Cumulative Effects Associated With Recurrent Concussion in Collegiate Football Players: The NCAA Concussion Study | Traumatic Brain Injury | JAMA | JAMA Network
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Bruce D, Schut L, Sutton L. Brain and cervical spine injuries occurring during organized sports activities in children and adolescents.  Clin Sports Med.1982;1:495-514. Scholar
Buckley WE. Concussion in college football: a multivariate analysis.  Am J Sports Med.1988;16:51-56. Scholar
Cantu R. Cerebral concussion in sports: management and prevention.  Sports Med.1992;14:64-74. Scholar
Cantu R. Minor head injuries in sports.  Adolesc Med.1991;2:141-154. Scholar
Gerberich S, Priest J, Boen J.  et al.  Concussion incidences and severity in secondary school varsity football players.  Am J Public Health.1983;73:1370-1375. Scholar
Ommaya A, Ommaya A, Salazar A. A spectrum of mild brain injuries in sports. In: Proceedings of the Mild Brain Injury in Sports Summit. Dallas, Tex: National Athletic Trainers' Association Inc; 1994:72-80.
Powell JW, Barber-Foss KD. Traumatic brain injury in high school athletes.  JAMA.1999;282:958-963. Scholar
Wilberger JE. Minor head injuries in American football: prevention of long term sequela.  Sports Med.1993;15:338-343. Scholar
Thurman D, Branche C, Sniezek J. The epidemiology of sports-related traumatic brain injuries in the United States: recent developments.  J Head Trauma Rehabil.1998;13:1-8. Scholar
Centers for Disease Control and Prevention.  Sports related recurrent brain injuries—United States.  MMWR Morb Mortal Wkly Rep.1997;46:224-227. Scholar
Collins MW, Lovell MR, Iverson GL, Cantu RC, Maroon JC, Field M. Cumulative effects of concussion in high school athletes.  Neurosurgery.2002;51:1175-1180. Scholar
Guskiewicz KM, Weaver N, Padua DA, Garrett WE. Epidemiology of concussion in collegiate and high school football players.  Am J Sports Med.2000;28:643-650. Scholar
Kutner KC, Erlanger DM, Tsai J, Jordan B, Relkin NR. Lower cognitive performance of older football players possessing apolipoprotein E e4 Neurosurgery.2000;47:651-658. Scholar
Barth JT, Alves W, Ryan T.  et al.  Mild head injury in sports: neuropsychological sequela and recovery of function. In: Levin H, Eisenberg H, Benton A, eds. Mild Head Injury. New York, NY: Oxford; 1989:257-275.
Dick RW. Football injury report. In: 2001-2002 NCAA Injury Surveillance System. Indianapolis, Ind: National Collegiate Athletic Association; 2002.
Committee on Head Injury Nomenclature of the Congress of Neurological Surgeons.  Glossary of head injury including some definitions of injury to the cervical spine.  Clin Neurosurg.1966;12:386-394.Google Scholar
Barth JT, Macciocchi SN, Giordani B.  et al.  Neuropsychological sequela of minor head injury.  Neurosurgery.1983;13:529-533. Scholar
Rimel R, Giordani B, Barth J.  et al.  Disability caused by minor head injury.  Neurosurgery.1981;9:221-228. Scholar
Barth JT, Freeman JR, Broshek DK, Varney RN. Acceleration-deceleration sport-related concussion: the gravity of it all.  J Athl Train.2001;36:253-256. Scholar
Cantu R. Guidelines for return to contact sports after a cerebral concussion.  Phys Sportsmed.1986;14:75-83.Google Scholar
Cantu RC. Posttraumatic retrograde and anterograde amnesia: pathophysiology and implications in grading and safe return to play.  J Athl Train.2001;36:244-248. Scholar
Jordan B. Sports injuries. In: Proceedings of the Mild Brain Injury in Sports Summit. Dallas, Tex: National Athletic Trainers' Association Inc; 1994:43-46.
Nelson WE, Jane JA, Gieck JH. Minor head injury in sport: a new classification and management.  Phys Sportsmed.1984;12:103-107.Google Scholar
Colorado Medical Society Sports Medicine Committee.  Guidelines for the management of concussion in sports. In: Proceedings of the Mild Brain Injury in Sports Summit. Dallas, Tex: National Athletic Trainers' Association Inc; 1994:106-109.
American Academy of Neurology.  Practice parameter: the management of concussion in sports.  Neurology.1997;48:581-585. Scholar
Giza CC, Hovda DA. Ionic and metabolic consequences of concussion. In: Cantu RC, Cantu RI. Neurologic Athletic and Spine Injuries. Philadelphia, Pa: WB Saunders Co; 2000:80-100.
Giza CC, Hovda DA. The neurometabolic cascade of concussion.  J Athl Train.2001;36:228-235. Scholar
