Purpose of Review
Sport-related concussion (SRC) and mild traumatic brain injury (mTBI) have been thrust into the national spotlight, with youth athletes bearing the burden of this public health problem. The current review aims to provide a practical summary of pediatric SRC, including key terminology, return to play/school, and risk factors for post-concussion syndrome (PCS).
While the majority of youth athletes recover within 2 to 4 weeks, approximately 10% of athletes experience a protracted recovery with symptoms lasting months, impacting social, scholastic, and sporting activities.
In the pediatric population, the strongest predictors of PCS are initial symptom burden and prior concussion, with mixed results behind the factors of gender, headaches, and learning disability. The role of psychiatric, family history, sports, and socioeconomic factors remain in their infancy.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Meehan WP 3rd, d'Hemecourt P, Comstock RD. High school concussions in the 2008-2009 academic year: mechanism, symptoms, and management. Am J Sports Med. 2010;38:2405–9.
Zuckerman SL, Kerr ZY, Yengo-Kahn A, Wasserman E, Covassin T, Solomon GS. Epidemiology of sports-related concussion in NCAA athletes from 2009-2010 to 2013-2014: incidence, recurrence, and mechanisms. Am J Sports Med. 2015;43:2654–62.
(2014) In Sports-related concussions in youth: improving the science, changing the culture, Graham R, Rivara FP, Ford MA, Spicer CM, eds., Washington (DC): National Academies Press (US); 2014 Feb.
Meehan WP 3rd, d'Hemecourt P, Collins CL, Comstock RD. Assessment and management of sport-related concussions in United States high schools. Am J Sports Med. 2011;39:2304–10.
Blume H, Hawash K. Subacute concussion-related symptoms and postconcussion syndrome in pediatrics. Curr Opin Pediatr. 2012;24:724–30.
Bernard CO, Ponsford JA, McKinlay A, McKenzie D, Krieser D. Predictors of post-concussive symptoms in young children: injury versus non-injury related factors. J Int Neuropsychol Soc. 2016;22:793–803.
Miller JH, Gill C, Kuhn EN, Rocque BG, Menendez JY, O'Neill JA, et al. Predictors of delayed recovery following pediatric sports-related concussion: a case-control study. J Neurosurg Pediatr. 2016;17:491–6.
Heyer GL, Schaffer CE, Rose SC, Young JA, McNally KA, Fischer AN. Specific factors influence postconcussion symptom duration among youth referred to a sports concussion clinic. J Pediatr. 2016;174(33–38):e32.
Meehan WP 3rd, Mannix R, Monuteaux MC, Stein CJ, Bachur RG. Early symptom burden predicts recovery after sport-related concussion. Neurology. 2014;83:2204–10.
Morgan CD, Zuckerman SL, Lee YM, King L, Beaird S, Sills AK, et al. Predictors of postconcussion syndrome after sports-related concussion in young athletes: a matched case-control study. J Neurosurg Pediatr. 2015;15:589–98.
Kerr ZY, Zuckerman SL, Wasserman EB, Vander Vegt CB, Yengo-Kahn A, Buckley TA, et al. Factors associated with post-concussion syndrome in high school student-athletes. J Sci Med Sport. 2017;21(5):447–52.
•• McCrory P, Meeuwisse W, Dvorak J, Aubry M, Bailes J, Broglio S, et al. Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2017;51:838–47 International consensus statement on sport-related concussion guidelines and most comprehensive summary of SRC to date, formualated by international experts across many sports.
McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorák J, Echemendia RJ, et al. Consensus statement on concussion in sport: the 4th international conference on concussion in sport held in Zurich, November 2012. Br J Sports Med. 2013;47:250–8.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Washington, DC: American Psychiatric Association; 2000.
World Health Organization. International statistical classification of diseases and related health problems. Geneva: World Health Organization; 1992.
Rose SC, Fischer AN, Heyer GL. How long is too long? The lack of consensus regarding the post-concussion syndrome diagnosis. Brain Inj. 2015;29:798–803.
Iverson GL, Lovell MR, Collins MW. Interpreting change on ImPACT following sport concussion. Clin Neuropsychol. 2003;17:460–7.
