeling slowed down, difficulty concentrating, difficulty remembering); and
    • sleep symptom cluster (e.g. drowsiness, sleeping less than usual, sleeping more than usual, trouble falling asleep)
  • were not significantly different in terms of reporting of symptoms in the emotional symptom cluster (e.g. irritability, sadness, more emotional, nervousness).

"Given that athletes with a history of multiple concussions are more likely to report concussion-related symptoms at baseline, and these athletes were more likely to have sought treatment (e.g. for headaches), the current study may reflect a combination of enduring symptoms and increased sensitivity to these symptoms," the study states. 

Because "a number of factors may effect symptom scores,"  said Dr. Robin Karpf, Medical Director at The Lawrenceville School, told MomsTeam, "further studies will be necessary to determine the risk of injury goingforward, but the study supports the more conservative approach" for athletes with a history of multiple concussions that she currently takes at the New Jersey school, and than typical under the concussion grading and return to play guidelines in use in the 1990s.  An athlete at the New Jersey school who sustains a second concussion in the same season, for instance, is "done for the season," she says.  "If that athlete suffers another concussion the next season, particularly where there are a lot of symptoms which take a month or more to resolve, I am reluctant to clear the athlete for a return to sports in less than six months." 

Potential management and policy implications

Noting earlier studies suggesting that the brains of younger athletes may be more vulnerable to concussion, that concussion in youth have long-lasting effects, and finding that high school athletes recover more slowly from concussion than collegiate or professional athletes, Dr. Schatz suggested that the implications of the study might extend beyond management of youth athletes with a history of concussion and have broader policy implications: "Coaches, parents, athletic trainers, school physicians, and all individuals involved in the organization, implementation, and supervision of high school and youth athletes may need to consider policy and practice revisions to insure [their] long-term safety. ..." 

While believing that imposing widespread restrictions on athletic participation for high school athletes with a history of multiple concussions based solely on the results of the study "may [be] premature,"  the study's authors recommended that such athletes be treated with "particular care." 

Our findings, said Dr. Schatz, should not only "serve as a caution for parents, coaches, and sports medicine personnel supervising high school and other youth athletes with a history of concussion" but as providing support for "the recent surge in advocacy on state and federal governmental levels to establish youth concussion management programs and to better regulate the rules of youth sports."

Source:  Schatz P, Moser RS, Covassin T, Karpf R.  Early Indicators of Enduring Symptoms in High School Athletes with Multiple Previous Concussions.  Neurosurgery 2011: 000 (in process).

Posted March 4, 2011