Hovda DA, Yoshino A, Kawamata T, Katayama Y, Becker DP. Diffuse prolonged depression of cerebral oxidative metabolism following concussive brain injury in the rat: a cytochrome oxidase histochemistry study.  Brain Res.1991;567:1-10. Scholar
Nilsson B, Ponten U. Experimental head injury in the rat, part 2: regional brain energy metabolism in concussion trauma.  J Neurosurg.1977;47:252-261. Scholar
Yang MS, DeWitt DS, Becker DP, Hayes RI. Regional brain metabolite levels following mild experimental head injury in the cat.  J Neurosurg.1985;63:617-621. Scholar
Lovell MR, Collins MW. Neuropsychological assessment of the college football player.  J Head Trauma Rehabil.1998;13:9-26. Scholar
Collins MW, Grindel SH, Lovell MR.  et al.  Relationship between concussion and neuropsychological performance in college football players.  JAMA.1999;282:964-970. Scholar
Guskiewicz K, Riemann B, Perrin D.  et al.  Alternative approaches to the assessment of mild head injury in athletes.  Med Sci Sports Exerc.1997;29(suppl):S213-S221. Scholar
Guskiewicz KM, Ross SE, Marshall SW. Postural stability and neuropsychological deficits after concussion in collegiate athletes.  J Athl Train.2001;36:263-273. Scholar
McCrea M, Guskiewicz KM, Marshall SW.  et al.  Acute effects and recovery time following concussion in collegiate football players: the NCAA Concussion Study.  JAMA.2003;290:2556-2563.Google Scholar
 1981-1982-2001-2002 NCAA Sports Sponsorship and Participation Rates Report . Indianapolis, Ind: National Collegiate Athletic Association; 2002.
Greenland S, Rothman KJ. Introduction to stratified analysis. In: Rothman KJ, Greenland S. Modern Epidemiology. 2nd ed. Philadelphia, Pa: Lippincott-Raven; 1998.
Frome EL. The analysis of rates using Poisson regression models.  Biometrics.1983;39:665-674. Scholar
Frome EL, Checkoway H. Use of Poisson regression models in estimating incidence rates and ratios.  Am J Epidemiol.1985;121:309-323. Scholar
McCulloch CE, Searle SR. Generalized, Linear, and Mixed Models. New York, NY: John Wiley & Sons; 2001:223-226.
Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes.  Biometrics.1986;42:121-130. Scholar
Liang KY, Zeger SL. Longitudinal data analysis using generalized linear models.  Biometrika.1986;73:13-22.Google Scholar
Meyer JS, Kondo A, Nomura F, Sakamoto K, Teraura T. Cerebral hemodynamics and metabolism following experimental head injury.  J Neurosurg.1970;32:304-319. Scholar
Nelson SR, Lowry OH, Passonneau JV. Changes in energy reserves in mouse brain associated with compressive head injury. In: Caveness WF, Walker AE, eds. Head Injury. Philadelphia, Pa: JB Lippincott; 1966:444-447.
Nilsson B, Nordstrom CH. Rate of cerebral energy consumption in concussive head injury in the rat.  J Neurosurg.1977;47:274-281. Scholar
Prince DA, Lux HD, Neher E. Measurement of extracellular potassium activity in cat cortex.  Brain Res.1973;50:489-495. Scholar
Albright JP, McAuley E, Martin RK.  et al.  Head and neck injuries in college football: an eight-year analysis.  Am J Sports Med.1985;13:147-152. Scholar
Leininger BE, Gramling S, Farrell A.  et al.  Neuropsychological deficits in symptomatic minor head injury patients after concussion and mild concussion.  J Neurol Neurosurg Psychiatr.1990;53:293-296. Scholar
Echemendia RJ, Putukian M, Macklin RS, Julian L, Shoss N. Neuropsychological test performance prior to and following sports-related mild traumatic brain injury.  Clin J Sport Med.2001;11:23-31. Scholar
McCrea M, Kelly JP, Kluge J.  et al.  Standardized assessment of concussion in football players.  Neurology.1997;48:586-588. Scholar
McCrea M. Standardized mental status testing on the sideline after sport-related concussion.  J Athl Train.2001;36:274-279. Scholar
Erlanger D, Saliba E, Barth J.  et al.  Monitoring resolution of postconcussion symptoms in athletes: preliminary results of a Web-based neuropsychological test protocol.  J Athl Train.2001;36:280-287. Scholar
Kelly JP. Loss of consciousness: pathophysiology and implications in grading and safe return to play.  J Athl Train.2001;36:249-252. Scholar
McCrea M, Hammeke T, Olsen G.  et al.  Unreported concussion in high school football players: implications for prevention.  Clin J Sports Med.In press.Google Scholar
Original Contribution
November 19, 2003