Hunt TN, Ferrara MS, Bornstein RA, Baumgartner TA. The reliability of the modified Balance Error Scoring System. Clin J Sport Med. 2009;19:471–5.
•• Collins MW, Kontos AP, Okonkwo DO, Almquist J, Bailes J, Barisa M, et al. Statements of agreement from the Targeted Evaluation and Active Management (TEAM) approaches to treating concussion meeting held in Pittsburgh, October 15-16, 2015. Neurosurgery. 2016;79:912–29 A summary statement of multi-disciplinary meeting among national experts regarding recovery after SRC. The experts provided a succinct summary of how active rehabilitation is the preferred treatment after SRC rather than isolation or cocoon therapy.
Storey EP, Wiebe DJ, D'Alonzo BA, Nixon-Cave K, Jackson-Coty J, Goodman AM, et al. Vestibular rehabilitation is associated with visuovestibular improvement in pediatric concussion. J Neurol Phys Ther. 2018;42:134–41.
Park K, Ksiazek T, Olson B. Effectiveness of vestibular rehabilitation therapy for treatment of concussed adolescents with persistent symptoms of dizziness and imbalance. J Sport Rehabil. 2018:1–6.
Lawrence DW, Richards D, Comper P, Hutchison MG. Earlier time to aerobic exercise is associated with faster recovery following acute sport concussion. PLoS One. 2018;13:e0196062.
Petraglia AL, Maroon JC, Bailes JE. From the field of play to the field of combat: a review of the pharmacological management of concussion. Neurosurgery. 2012;70:1520–33 discussion 1533.
Solomon GS, Sills AK. Pharmacologic treatment of sport-related concussion: a review. J Surg Orthop Adv. 2013;22:193–7.
McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, Molloy M, et al. Consensus statement on concussion in sport: the 3rd international conference on concussion in sport held in Zurich, November 2008. Br J Sports Med. 2009;43(Suppl 1):i76–90.
Hang B, Babcock L, Hornung R, Ho M, Pomerantz WJ. Can computerized neuropsychological testing in the emergency department predict recovery for young athletes with concussions? Pediatr Emerg Care. 2015;31:688–93.
Castile L, Collins CL, McIlvain NM, Comstock RD. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010. Br J Sports Med. 2012;46:603–10.
Ellis MJ, Ritchie LJ, Koltek M, Hosain S, Cordingley D, Chu S, et al. Psychiatric outcomes after pediatric sports-related concussion. J Neurosurg Pediatr. 2015;16:709–18.
Greenhill DA, Navo P, Zhao H, Torg J, Comstock RD, Boden BP. Inadequate helmet fit increases concussion severity in American high school football players. Sports Health. 2016;8:238–43.
Iverson G. Predicting slow recovery from sport-related concussion: the new simple-complex distinction. Clin J Sport Med. 2007;17:31–7.
•• Zemek R, Barrowman N, Freedman SB, Gravel J, Gagnon I, McGahern C, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 2016;315:1014–25 Large study of pertinent risk factors for persistent symptoms after pediatric concussion, though this was not exclusively a sports population.
Fehr SD, Nelson LD, Scharer KR, Traudt EA, Veenstra JM, Tarima SS, et al. Risk factors for prolonged symptoms of mild traumatic brain injury: a pediatric sports concussion clinic cohort. Clin J Sport Med. 2017 Oct 27. https://doi.org/10.1097/JSM.0000000000000494. [Epub ahead of print]
Thomas DJ, Coxe K, Li H, Pommering TL, Young JA, Smith GA, et al. Length of recovery from sports-related concussions in pediatric patients treated at concussion clinics. Clin J Sport Med. 2018;28:56–63.
Barlow M, Schlabach D, Peiffer J, Cook C. Differences in change scores and the predictive validity of three commonly used measures following concussion in the middle school and high school aged population. Int J Sports Phys Ther. 2011;6:150–7.
Moor HM, Eisenhauer RC, Killian KD, Proudfoot N, Henriques AA, Congeni JA, et al. The relationship between adherence behaviors and recovery time in adolescents after a sports-related concussion: an observational study. Int J Sports Phys Ther. 2015;10:225–33.
