Clinical Outcome Following Concussion Among College Athletes with a History of Prior Concussion: A Systematic Review

Abstract

Background: There is long-standing interest in, and concern about, whether collegiate athletes with a history of concussion will experience worse clinical outcomes, or prolonged recovery, should they sustain a subsequent concussion.

Objectives: This systematic review examined the association between prior concussion history and clinical outcomes following a subsequent sport-related concussion among college-age student athletes.

Study design: Systematic review.

Methods: We screened 5,118 abstracts and 619 full-text articles that were appraised to determine whether they met inclusion criteria. We utilized a likelihood heuristic to assess the probability of observing a specific number of statistically significant and nonsignificant studies reporting an association between concussion history and clinical outcomes. We conducted a narrative synthesis of the study findings.

Results: Sixteen studies met the inclusion criteria. Thirteen studies reported the number of participants with a history of prior concussions (≥ 1), which totaled 1690 of 4573 total participants (on average 37.0% of study participants; median = 46.0%, range 5.6-63.8%). On the Newcastle-Ottawa Quality Assessment Scale, the risk of bias ratings ranged from 3 to 9 (mean = 5.4, SD = 1.4). Across all studies, 43.8% (k = 7/16) reported at least one statistically significant result among primary analyses showing an association between concussion history and worse clinical outcome. A minority of studies reporting on symptom duration (4/13, 30.8%) and time to return to play (2/7, 28.6%) found an association between concussion history and worse outcome. Studies included in the review reported limited information pertaining to the characteristics of prior concussions, such as presence or duration of loss of consciousness or posttraumatic amnesia, age at first lifetime concussion, time since most recent past concussion, or length of recovery from prior concussions.

Conclusion: The question of whether college athletes with a prior history of concussion have worse clinical outcome from their next sport-related concussion remains unresolved. The published results are mixed and in aggregate show modest evidence for an association. Many studies have small samples, and only three studies were designed specifically to address this research question. Important outcomes, such as time to return to academics, have not been adequately studied. Larger hypothesis-driven studies considering the number of prior concussions (e.g., 3 or more) are needed.

Trial registration: PROSPERO CRD42016041479, CRD42019128300.

Keywords: Clinical recovery; College athletes; Concussion; Mild traumatic brain injury; Prior concussions.

Fig. 1

Systematic literature search (PRISMA). Note: There was a mistake in the reporting of the number of records identified in the original search from 2016, as published by Iverson et al. in 2017. The initial search in 2016 yielded 4746 records, as noted in this figure.