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doi: 10.3810/psm.2010.12.1830
The Physician and Sportsmedicine: Volume 38: No.4
Tracking Neurocognitive Performance Following Concussion in High School Athletes
Tracey Covassin, PhD; R.J. Elbin, PhD; And Yusuke Nakayama, MS, ATC
Copyright 2010 All rights reserved. Cover and contents may not be reproduced in whole or in part without prior written permission. The Physician and Sportsmedicine is a registered trademark of JTE Multimedia, LLC. Sending and distribution of any document from this site is strictly prohibited either for free and or a service fee, and will be sited as a violation of copyright under the laws of THE UNITED STATES OF AMERICA

Abstract: Objective To extend previous research designs and examine cognitive performance up to 30 days postconcussion. Method A prospective cohort design was used to examine 2021 athletes from 8 mid-Michigan area high schools to compare baseline neurocognitive performance with postconcussion neurocognitive performance. All concussed athletes were readministered the Immediate Post Assessment and Cognitive Test (ImPACT) at 2, 7, 14, 21, and 30 days postconcussion. Results A total of 72 high school athletes (aged 15.8 ± 1.34 years) sustained a concussion. A significant within-subjects effect for reaction time (F = 10.01; P = 0.000), verbal memory (F = 3.05; P = 0.012), motor processing speed (F = 18.51; P = 0.000), and total symptoms following an injury (F = 16.45; P = 0.000) was found. Concussed athletes demonstrated a significant decrease in reaction time up to 14 days postconcussion (P = 0.001) compared with baseline reaction time. Reaction time returned to baseline levels at 21 days postinjury (P = 0.25). At 7 days postinjury, impairments in verbal memory (P = 0.003) and motor processing speed (P = 0.000) were documented and returned to baseline levels by 14 days postinjury. Concussed athletes self-reported significantly more symptoms at 2 days postconcussion (P = 0.000) and exhibited a resolution of symptoms by 7 days postinjury (P = 0.06). Conclusion High school athletes could take up to 21 days to return to baseline levels for reaction time. These data support current recommendations for the conservative management of concussion in the high school athlete.

Keywords: concussion; neurocognitive function; high school athletes; ImPACT


The time required for an athlete to recover from a sports-related concussion continues to be one of the more germane issues for both physicians and researchers alike. Until recently, determining the recovery of a concussed athlete was primarily a subjective decision made by sports medicine professionals. It is now highly recommended that the management of a sports-related concussion involve a multifaceted approach that consists of various measures, such as an evaluation of symptoms, sideline mental status test, postural stability assessment, and neurocognitive test batteries.1-3 The increased availability of computerized neurocognitive testing has offered physicians additional information on the cognitive recovery of the concussed athlete by comparing postinjury to preinjury (ie, baseline) neurocognitive performance. This prospective methodology has added much-needed objectivity to concussion management and has helped quantify the cognitive recovery time following concussion.4

Previous research has evaluated the recovery time required following a sports-related concussion, as determined by the resolution of neurocognitive impairment (ie, back to baseline). McClincy et al5 prospectively administered a computerized neurocognitive test battery at approximately 2, 7, and 14 days postconcussion to a sample of high school and collegiate athletes. As expected, a general decrease in overall cognitive performance (eg, verbal and visual memory, reaction time, and motor processing speed) was observed at 2 days postconcussion. With the exception of motor processing speed, these neurocognitive decrements persisted up to 7 days postinjury. Neurocognitive performance returned to baseline between 7 and 14 days postconcussion for visual memory and reaction time. However, significant decreases in verbal memory performance were still evident at 14 days postconcussion. Although the results of this study demonstrate neurocognitive recovery over a 2-week period, these researchers did not examine recovery time between the age groups included in their sample (eg, high school vs collegiate athletes). Other researchers who have specifically compared neurocognitive recovery rates between high school and collegiate athletes have found differences between these groups.6