Chrisman SP, Rivara FP, Schiff MA, Zhou C, Comstock RD. Risk factors for concussive symptoms 1 week or longer in high school athletes. Brain Inj. 2013;27:1–9.
Corwin DJ, Zonfrillo MR, Master CL, Arbogast KB, Grady MF, Robinson RL, et al. Characteristics of prolonged concussion recovery in a pediatric subspecialty referral population. J Pediatr. 2014;165:1207–15.
Terwilliger VK, Pratson L, Vaughan CG, Gioia GA. Additional post-concussion impact exposure may affect recovery in adolescent athletes. J Neurotrauma. 2016;33:761–5.
Lau BC, Collins MW, Lovell MR. Cutoff scores in neurocognitive testing and symptom clusters that predict protracted recovery from concussions in high school athletes. Neurosurgery. 2012;70:371–9 discussion 379.
Mautner K, Sussman WI, Axtman M, Al-Farsi Y, Al-Adawi S. Relationship of attention deficit hyperactivity disorder and postconcussion recovery in youth athletes. Clin J Sport Med. 2015;25:355–60.
Baker JG, Leddy JJ, Darling SR, Rieger BP, Mashtare TL, Sharma T, et al. Factors associated with problems for adolescents returning to the classroom after sport-related concussion. Clin Pediatr (Phila). 2015;54:961–8.
Eisenberg MA, Andrea J, Meehan W, Mannix R. Time interval between concussions and symptom duration. Pediatrics. 2013;132:8–17.
Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train. 2007;42:495–503.
•• Covassin T, Moran R, Elbin RJ. Sex differences in reported concussion injury rates and time loss from participation: an update of the National Collegiate Athletic Association Injury Surveillance Program from 2004–2005 through 2008–2009. J Athl Train. 2016;51:189–94 Large study summarizing sex differences in concussion rates and recovery after SRC in collegiate athletes.
Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40:747–55.
Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Norris JB, Hinton RY. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39:958–63.
O'Connor KL, Baker MM, Dalton SL, Dompier TP, Broglio SP, Kerr ZY. Epidemiology of sport-related concussions in high school athletes: National Athletic Treatment, Injury and Outcomes Network (NATION), 2011-2012 through 2013-2014. J Athl Train. 2017;52:175–85.
Berz K, Divine J, Foss KB, Heyl R, Ford KR, Myer GD. Sex-specific differences in the severity of symptoms and recovery rate following sports-related concussion in young athletes. Phys Sportsmed. 2013;41:58–63.
Bock S, Grim R, Barron TF, Wagenheim A, Hu YE, Hendell M, et al. Factors associated with delayed recovery in athletes with concussion treated at a pediatric neurology concussion clinic. Childs Nerv Syst. 2015;31:2111–6.
Kostyun RO, Hafeez I. Protracted recovery from a concussion: a focus on gender and treatment interventions in an adolescent population. Sports Health. 2015;7:52–7.
Zuckerman SL, Solomon GS, Forbes JA, Haase RF, Sills AK, Lovell MR. Response to acute concussive injury in soccer players: is gender a modifying sfactor? J Neurosurg Pediatr. 2012;10:504–10.
Lax ID, Paniccia M, Agnihotri S, Reed N, Garmaise E, Azadbakhsh M, et al. Developmental and gender influences on executive function following concussion in youth hockey players. Brain Inj. 2015;29:1409–19.
Ono KE, Burns TG, Bearden DJ, McManus SM, King H, Reisner A. Sex-based differences as a predictor of recovery trajectories in young athletes after a sports-related concussion. Am J Sports Med. 2016;44:748–52.
Wallace J, Covassin T, Beidler E. Sex differences in high school athletes’ knowledge of sport-related concussion symptoms and reporting behaviors. J Athl Train. 2017;52:682–8.
Meehan WI, Mannix R, Stracciolini A, Elbin R, Collins M. Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not. J Pediatr. 2013;163:721–5.
Sufrinko A, McAllister-Deitrick J, Elbin RJ, Collins MW, Kontos AP. Family history of migraine associated with posttraumatic migraine symptoms following sport-related concussion. J Head Trauma Rehabil. 2018;33:7–14.
