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Optimizing Order of Administration for Concussion Baseline Assessment Among NCAA Student-Athletes and Military Cadets



Concussion pre-injury (i.e., baseline) assessments serve as a benchmark comparison point in the event an individual sustains a concussion and allows clinicians to compare to post-injury measures. However, baseline assessments must reflect the individual’s true and most optimized performance to serve as a useful comparison. Mental fatigue and motivation throughout baseline testing may alter individual assessment performance, indicating an order of administration (OoA) may play an influential role in assessment outcomes.


To examine the influence concussion baseline battery OoA has on symptom, postural stability, cognitive screening, and computerized neurocognitive test outcomes.


We employed a retrospective observational cohort study to examine healthy collegiate student-athletes and military cadets (n = 2898, 19.0 ± 1.4 years, 66.1% male, 75.6% white, 54.4% Division-I) baseline assessment performance on the Sport Concussion Assessment Tool (SCAT; total symptom number and severity), Balance Error Scoring System (BESS; total error scores), Standardized Assessment of Concussion (SAC; total score), and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) domain scores (verbal and visual memory, visual-motor speed, reaction time). Assessments were binned to beginning, middle, or end tertiles based upon OoA. We used one-way ANOVAs with Tukey post-hoc t tests, 95% confidence intervals (CI), and Cohen’s d effect sizes for significant models (α = 0.05).


SCAT total symptom number (mean difference = 2.23; 95% CI 1.76–2.70; d = 0.49, p < 0.001) and severity (mean difference = 5.58; 95% CI 4.42–6.74; d = 0.50; p < 0.001) were lower when completed at the end of baseline testing compared to the middle. Total BESS errors were 1.06 lower when completed at the middle relative to the end (95% CI 0.43–1.69; d = 0.17; p = 0.001). Total SAC scores were better at the beginning relative to middle (mean difference = 0.58; 95% CI 0.25–0.90; d = 0.33; p < 0.001) and end (mean difference = 0.44; 95% CI 0.16–0.73; d = 0.24; p = 0.001). Verbal memory, visual memory, and reaction time performance were highest at the beginning (p ≤ 0.002), while visual-motor speed performance was highest at the middle (p = 0.001).


Completing baseline assessments in the order of (1) ImPACT, (2) SAC, (3) BESS, and (4) SCAT symptom checklist may improve performance across assessments collectively. Clinicians and researchers should consider completing baseline assessments in this order when possible to potentially aid in optimizing concussion baseline assessment performance and maximize post-concussion comparisons.

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We would like to thank Jody Harland, Janetta Matesan, Larry Riggen (Indiana University); Ashley Rettmann (University of Michigan); Melissa Koschnitzke (Medical College of Wisconsin); Michael Jarrett, Vibeke Brinck and Bianca Byrne (Quesgen); and the research and medical staff at each of the participating sites.