High school-aged athletes who sustain a concussion have been found to exhibit longer recovery times than concussed collegiate and professional athletes.6-9 Lovell et al10 found memory impairments lasting up to 7 days postinjury in a sample of concussed high school athletes. Similarly, Iverson et al11 found that 11 (37%) of 30 concussed high school athletes demonstrated clinical impairment on ≥ 2 neurocognitive measures (verbal and visual memory, reaction time, motor processing speed) at 10 days postconcussion. These recovery patterns observed in high school athletes are more prolonged than the 5-day period of neurocognitive recovery found in collegiate athletes.6,12,13

The discrepancy in recovery time following concussion between these age groups has been attributed to the documented anatomical (ie, larger subarachnoid space in the cranium allowing more room for brain movement), behavioral, and physical (ie, immature musculoskeletal systems) differences between adolescents and adults.6,14 Collectively, these studies have prompted the consideration of age differences in regards to the management of sports-related concussion (ie, recommending abolishing one-size-fits-all grading scales2,3 ) and have provided an impetus for continued research. However, none of aforementioned studies examined neurocognitive performance for > 14 days postinjury.

Most studies investigating the recovery time following concussion have largely focused on recovery outcomes in the initial days following injury. Although this timeframe for recovery (eg, 5–10 days) is applicable to making return-to-play decisions, the continued study of recovery time of concussed athletes have been warranted.6 Such studies may provide valuable information regarding the potential lasting effects of mild concussion, especially in younger athletes. Therefore, the purpose of the current study is to extend previous research designs and examine cognitive performance up to 30 days postconcussion. Extending a neurocognitive retest protocol would help to identify a more protracted or long-term recovery pattern (ie, neurocognitive performance) in high school athletes.

Materials and Methods
Research Design

A prospective cohort design was used to compare baseline neurocognitive performance with postconcussion neurocognitive performance. The independent variable was time (baseline, 2, 7, 14, 21, and 30 days postconcussion). The dependent variables were neurocognitive performance on verbal memory, visual memory, processing speed, reaction time, and total symptom scores.


Approximately 2021 athletes from 8 mid-Michigan high schools participating in baseball, men’s and women’s basketball, cheerleading, football, women’s gymnastics, men’s ice hockey, men’s and women’s soccer, softball, volleyball, and wrestling volunteered to participate in the study. Any athlete with a history of learning disability, color blindness, psychological disorder, brain surgery, major neurological condition, history of a traumatic brain injury, or experienced loss of consciousness for > 5 minutes were excluded from the study. A total of 76 athletes (58 males; 14 females; height, 175.3 ± 8.26 cm; body weight, 72.2021 ± 17.13 kg) sustained a concussion over the 2-year study period. Of these injured athletes, 4 were excluded from the study because of exclusion criteria. The average age of the 72 concussed athletes was approximately 15.8 (± 1.34) years with a fairly equal distribution of high school education levels (ninth grade, n = 14; tenth grade, n = 21; eleventh grade, n = 14; twelfth grade, n = 23). Concussion history is reported in Table 1.

View: (Table 1 ) - Description of Concussion History (N = 72)
Evaluation Measures and Instrumentation
Definition of Concussion

The Concussion in Sport group definition was used to identify athletes with a concussion.2,3 According to this definition, a concussion is a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.2,3 Concussion was also further described as a rapid onset of short neurological impairments and neuropathological changes.2,3 The Concussion in Sport group also qualifies this injury as a graded set of clinical syndromes that may or may not involve loss of consciousness.2,3

Immediate Postconcussion Assessment Cognitive Testing 5.0

The Immediate Postconcussion Assessment and Cognitive Test (ImPACT) was used to measure neurocognitive performance of each athlete pre- and postconcussion. The ImPACT test is widely used for the detection and management of concussion in athletes.15 This neurocognitive test battery consists of 3 general sections. In the first section, athletes input demographic and descriptive information through a series of instructional screens. The demographic section includes history of sports participation, history of alcohol and drug use, learning disabilities, attention-deficit/hyperactivity disorders, major neurological disorders, and history of previous concussion(s). The second section requires athletes to indicate if they are currently experiencing any of the 22 concussion symptoms, while rating the severity of each symptom using a 7-point Likert scale (0 = experiencing no symptoms, 6 = experiencing severe symptoms). The third section is composed of 6 neurocognitive modules that evaluate a wide variety of cognitive domains, including attention, working memory, processing speed, learning, and delayed memory. The ImPACT test takes approximately 25 minutes to complete, and has 5 different test iterations to minimize practice effects.