Kontos AP, Elbin RJ, Lau B, Simensky S, Freund B, French J, et al. Posttraumatic migraine as a predictor of recovery and cognitive impairment after sport-related concussion. Am J Sports Med. 2013;41:1497–504.
Nelson LD, Guskiewicz KM, Marshall SW, Hammeke T, Barr W, Randolph C, et al. Multiple self-reported concussions are more prevalent in athletes with ADHD and learning disability. Clin J Sport Med. 2016;26:120–7.
• Zuckerman SL, Lee YM, Odom MJ, Solomon GS, Sills AK. Baseline neurocognitive scores in athletes with attention deficit-spectrum disorders and/or learning disability. J Neurosurg Pediatr. 2013;12:103–9 One of earliest studies showing differences in neurocognitive baseline testing among athlets with learning disabilities compared to those without learning disabilities.
Guerriero RM, Kuemmerle K, Pepin MJ, Taylor AM, Wolff R, Meehan WP 3rd. The association between premorbid conditions in school-aged children with prolonged concussion recovery. J Child Neurol. 2018;33:168–73.
Legarreta AD, Brett BL, Solomon GS, Zuckerman SL. The role of family and personal psychiatric history in postconcussion syndrome following sport-related concussion: a story of compounding risk. J Neurosurg Pediatr. 2018:1–6.
Yengo-Kahn AM, Solomon G. Are psychotropic medications associated with differences in baseline neurocognitive assessment scores for young athletes? A pilot study. Phys Sportsmed. 2015;43:227–35.
Gardner RM, Yengo-Kahn A, Bonfield CM, Solomon GS. Comparison of baseline and post-concussion ImPACT test scores in young athletes with stimulant-treated and untreated ADHD. Phys Sportsmed. 2017;45:1–10.
• Zuckerman SL, Totten DJ, Rubel KE, Kuhn AW, Yengo-Kahn AM, Solomon GS. Mechanisms of injury as a diagnostic predictor of sport-related concussion severity in football, basketball, and soccer: results from a regional concussion registry. Neurosurgery. 2016;63(Suppl 1):102–12 Important study analyzing the importance of mechanism of injury in recovery after SRC.
Brett BL, Kuhn AW, Yengo-Kahn AM, Kerr ZY, Bonfield CM, Solomon GS, et al. Initial symptom presentation after high school football-related concussion varies by time point in a season: an initial investigation. Sports Med Open. 2018;4:8.
Zuckerman SL, Lee YM, Odom MJ, Forbes JA, Solomon GS, Sills AK. Sports-related concussion in helmeted vs. unhelmeted athletes: who fares worse? Int J Sports Med. 2015;36:419–25.
Stancin T, Wade SL, Walz NC, Yeates KO, Taylor HG. Family adaptation 18 months after traumatic brain injury in early childhood. J Dev Behav Pediatr. 2010;31:317–25.
Olsson KA, Lloyd OT, Lebrocque RM, McKinlay L, Anderson VA, Kenardy JA. Predictors of child post-concussion symptoms at 6 and 18 months following mild traumatic brain injury. Brain Inj. 2013;27:145–57.
Zuckerman SL, Zalneraitis BH, Totten DJ, Rubel KE, Kuhn AW, Yengo-Kahn AM, et al. Socioeconomic status and outcomes after sport-related concussion: a preliminary investigation. J Neurosurg Pediatr. 2017;19:652–61.
Conflict of Interest
Gary S. Solomon reports personal fees from the National Football League, personal fees from NHL Nashville Predators, other from Tennessee Titans, other from University of Tennessee Athletics, other from Tennessee Tech Athletics, other from Department of Defense, outside the submitted work. Benjamin L. Brett, Aaron M. Yengo-Kahn, Scott L. Zuckerman, and Aaron Jeckell each declare no potential conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
This article is part of the Topical Collection on Pediatric Neurology
About this article
Cite this article
Zuckerman, S.L., Brett, B.L., Jeckell, A.S. et al. Prognostic Factors in Pediatric Sport-Related Concussion. Curr Neurol Neurosci Rep 18, 104 (2018). https://doi.org/10.1007/s11910-018-0909-4
- Sport-related concussion
- Traumatic brain injury
- Post-concussion syndrome
- Modifying factors