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Estimating the Relationship Between the Symptom-Free Waiting Period and Injury Rates After Return-to-Play from Concussion: A Simulation Analysis Using CARE Consortium Data

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Abstract

Background

A key component of return-to-play (RTP) from sport-related concussion is the symptom-free waiting period (SFWP), i.e., the period during which athletes must remain symptom-free before permitting RTP. Yet, the exact relationship between SFWP and post-RTP injury rates is unclear.

Objective

We design computational simulations to estimate the relationship between the SFWP and rates of repeat concussion and non-concussion time-loss injury up to 30 days post-RTP for male and female collegiate athletes across 13 sports.

Methods

We leverage N = 735 female and N = 1,094 male post-injury trajectories from the National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research, and Education Consortium.

Results

With a 6-day SFWP, the mean [95% CI] rate of repeat concussion per 1,000 simulations was greatest in ice hockey for females (20.31, [20.16, 20.46]) and American football for males (24.16, [24.05, 24.28]). Non-concussion time-loss injury rates were greatest in field hockey for females (153.66, [152.59, 154.74]) and wrestling for males (247.34, [246.20, 248.48]). Increasing to a 13-day SFWP, ice hockey for females (18.88, [18.79, 18.98]) and American football for males (23.16, [23.09, 24.22]) exhibit the greatest decrease in repeat concussion rates across all sports within their respective sexes. Field hockey for females (143.24, [142.53, 143.94]) and wrestling for males (237.73, [236.67, 237.90]) exhibit the greatest decrease in non-concussion time-loss injury rates. Males receive marginally smaller reductions in injury rates for increased SFWP compared to females (OR = 1.003, p ≤ 0.002).

Conclusion

Longer SFWPs lead to greater reductions in post-RTP injury rates for athletes in higher risk sports. Moreover, SFWPs should be tailored to sport-specific post-RTP injury risks.

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Acknowledgements

We thank Jody Harland, Susan Perkins, Barry Katz, Janetta Matesan, and Larry Riggen (Indiana Univ.), Ashley Rettmann, Nicole L'Heureux (Univ. of Michigan), Melissa Koschnitzke (Medical College of Wisconsin), Michael Jarrett, Vibeke Brinck, and Bianca Byrne (Quesgen), Thomas Dompier, Christy Collins, Melissa Niceley Baker, and Sara Dalton (Datalys Center for Sports Injury Research and Prevention), Stacey Harcum (Uniformed Services Univ.), and the research/medical staff at each participating site. CARE Consortium Investigators include (alphabetical by institution): Louise A. Kelly, Ph.D. (California Lutheran University); Justus D. Ortega, PhD (California State Polytechnic University, Humboldt); Kenneth L. Cameron, Ph.D., MPH, ATC (United States Military Academy); Joshua T. Goldman, MD, MBA (University of California, Berkeley); Holly J. Benjamin, MD (University of Chicago); Thomas Buckley, EdD, ATC, and Thomas W. Kaminski, Ph.D., ATC (University of Delaware); James R. Clugston, MD, MS, CAQSM (University of Florida); Julianne Schmidt, Ph.D., ATC (University of Georgia); Luis A. Feigenbaum, PT, DPT, ATC (University of Miami); James T. Eckner, MD, MS (University of Michigan); Jason P. Mihalik, Ph.D., CAT(C), ATC (University of North Carolina at Chapel Hill); Scott A. Anderson, ATC (University of Oklahoma); Christina L. Master, MD, CAQSM (University of Pennsylvania); Anthony P. Kontos, Ph.D. (University of Pittsburgh); Sara Chrismas, MD, MPH (University of Washington); Alison Brooks, MD MPH (University of Wisconsin-Madison); Chris Miles, MD (Wake Forest University).