The ImPACT neurocognitive test battery has undergone extensive reliability and validity testing.11,16-19 Using reliable change index (RCI), repeated administrations over a 2-week period revealed no practice effects.20 Schatz et al19 documented a combined sensitivity of 81.9% for ImPACT indices and total symptom score, and a specificity of 89.4%, while Broglio et al21 found a sensitivity of ImPACT and concussion symptoms to be slightly lower at 79.2%.


The research protocol was approved by Michigan State University’s institutional review board for the protection of human subjects prior to data collection. Parental consent and athlete assent were obtained prior to data collection.

Preseason Baseline Evaluation

All athletes reported in groups of ≤ 10 at a time to their own institution’s designated computer laboratory for baseline testing. Athletes were administered the ImPACT neurocognitive test battery on a desktop computer.

Postconcussion Evaluation

Certified athletic trainers were present at all practice sessions and games. All certified athletic trainers and physicians at the participating institutions were instructed to use the Concussion in Sport group guidelines to determine if an athlete had sustained a concussion.2,3 All athletes who sustained a concussion were evaluated, and return-to-play decisions were determined by their respective institutions’ sports medicine staff. All concussed athletes (n = 72) were readministered the ImPACT test at 2, 7, 14, 21, and 30 days postconcussion.

Statistical Analysis

Data were analyzed using descriptive and inferential statistics. The ImPACT test version 5.0 yields individual and composite scores for verbal memory, visual memory, visual motor speed, and reaction time. A higher score on visual motor speed and visual/verbal memory indicates a better performance. A lower score on reaction time indicates a better performance. Athletes receive a total score for postconcussion symptoms. A series of 1-way repeated measures of analysis of variance (ANOVA) were conducted on each neurocognitive composite score and total symptom score to identify the time interval (2, 7, 14, 21, and 30 days) required for concussed athletes to return to their baselines scores.

In addition, RCI (verbal memory ≥ 9, verbal memory ≥ 14, motor processing speed ≥ 5, reaction time > 0.06, total symptom score ≥ 10) were used to determine when an athlete had recovered from his/her concussion.11 All analyses were conducted using SPSS version 18.1 (SPSS Inc., Chicago, IL). The level of significance was set a priori at P ≤ 0.05.


It should be noted that Mauchly’s test was significant for reaction time (W = 0.05; χ2 [14], 78.22; P = 0.000). To correct for lack of sphericity, we used the Huynh-Feldt epsilon correction, which least affects the degrees of freedom. Results indicated a significant within-subjects effect for reaction time (F = 10.01; P = 0.000; η2 = 0.263). Specifically, pairwise comparisons revealed significantly slower reaction times of ≤ 14 days postconcussion (P = 0.001) compared with baseline reaction time (Figure 1). However, reaction time returned back to baseline levels by 21 days postinjury (P = 0.25). We did not violate sphericity for verbal memory (W = 0.646; χ2 [14] = 11.40; P = 0.656); however, we have chosen to use Huynh-Feldt epsilon correction for the remainder of the results. A significant within-subjects effect for verbal memory composite scores (F = 3.05; P = 0.012; η2 = 0.02021) was also observed as concussed athletes demonstrated significant impairment on verbal memory at 7 days postinjury (P = 0.003) and returned to baseline levels by 14 days postinjury (P = 0.101) (Figure 2). Sphericity was violated for motor processing speed (W = 0.163; χ2 [14] = 47.30; P = 0.000). Significant decreases in motor processing speed were also found (F = 18.51; P = 0.000; η2 = 0.32021). Concussed athletes’ motor processing speed was impaired 7 days postconcussion (P = 0.000) and returned to baseline levels by day 14 (P = 0.176) (Figure 3). Sphericity was violated for total concussion symptoms (W = 0.234; χ2 [14] = 26.30; P = 0.025). As expected, significant increases in self-reported concussion symptoms were documented following a concussion (F = 16.45; P = 0.000; η2 = 0.451). At 2 days postinjury, an average of 20 total symptoms (P = 0.000) were reported by the athletes; however, by 7 days postinjury, athletes’ symptom scores were similar to baseline symptom scores (P = 0.06) (Figure 4). We did not violate sphericity for visual memory (W = 0.685; χ2 [14] = 9.89; P = 0.771). There were no significant within-subjects differences in visual memory composite scores (F = 2.28; P = 0.051; η2 = 0.075) (Figure 2).

View: (Figure 1 ) - Recovery curve for ImPACT reaction time composites (n = 72) at baseline.
View: (Figure 2 ) - Recovery curve for ImPACT verbal and visual memory composites at baseline and 2, 7, 14, 21, and 30 days postconcussion.
View: (Figure 3 ) - Recovery curve for ImPACT motor processing speed composite at baseline and 2, 7, 14, 21, and 30 days postconcussion.
View: (Figure 4 ) - Recovery curve for ImPACT total symptoms scores at baseline and 2, 7, 14, 21, 30 days postconcussion.

In addition to investigating the statistical significance of the difference in scores between baseline and postconcussion administrations of ImPACT, clinically significant performance was also considered. Reliable change indices were calculated to determine if an athlete was clinically significant on ≥ 1 ImPACT composite score or exhibiting significantly more total symptoms compared with baseline scores. Results indicated that 93.1% of concussed athletes exhibited ≥ 1 RCI 2 days following a concussion. At 7 days postconcussion, 79.3% still exhibited ≥ 1 RCI. In addition, clinical impairment still remained in 33.5% and 12.5% of athletes at 14 days and 21 days postconcussion, respectively. There were no clinically significant changes in neurocognitive performance in any athlete at 30 days postinjury.


Neurocognitive testing is one tool in the recommended multifaceted approach to concussion management. The prospective administration of neurocognitive testing has been suggested to reveal a more complete picture of the cognitive sequelae following sports-related concussion, which can be missed by only assessing self-reported symptoms and postinjury behaviors.22 This management tool has also proven valuable in assessing the long-term cognitive recovery from concussion.1 The purpose of the current study was to extend previously published research designs that only evaluated cognitive performance in concussed athletes up to 14 days postconcussion. The present study examined neurocognitive performance up to 30 days postconcussion.

Overall, the results from the present study suggest that concussed high school athletes could exhibit longer cognitive recovery times than previously reported. More specifically, high school athletes may take up to 21 days to return to baseline levels for reaction time. However, it should be noted that more than half of these athletes had ≥ 1 previous concussion; therefore, their longer recovery time may be due to their history of previous concussion(s). In addition, verbal memory and motor processing speed did not exhibit a prolonged recovery pattern, as impairments were observed at 7 days postconcussion but seemed to resolve by 14 days postinjury. These findings not only compliment previous studies, but contribute to the data suggesting high school athletes may exhibit a more prolonged recovery pattern in different cognitive domains, such as reaction time, following a concussion.

To date, there have been several studies that investigated the temporal resolution of neurocognitive impairment following sports-related concussion.5,11,23 Interestingly, in studies using a sample composed of both high school and collegiate athletes, neurocognitive decrements were reported to be resolved as early as 2 days following injury23 or persisting up to 14 days postinjury.5 Other researchers have delineated between these 2 age groups and exclusively studied neurocognitive recovery in high school athletes. Lovell et al10 evaluated neurocognitive performance in a sample of concussed high school athletes and found memory impairments lasting up to 7 days postinjury. Unfortunately, these researchers were unable to track neurocognitive performance past 7 days postconcussion. Nonetheless, these results were supported by Field et al6 , who found significant memory impairment up to 7 days postconcussion in a sample of high school athletes. Iverson et al11 found that 11 (37%) of 30 concussed high school athletes were still clinically impaired on ≥ 2 neurocognitive measures (verbal memory, visual memory, reaction time, processing speed) at 10 days postconcussion. Although these studies certainly contribute to the understanding of the timeline associated with neurocognitive recovery following concussion, most of the retest protocols did not follow athletes until they were recovered back to baseline.

In addition to neurocognitive impairment observed at 21 days postconcussion, the current study applied RCI to identify athletes who exhibited clinically significant decreases in neurocognitive performance following concussion. As expected, the total number of athletes exhibiting clinical decreases in neurocognitive performance increased in the acute period following concussion (eg, 7 days postinjury) and decreased over time. It can be concluded that the present study evaluated the entire recovery pattern for all participants, as no statistical or clinical differences were found past 21 days postconcussion.

Other researchers have found similar data, suggesting longer recovery from concussion in high school athletes. Lau et al24 presented data suggesting a longer period of recovery of reaction time in high school athletes. However, these researchers classified concussion according to the published Prague guidelines,25 which categorized concussive injury as either simple or complex. Interestingly, high school athletes who sustained a complex concussion were found to exhibit the largest effect size for reaction time composite score and a slower reaction time compared with athletes who sustained a simple concussion. However, the simple and complex concussion definitions are no longer recommended for classifying concussions.2 Regardless of how concussions are classified, it has been suggested that reaction time may be a prominent predictor of recovery from concussion.24 Moreover, this finding has direct implications on concussion management, particularly for younger athletes.

The wide variability for the neurocognitive recovery following concussion described in the aforementioned studies and the prolonged impairment in reaction time found in the current study further supports the need for an individualized approach to concussion management. The cognitive sequelae that follows a concussion is unique to each injured athlete. Experts highlight the need to manage concussion on a case-by-case basis and use objective methods of management (eg, neurocognitive testing and balance assessment) whenever possible.

This study has several limitations that warrant mentioning. First, the study is constrained by a small sample size. Therefore, caution needs to be taken when interpreting the results of this study. A second limitation is the sole inclusion of high school athletes from the state of Michigan. Finally, more than half of these athletes had a history of concussion. Although concussion history was used as a covariate for the within-subjects analyses, RCI calculated in the present study could be influenced by prior concussion history. Therefore, in regards to the resolution of clinically significant neurocognitive impairment, concussion history may have served a role. Future research should extend sample selection parameters to include high school athletes that may be more representative of a national sample. Additional studies are also warranted for examining the possible long-term cognitive impairments between male and female athletes with a history of multiple concussions.


The present study’s results suggest that high school concussed athletes appear to take > 14 days to resolve impairments in reaction time. Additional RCI analyses supported this protracted recovery, as there was evidence of clinically significant changes in neurocognitive performance persisting at 14 days postconcussion. These data are consistent with previous studies that also suggest high school athletes take > 7 days to recover on neurocognitive function.6 In addition, the results from this study are in agreement with recent consensus recommendations that promote the conservative management of the high school athlete. This conservative approach will ultimately help to avoid potential catastrophic consequences that may result from sustaining another concussion before the first injury completely resolves (eg, second-impact syndrome).2 However, these results should be interpreted with caution, as additional research on the recovery time of high school athletes is needed.

We would like to acknowledge Michigan State University for an IRPG grant.

Conflict of Interest Statement
Tracey Covassin, PhD, R. J. Elbin, PhD, and Yusuke Nakayama. MS, ATC disclose no conflicts of interest.
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Tracey Covassin, PhD 1
R.J. Elbin, PhD 2
Yusuke Nakayama, MS, ATC 1

1Michigan State University, East Lansing, MI 2Department of Kinesiology, Leisure and Sport Sciences, East Tennessee State University, Johnson City, TN

Correspondence: Tracey Covassin, PhD, Michigan State University, 105 IM Sport Circle, East Lansing, MI 48824.
Tel: 517-353-2010,
Fax: 517-355-1944,
E-mail: [email protected]
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