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.

Keywords: affective symptoms; anxiety; athletics; female; mild TBI; symptomology; traumatic brain injury.

Figure 1.

Kaplan-Meier survival curves showing differences in time to symptom resolution for a. women with >11 symptoms (11 vs 6 days); b. men with >11 symptoms (10 vs 5 days); and for c. women with >11 symptoms and ≥1 previous concussion(s) (12 days), ≤11 symptoms and no previous concussions (5 days); d. men with >11 symptoms and no previous concussions (10 days), ≤11 symptoms and ≥1 previous concussion(s) (4 days). Median days and interquile ranges [IQR] are presented for the outcome symptom resolution. Log-Rank tests compare differences by symptom burden and concussion history.

Figure 2.

Kaplan-Meier survival curves showing differences in time to return to full play for a. women with >11 symptoms (17 vs 11 days); b. men with >11 symptoms (15 vs 11 days); and for c. women with >11 symptoms and no previous concussions (18 days), ≤11 symptoms and no previous concussions (10 days); d. men with >11 symptoms and ≥1 previous concussion(s) (16 days), ≤11 symptoms and no previous concussions (10 days). Median days and interquile ranges [IQR] are presented for the outcome return to full play. Log-Rank tests compare differences by symptom burden and concussion history.

Figure 3.

Symptom prevalence among women and men. Symptoms are from the SCAT 22-symptom inventory.

Figure 4.

Kaplan-Meier survival curves showing differences in time to symptom resolution for a. women with co-occurring affective symptoms (11 days), no affective symptoms (6 days); b. men with co-occurring affective symptoms (11 days), no affective symptoms (5 days); and return to full play for c. women with co-occurring saffective symptoms (19 days), no affective symptoms (12 days); d. men with co-occurring affective symptoms (19 days), no affective symptoms (12 days) or only nervous-anxious symptom (12 days). Median days and interquile ranges [IQR] are presented for the outcomes symptom resolution and return to full play. Log-Rank tests compare differences by affective domain category.