Author information

Authors and Affiliations

  1. H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA

    Gian-Gabriel P. Garcia

  2. Department of Industrial and Operations Engineering, University of Michigan, Ann Arbor, MI, USA

    Lauren L. Czerniak & Mariel S. Lavieri

  3. Department of Neurology, University of Utah, Salt Lake City, UT, USA

    Spencer W. Liebel

  4. Synaptek LLC, Lexington, KY, USA

    Kathryn L. Van Pelt

  5. Department of Physical Medicine and Rehabilitation, Uniformed Services University of the Health Sciences, Bethesda, MD, USA

    Paul F. Pasquina

  6. Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA

    Thomas W. McAllister

  7. Departments of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA

    Michael A. McCrea

  8. Michigan Concussion Center, University of Michigan, Ann Arbor, MI, USA

    Steven P. Broglio

Authors
  1. Gian-Gabriel P. Garcia
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  2. Lauren L. Czerniak
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  3. Mariel S. Lavieri
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  4. Spencer W. Liebel
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  5. Kathryn L. Van Pelt
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  6. Paul F. Pasquina
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  7. Thomas W. McAllister
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  8. Michael A. McCrea
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  9. Steven P. Broglio
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Consortia

CARE Consortium Investigators

  • Louise A. Kelly
  • , Justus D. Ortega
  • , Kenneth L. Cameron
  • , Joshua T. Goldman
  • , Holly J. Benjamin
  • , Thomas Buckley
  • , Thomas W. Kaminski
  • , James R. Clugston
  • , Julianne Schmidt
  • , Luis A. Feigenbaum
  • , James T. Eckner
  • , Jason P. Mihalik
  • , Scott A. Anderson
  • , Christina L. Master
  • , Anthony P. Kontos
  • , Sara Chrismas
  • , Alison Brooks
  •  & Chris Miles

Corresponding author

Correspondence to Gian-Gabriel P. Garcia.

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Author contributions

GPG led the design of the study, data analysis, and writing of the manuscript. LLC and MSL contributed to the design of the study, data analysis, and writing of the manuscript. SWL contributed to the interpretation of results and writing of the manuscript. KLV contributed to the derivation of injury rates, interpretation of results, and writing of the manuscript. PFP, TWM, and MAM aided in obtaining the dataset, securing funding, and revising the manuscript. SPB contributed to the design of the study, data acquisition, interpretation of results, and writing of the manuscript.

Conflict of interest

LLC, MSL, SWL, and PFP have no conflicts of interest; GPG was a paid consultant for Synaptek LLC NSF SBIR (Award 2051965); KLV is co-founder and has equity interest in concussion management software company Synaptek LLC; TWM has current or past research funding from the National Institutes of Health, Department of Defense, and National Collegiate Athletic Association; MAM has current or past research funding from the Department of Defense and National Collegiate Athletic Association; SPB has current or past research funding from the National Institutes of Health; Centers for Disease Control and Prevention; Department of Defense—USA Medical Research Acquisition Activity, National Collegiate Athletic Association; National Athletic Trainers’ Association Foundation; National Football League/Under Armour/GE; Simbex; and ElmindA. He has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medico-legal litigation, and received speaker honorarium and travel reimbursements for talks given. He is co-author of “Biomechanics of Injury (3rd edition)” and has a patent pending on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” (U.S. Application No. 17/164,490). He is/was on the editorial boards (all unpaid) for Journal of Athletic Training (2015 to present), Concussion (2014 to present), Athletic Training & Sports Health Care (2008 to present), and British Journal of Sports Medicine (2008 to 2019).

Funding

This material is based upon work supported by the National Science Foundation Graduate Research Fellowship under Grant No. DGE 1256260. This publication was also made possible, in part, by support from the Grand Alliance CARE Consortium, funded by the NCAA 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).

Ethics approval

This research study follows the standards of ethics stated in the Declaration of Helsinki.

Consent to participate

All individuals provided written informed consent that was approved by their local institution review board and the US Army Human Research Protection Office.

Availability of data and material

The NCAA-DoD CARE dataset is available in the FITBIR database (https://fitbir.nih.gov/).

Code availability

The Python code is accessible by contacting the corresponding author.

Additional information

The members of CARE Consortium Investigators are listed in acknowledgements.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 327 kb)

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Garcia, GG.P., Czerniak, L.L., Lavieri, M.S. et al. Estimating the Relationship Between the Symptom-Free Waiting Period and Injury Rates After Return-to-Play from Concussion: A Simulation Analysis Using CARE Consortium Data. Sports Med 53, 2513–2528 (2023). https://doi.org/10.1007/s40279-023-01901-5

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