Skip to main content Accessibility help

Standard regression-based methods for measuring recovery after sport-related concussion

  • MICHAEL McCREA (a1) (a2), WILLIAM B. BARR (a3), KEVIN GUSKIEWICZ (a4) (a5) (a6), CHRISTOPHER RANDOLPH (a7), STEPHEN W. MARSHALL (a6) (a8), ROBERT CANTU (a4) (a9), JAMES A. ONATE (a10) and JAMES P. KELLY (a11)...


Clinical decision making about an athlete's return to competition after concussion is hampered by a lack of systematic methods to measure recovery. We applied standard regression-based methods to statistically measure individual rates of impairment at several time points after concussion in college football players. Postconcussive symptoms, cognitive functioning, and balance were assessed in 94 players with concussion (based on American Academy of Neurology Criteria) and 56 noninjured controls during preseason baseline testing, and immediately, 3 hr, and 1, 2, 3, 5, and 7 days postinjury. Ninety-five percent of injured players exhibited acute concussion symptoms and impairment on cognitive or balance testing immediately after injury, which diminished to 4% who reported elevated symptoms on postinjury day 7. In addition, a small but clinically significant percentage of players who reported being symptom free by day 2 continued to be classified as impaired on the basis of objective balance and cognitive testing. These data suggest that neuropsychological testing may be of incremental utility to subjective symptom checklists in identifying the residual effects of sport-related concussion. The implementation of neuropsychological testing to detect subtle cognitive impairment is most useful once postconcussive symptoms have resolved. This management model is also supported by practical and other methodological considerations. (JINS, 2005, 11, 58–69.)


Corresponding author

Reprint requests to: Michael McCrea, Ph.D., ABPP-CN, Program Director, Neuroscience Center, Waukesha Memorial Hospital, 721 American Avenue, Suite 501, Waukesha, WI 53188. E-mail:


Hide All


Aubry, M., Cantu, R., Dvorak, J., Graf-Baumann, T., Johnston, K., Kelly, J.P., Lovell, M., McCrory, P., Meeuwisse, W., & Schamasch, P. (2002). Concussion in sport group. Summary and agreement statement of the first International Conference on concussion in sport, Vienna 2001. Physician and Sports Medicine, 30, 5763.
Barr, W.B. (2002). Neuropsychological testing for assessment of treatment effects: Methodological issues. CNS Spectrums, 7, 300306.
Barr, W.B. (2003). Neuropsychological testing of high school athletes. Preliminary norms and test–retest indices. Archives of Clinical Neuropsychology, 18, 91101.
Barr, W.B. & McCrea, M. (2001). Sensitivity and specificity of standardized neurocognitive testing immediately following sports concussion. Journal of the International Neuropsychological Society, 7, 693702.
Benton, A.L., Hamsher, K., & Sivian, A.B. (1983). Multilingual Aphasia Examination (3rd ed.). Iowa City, IA: AJA Associates.
Cantu, R.C. (1986). Guidelines for return to contact sports after a cerebral concussion. Physician and Sports Medicine, 14, 7583.
Cantu, R.C. (1998). Return to play guidelines after a head injury. Clinics in Sports Medicine, 17, 4560.
Collins, M.W., Grindel, S.H., Lovell, M.R., Dede, D.E., Moser, D.J., Phalin, B.R., Nogle, S., Wasik, M., Cordry, D., Daugherty, K.M., Sears, S.F., Nicolette, G., Indelicato, P., & McKeag, D.B. (1999). Relationship between concussion and neuropsychological performance in college athletes. Journal of the American Medical Association, 282, 964970.
Collins, M.W., Lovell, M.R., & McKeag, D.B. (1999). Current issues in managing sports-related concussion. Journal of the American Medical Association, 282, 22832285.
Collins, M.W., Field, M., Lovell, M.R., Iverson, G., Johnston, K.M., Maroon, J., & Fu, F.H. (2003). Relationship between postconcussion headache and neuropsychological test performance in high school athletes. American Journal of Sport Medicine, 31, 168173.
Colorado Medical Society (1991). Report of the sports medicine committee: Guidelines for the management of concussion in sports. Denver, CO: Colorado Medical Society.
Covassin, T., Swanik, C.B., & Sachs, M.L. (2003). Epidemiological considerations of concussions among intercollegiate athletes. Applied Neuropsychology, 10, 1222.
Dick, R. (2003). National Collegiate Athletic Association (NCAA) Injury Survellience System 2002–2003. Indianapolis, IN: NCAA.
Diggle, P.J., Liang, K.Y., & Zeger, S.L. (1994). Analysis of longitudinal data. Oxford, England: Oxford University Press.
Echemendia, R.J. & Julian, L.J. (2001). Mild traumatic brain injury in sports: Neuropsychology's contribution to a developing field. Neuropsychological Reviews, 11, 6988.
Echemendia, R.J., Putukian, M., Mackin, R.S., Julian, L., & Shoss, N. (2001). Neuropsychological test performance prior to and following sports-related mild traumatic brain injury. Clinical Journal of Sport Medicine, 11, 2331.
Erlanger, D., Kaushik, T., Cantu, R., Barth, J.T., Broshek, D.K., Freeman, J.R., & Webbe, F.M. (2003). Symptom-based assessment of the severity of a concussion. Journal of Neurosurgery, 98, 477484.
Golden, J.C. (1978). Stroop Color and Word Test. Chicago, Illinois: Stoelting Co.
Guskiewicz, K.M., McCrea, M., Marshall, S.W., Cantu, R.C., Randolph, C., Barr, W., Onate, J.A., & Kelly, J.P. (2003). Cumulative effects associated with recurrent concussion in collegiate football players: The NCAA Concussion Study. Journal of the American Medical Association, 290, 25492555.
Guskiewicz, K.M., Ross, S.E., & Marshall, S.W. (2001). Postural stability and neuropsychological deficits after concussion in collegiate athletes. Journal of Athletic Training, 36, 263273.
Guskiewicz, K.M., Weaver, N.L., Padua, D.A., & Garrett, W.E. (2000). Epidemiology of concussion in collegiate and high school football players. American Journal of Sport Medicine, 28, 642650.
Hinton-Bayre, A.D., Geffen, G.M., Geffen, L.B., McFarland, K.A., & Friis, P. (1999). Concussion in contact sports: Reliable change indices of impairment and recovery. Journal of Clinical and Experimental Neuropsychology, 21, 7086.
Kelly, J. (1999). Traumatic brain injury and concussion in sports. Journal of the American Medical Association, 282, 989991.
Kelly, J.P. & Rosenberg, J.H. (1997). Diagnosis and management of concussion in sports. Neurology, 48, 575580.
Lovell, M.R. & Collins, M.W. (1998). Neuropsychological assessment of the college football player. Journal of Head Trauma Rehabilitation, 13, 926.
Lovell, M.R., Collins, M.W., Iverson, G.L., Field, M., Maroon, J.C., Cantu, R., Podell, K., Powell, J.W., Belza, M., & Fu, F.H. (2003). Recovery from mild concussion in high school athletes. Journal of Neurosurgery, 98, 296301.
Macciocchi, S.N., Barth, J.T., Alves, W., Rimel, R.W., & Jane, J.A. (1996). Neuropsychological functioning and recovery after mild head injury in collegiate athletes. Neurosurgery, 39, 510514.
Maddocks, D. & Saling, M. (1996). Neuropsychological deficits following concussion. Brain Injury, 10, 99103.
McCrea, M. (2001). Standardized mental status testing on the sideline after sport-related concussion. Journal of Athletic Training, 36, 274279.
McCrea, M., Guskiewicz, K.M., Marshall, S., Barr, W.B., Randolph, C., Cantu, R.C, Onate, J.A., Yang, J., & Kelly, J.P. (2003). Acute effects and recovery time following concussion in collegiate football players: The NCAA Concussion Study. Journal of the American Medical Association, 290, 25562563.
McCrea, M., Hammeke, T., Olsen, G., Leo, P., & Guskiewicz K. (2004). Unreported concussion in high school football players: Implications for prevention. Clinical Journal of Sport Medicine, 14, 1317
McCrea, M., Kelly, J.P, Kluge, J., Ackley, B., & Randolph, C. (1997). Standardized assessment of concussion in football players. Neurology, 48, 586588.
McCrea, M., Kelly, J.P., Randolph, C., Cisler, R.A., & Berger, L. (2002). Immediate neurocognitive effects of concussion. Neurosurgery, 50, 10321042.
McCrea, M., Kelly, J.P., Randolph, C., Kluge, J., Bartolic, E., Finn, G., & Baxter, B. (1998). Standardized assessment of concussion: On-site mental status evaluation of the athlete. Journal of Head Trauma Rehabilitation, 13, 2735.
McCrea, M., Randolph, C., & Kelly, J.P. (2000). The Standardized Assessment of Concussion (SAC): Manual for Administration, Scoring and Interpretation (2nd ed.). Waukesha, WI.
McSweeny, A.J., Naugle, R.I., & Chelune, G.J. (1993). T-scores for change: An illustration of a regression approach to depicting change in clinical neuropsychology. The Clinical Neuropsychologist, 7, 300312.
Powell, J.W. & Barber-Foss, K.D. (1999). Traumatic brain injury in high school athletes. Journal of the American Medical Association, 282, 958963.
Practice Parameter (1997). The management of concussion in sports (summary statement). Report of the quality standards committee. Neurology, 48, 581585.
Reitan, R.M. & Wolfson, D. (1985). The Halstead-Reitan Neuropsychological Test Battery. Tucson, AZ: Neuropsychology Press.
Riemann, B.L. & Guskiewicz, K.M. (2000). Effects of mild head injury on postural stability as measured through clinical balance testing. Journal Athletic Training, 25, 1925.
Riemann, B.L., Guskiewicz, K.M., & Shields, E.W. (1999). Relationship between clinical and forceplate measures of postural stability. Journal of Sports Rehabilitation, 8, 7182.
Rubin, D.B. (1976). Inference and missing data. Biometrika, 63, 581592.
Rubin, D.B. (1996). Multiple imputation after 18+ years. Journal of the American Statistical Association, 91, 473489.
Schafer, J.L. (1997). Analysis of incomplete multivariate data. New York, NY: Chapman and Hall.
Shapiro, A.M., Benedict, R.H., Schretlen, D., & Brandt, J. (1999). Construct and concurrent validity of the Hopkins Verbal Learning Test–Revised. Clinical Neuropsychologist, 13, 348358.
Smith, A. (1991). Symbol Digit Modalities Test. Los Angeles, CA: Western Psychological Services.
SPSS (1999). SPSS Advanced Models 10.0. SPSS, Inc.
Temkin, N.R., Heaton, R.K., Grant, I., & Dikmen, S.S. (1999). Detecting significant change in neuropsychological test performance: A comparison of four models. Journal of the International Neuropsychological Society, 5, 357369.
Thurman, D., Branche, C., & Sniezek, J. (1998). The epidemiology of sports-related traumatic brain injuries in the United States: recent developments. Journal of Head Trauma Rehabilitation, 13, 18.
Vastag, B. (2002). Football brain injuries draw increased scrutiny. Journal of the American Medical Association, 287, 437439.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Journal of the International Neuropsychological Society
  • ISSN: 1355-6177
  • EISSN: 1469-7661
  • URL: /core/journals/journal-of-the-international-neuropsychological-society
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed