Brain, Biology and Behavior, Center for


Date of this Version


Document Type



Published in The American Journal of Sports Medicine (2022), 13 pp.

DOI: 10.1177/03635465221098112


Copyright © 2022 by the authors. Published by SAGE Publications. Used by permission.


Background: There is growing awareness and clinical interest in athletes with affective symptoms after sport-related concussion (SRC), as these symptoms may contribute to overall symptoms and represent a modifiable risk factor of longer recovery. However, evidence of their effects on the entire return-to-play (RTP) trajectory, particularly among women and men, is limited.

Purpose/Hypothesis: To examine the relationship between affective symptom reporting and RTP progression after SRC among a cohort of Division 1 student-athletes. We hypothesized that those endorsing affective symptoms, specifically nervous-anxious symptoms, spend more time in RTP progression and recovery.

Study Design: Cohort study; Level of evidence, 3.

Methods: Using SRC data from the Ivy League–Big Ten Epidemiology of Concussion Study among varsity athletes through February 2020, we identified the 4 affective symptoms from the Sport Concussion Assessment Tool symptom inventory. We modeled the relationship between a 4-category affective symptom variable and time to symptom resolution, RTP, and RTP progression, adjusting for nonaffective symptom prevalence and concussion history. Cox regressions were used to estimate hazard ratios for time to event outcomes, and linear regressions were used to evaluate mean differences for continuous outcomes.

Results: Among 2077 student-athletes (men, 63.5%) with SRC symptoms, affective symptom prevalence was 47.6% and 44.3% in women and men, respectively, and nervous-anxious prevalence was 24.2% and 22.5%, respectively. When comparing women with and without co-occurring affective symptoms, rates of symptom resolution and RTP were significantly lower in those with affective symptoms, and women with nervous-anxious symptoms spent significantly longer in RTP progression. When comparing men with and without co-occurring affective symptoms, rates of symptom resolution and RTP were significantly lower in those with co-occurring affective symptoms, and affective symptoms were not associated with time in RTP progression.

Conclusion: Student-athletes with affective symptoms and nervous-anxious symptoms exhibited delayed clinical recovery and RTP timelines, particularly for time in RTP. Symptom prevalence and concussion history contributed to this; however, unmeasured confounding remains, as indicated by the poor model fit. This study motivates future work to explore affective symptoms and RTP timelines, considering anxiety and risk/protective factors over time.

Ivy League–Big Ten Epidemiology of Concussion Study Investigators: Current and past site investigators have been instrumental in accomplishing this work: Russell Fiore, MEd, ATC, and Bryn VanPatten, PhD, MSEd, ATC (Brown University) William N. Levine, MD, and Natasha Desai, MD (Columbia University) David C. Wentzel, DO, and Amy Sucheski-Drake, MD (Cornell University) Kristine A. Karlson, MD (Dartmouth College) Frank Wang, MD, and Lars Richardson, MD, PhD (Harvard University) Nicholas L. Port, PhD (Indiana University) Mathew Saffarian, DO, (Michigan State University) Brian Vesci, MA, ATC (Northwestern University) Michael Gay, PhD, ATC (Pennsylvania State University) Carly Day, MD (Purdue University) Margot Putukian, MD (Princeton University) Carrie Esopenko, PhD (Rutgers University) Matthew B. Wheeler, PhD, and Randy A. Ballard, ATC (University of Illinois) Andy Peterson, MD, MSPH (University of Iowa) David Klossner, PhD (University of Maryland) Erin M. Moore, MEd, ATC (University of Minnesota) Art Maerlender, PhD, and Cary R Savage, PhD (University of Nebraska-Lincoln) Brian J. Sennett, MD (University of Pennsylvania) Stephanie Arlis-Mayor, MD (Yale University).

Includes Appendix