The Role of Reported Affective Symptoms and Anxiety in Recovery Trajectories After Sport-Related Concussion

Abstract

Background: There is growing awareness and clinical interest in athletes with affective symptoms after sport-related concussion (SRC), as these symptoms may contribute to overall symptoms and represent a modifiable risk factor of longer recovery. However, evidence of their effects on the entire return-to-play (RTP) trajectory, particularly among women and men, is limited. Purpose/Hypothesis: To examine the relationship between affective symptom reporting and RTP progression after SRC among a cohort of Division 1 student-athletes. We hypothesized that those endorsing affective symptoms, specifically nervous-anxious symptoms, spend more time in RTP progression and recovery. Study Design: Cohort study; Level of evidence, 3. Methods: Using SRC data from the Ivy League–Big Ten Epidemiology of Concussion Study among varsity athletes through February 2020, we identified the 4 affective symptoms from the Sport Concussion Assessment Tool symptom inventory. We modeled the relationship between a 4-category affective symptom variable and time to symptom resolution, RTP, and RTP progression, adjusting for nonaffective symptom prevalence and concussion history. Cox regressions were used to estimate hazard ratios for time to event outcomes, and linear regressions were used to evaluate mean differences for continuous outcomes. Results: Among 2077 student-athletes (men, 63.5%) with SRC symptoms, affective symptom prevalence was 47.6% and 44.3% in women and men, respectively, and nervous-anxious prevalence was 24.2% and 22.5%, respectively. When comparing women with and without co-occurring affective symptoms, rates of symptom resolution and RTP were significantly lower in those with affective symptoms, and women with nervous-anxious symptoms spent significantly longer in RTP progression. When comparing men with and without co-occurring affective symptoms, rates of symptom resolution and RTP were significantly lower in those with co-occurring affective symptoms, and affective symptoms were not associated with time in RTP progression. Conclusion: Student-athletes with affective symptoms and nervous-anxious symptoms exhibited delayed clinical recovery and RTP timelines, particularly for time in RTP. Symptom prevalence and concussion history contributed to this; however, unmeasured confounding remains, as indicated by the poor model fit. This study motivates future work to explore affective symptoms and RTP timelines, considering anxiety and risk/protective factors over time.

Influence of Personal and Injury-Related Factors Predicting Deficits in Quality of Life Domains Among Pediatric Athletes: Findings From the Sport Concussion Outcomes in Pediatrics Study

“…43 Lower QoL related to anxiety and depressive symptoms suggests ongoing mental health concerns, which have also been associated with a persistent symptoms. 44–46 Sleep disruptions are also common after concussion and can influence recovery, 47,48 perhaps contributing to worse initial perceptions of fatigue, suggesting this domain of the PROMIS-PP may be an additional important prognostic indicator. Finally, with respect to worse pain interference, pain perception can play an important role in a patient's overall health status and may relate to the overall concussion symptom burden, which has been found to be predictive of delayed recovery.…”

Relationship between anxiety and concussion symptoms among adolescents enrolled in a randomized controlled trial of aerobic exercise

“…Findings suggest a positive correlation between anxiety and depressive symptoms, and overall concussion symptom burden (Edmed & Sullivan, 2012;. Athletes with anxiety and depressive symptoms also performed worse on attention and processing speed measures in neurocognitive outcomes compared to healthy controls , and experienced longer timelines to symptom resolution and return-to-play (D'Alonzo et al, 2022).…”

“…Investigations into the role of anxiety and depression after concussion have been limited and focused predominantly on college-aged athletes, and on cognitive performance and return-to-play outcomes (Ali et al, 2021;Covassin et al, 2013;D'Alonzo et al, 2022;. Findings suggest a positive correlation between anxiety and depressive symptoms, and overall concussion symptom burden (Edmed & Sullivan, 2012;.…”

“…This study focuses on pediatric athletes in particular, where sport-related concussions (SRC) occur relatively often (Halstead et al, 2010;Veliz et al, 2017;Yaramothu et al, 2019); and account for approximately 15% of injuries among high school athletes (Meehan et al, 2011). While recent studies have examined the influence of symptom burden and symptom type on clinical recovery (Ali et al, 2021;Putukian et al, 2021;Schilling et al, 2020;Sicard et al, 2021) and return-to-play trajectories (D'Alonzo et al, 2022), it is unclear how certain symptom domains, including physical, cognitive, emotional, and sleep factors respond to current approaches to treatment following concussion. Given the burden of SRC and increasing efforts to inform and create multidimensional clinical care teams (Polinder et al, 2018) to treat concussion symptoms in this population, adolescent athletes are well-positioned as an appropriate group in which to study these complex relationships.…”

Screening for Anxiety and Depression Symptoms Using Concussion Symptom Scales Among Varsity Athletes

“…1 Researchers have suggested the use of existing postconcussion scales as screeners to identify athletes with preinjury mental health concerns. 1,14,15,37–41 Reliable change indices from baseline to postconcussion have been reported for an affective symptom cluster (ie, irritability, sadness, nervousness, and feeling more emotional) in the Post-Concussion Symptom Scale (PCSS) from the Immediate Postconcussion Assessment and Cognitive Testing (ImPACT) 42 which could help identify athletes at risk for affective problems postconcussion. 43 Although promising, the aforementioned study had a small sample size (N = 38) making it difficult to reliably use these data to identify mental health problems.…”