Contributing CARE Consortium Investigators include: Thomas Buckley, EdD, ATC and Thomas W. Kaminski, PhD, ATC (University of Delaware); James T. Eckner MD, MS (University of Michigan); Micky Collins and Anthony P. Kontos, PhD (University of Pittsburgh); Stefan Duma, PhD (Virginia Tech); Louise A. Kelly, PhD (California Lutheran University); Alison Brooks, MD, MPH (University of Wisconsin-Madison); April Hoy, MS, ATC (Azusa Pacific University); Luis A. Feigenbaum, PT, DPT, ATC (University of Miami); Christina L. Master, MD, FAAP, CAQSM, FACSM (Children’s Hospital of Philadelphia); Laura Lintner, DO (Wake Forest University); Jason P. Mihalik, PhD, CAT(C), ATC (University of North Carolina at Chapel Hill); Justus Ortega, PhD (Humboldt State University); Nicholas Port, PhD (Indiana University); and Adam J. Susmarski, DO (United States Naval Academy). CARE Consortium Investigators are listed alphabetically by institution: April M. (Reed) Hoy, MS, ATC (Azusa Pacific University); Joseph B. Hazzard Jr., EdD, ATC (Bloomsburg University); Louise A. Kelly, PhD (California Lutheran University); Justus D. Ortega, PhD (Humboldt State University); Nicholas Port, PhD (Indiana University); Margot Putukian MD (Princeton University); T. Dianne Langford, PhD, and Ryan Tierney, PhD, ATC (Temple University); Christopher C. Giza, MD and Joshua T. Goldman, MD, MBA (University of California, Los Angeles); Holly J. Benjamin MD (University of Chicago); Thomas Buckley, EdD, ATC, and Thomas W. Kaminski, PhD, ATC (University of Delaware); James R. Clugston, MD, MS (University of Florida); Julianne D. Schmidt, PhD, ATC (University of Georgia); Luis A. Feigenbaum, DPT, ATC (University of Miami); Steven P. Broglio, PhD, ATC and James T. Eckner, MD, MS (University of Michigan); Kevin Guskiewicz, PhD, ATC, and Jason P. Mihalik, PhD, CAT(C), ATC (University of North Carolina at Chapel Hill); Jessica Dysart Miles, PhD, ATC (University of North Georgia); Scott Anderson, ATC (University of Oklahoma); Christina L. Master, MD (University of Pennsylvania); Micky Collins, PhD, and Anthony P. Kontos, PhD (University of Pittsburgh Medical Center); Jeffrey J. Bazarian, MD, MPH (University of Rochester); Sara P. O. Chrisman, MD, MPH (University of Washington); Alison Brooks, MD, MPH (University of Wisconsin-Madison); Jonathan Jackson, MD, and Gerald McGinty, DPT (United States Air Force Academy); Patrick O’Donnell, MHA (United States Coast Guard Academy); Kenneth Cameron, PhD, MPH, ATC; Megan N. Houston, PhD, ATC (United States Military Academy); Adam Susmarski, MD (United States Naval Academy); Stefan Duma, PhD and Steve Rowson, PhD (Virginia Tech); Christopher Todd Bullers, MD, and Christopher M. Miles, MD (Wake Forest University); Brian H. Dykhuizen, MS, ATC (Wilmington College); Laura Lintner DO (Winston-Salem University).

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Correspondence to Landon B. Lempke.

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Author Contributions

All authors contributed to the study conception, study design, critical review and interpretation of findings, and drafting and/or critique of the manuscript. All authors read and approved the final manuscript. Specifically, Landon B. Lempke contributed to conceptualization, methodology, data analysis, and original and revised manuscript drafts. Robert C. Lynall and Melissa N. Anderson contributed to conceptualization, analysis interpretation, and original and revised manuscript drafting. Michael A. McCrea, Thomas W. McAllister, and Steven P. Broglio contributed to conceptualization, methodology, data analysis and manuscript critique, and funding acquisition. Julianne D. Schmidt contributed to conceptualization, analysis interpretation, original and revised manuscript drafting, and funding acquisition. The CARE Consortium Investigators contributed to critical critique and review of methodology, data analysis, and original manuscript review.


This study was made possible, in part, with support from the Grand Alliance Concussion Assessment, Research, and Education Consortium, funded by the National Collegiate Athletic Association and the Department of Defense. The US Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702-5014, USA is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Psychological Health and Traumatic Brain Injury Program under Award no. W81XWH-14-2-0151. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense (Defense Health Program funds).

Conflict of interest

Landon B. Lempke, Robert C. Lynall, Melissa N. Anderson, Michael A. McCrea, Thomas W. McAllister and Julianne D. Schmidt declare that they have no additional conflicts of interest relevant to the content of this manuscript.

Availability of data and material

The CARE Consortium datasets generated and analyzed during the current study are available in the FITBIR repository (

Research involving human participants

The study was performed in accordance with the standards of ethics outlined in the Declaration of Helsinki.

Informed consent

All study procedures were reviewed and approved by the University of Michigan IRB, the US Army Medical Research and Materiel Command Human Research Protection Office (HRPO), as well the local IRB at each of the performance sites. Participants provided written informed consent prior to participation.

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Not applicable.

Additional information

This article is part of a Topical Collection on The NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium.

Members of the ‘CARE Consortium Investigators’ are given in the Acknowledgements section.

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Lempke, L.B., Lynall, R.C., Anderson, M.N. et al. Optimizing Order of Administration for Concussion Baseline Assessment Among NCAA Student-Athletes and Military Cadets. Sports Med (2021).

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