Cumulative Effects Associated With Recurrent Concussion in Collegiate Football Players: The NCAA Concussion Study

Author Affiliations

Author Affiliations: Departments of Exercise and Sport Science (Drs Guskiewicz and Cantu), Orthopaedics (Drs Guskiewicz and Marshall), and Epidemiology (Dr Marshall), and Injury Prevention Research Center (Drs Guskiewicz and Marshall), University of North Carolina at Chapel Hill; Neuroscience Center, Waukesha Memorial Hospital, Waukesha, Wis (Dr McCrea); Department of Neurology, Medical College of Wisconsin, Milwaukee (Dr McCrea); Neurosurgery Service, Emerson Hospital, Concord, Mass (Dr Cantu); Chicago Neurological Institute (Drs Randolph and Kelly) and Department of Neurology, Northwestern University Feinberg School of Medicine (Dr Kelly), Chicago, Ill; Department of Neurology, Loyola University Medical School, Maywood, Ill (Dr Randolph); Department of Neurology, New York University School of Medicine, New York (Dr Barr); and Department of Rehabilitation Sciences Athletic Training Program, Sargent College of Health and Rehabilitation Sciences, Boston University, Boston, Mass (Dr Onate).

JAMA. 2003;290(19):2549-2555. doi:10.1001/jama.290.19.2549

Context Approximately 300 000 sport-related concussions occur annually in the United States, and the likelihood of serious sequelae may increase with repeated head injury.

Objective To estimate the incidence of concussion and time to recovery after concussion in collegiate football players.

Design, Setting, and Participants Prospective cohort study of 2905 football players from 25 US colleges were tested at preseason baseline in 1999, 2000, and 2001 on a variety of measures and followed up prospectively to ascertain concussion occurrence. Players injured with a concussion were monitored until their concussion symptoms resolved and were followed up for repeat concussions until completion of their collegiate football career or until the end of the 2001 football season.

Main Outcome Measures Incidence of concussion and repeat concusion; type and duration of symptoms and course of recovery among players who were injured with a concussion during the seasons.

Results During follow-up of 4251 player-seasons, 184 players (6.3%) had a concussion, and 12 (6.5%) of these players had a repeat concussion within the same season. There was an association between reported number of previous concussions and likelihood of incident concussion. Players reporting a history of 3 or more previous concussions were 3.0 (95% confidence interval, 1.6-5.6) times more likely to have an incident concussion than players with no concussion history. Headache was the most commonly reported symptom at the time of injury (85.2%), and mean overall symptom duration was 82 hours. Slowed recovery was associated with a history of multiple previous concussions (30.0% of those with ≥3 previous concussions had symptoms lasting >1 week compared with 14.6% of those with 1 previous concussion). Of the 12 incident within-season repeat concussions, 11 (91.7%) occurred within 10 days of the first injury, and 9 (75.0%) occurred within 7 days of the first injury.

Conclusions Our study suggests that players with a history of previous concussions are more likely to have future concussive injuries than those with no history; 1 in 15 players with a concussion may have additional concussions in the same playing season; and previous concussions may be associated with slower recovery of neurological function.