Original research| Volume 18, ISSUE 5, P507-511, September 2015

The underreporting of self-reported symptoms following sports-related concussion



      This cohort study was conducted to examine patterns of symptom reporting in concussed athletes in two different testing environments.


      A prospective cohort study was conducted with repeated measures.


      Self-reported symptoms collected by team athletic trainers using the ImPACT Post-Concussion Scale (PCS) were compared to symptoms collected in a confidential setting using structured interviews for depression and anxiety. Ratings were scaled to match scoring of the PCS and categorized into symptom-domains. Scores collected 2 days post-concussion were compared across different rating scales. Confidential self-report scores approximately 9 days post-concussion in cleared athletes were compared to PCS scores collected during return-to-play decisions. Finally, confidential self-report scores collected 9 days post-concussion were compared between cleared and not cleared athletes.


      Athletes self-reported significantly fewer symptoms to team athletic trainers using the ImPACT test compared to self-reported symptoms collected in a confidential setting during the acute phase of concussion using standard psychiatric interviews. Athletes cleared to play continued to underreport symptoms 9 days post-concussion, particularly psychiatric symptoms. Finally, cleared athletes self-reported similar magnitude of symptoms than non-cleared athletes 9 days post-concussion in confidential research setting.


      The systematic underreporting of post-concussion symptoms may represent motivated behavior or differences in self-reporting data acquisition. By underreporting symptoms, many cleared athletes are still symptomatic over 1-week post-concussion. This study highlights the need for objective measures for somatic and psychiatric symptoms.


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        • McCrory P.
        • Meeuwisse W.H.
        • Echemendia R.J.
        • et al.
        What is the lowest threshold to make a diagnosis of concussion?.
        Br J Sports Med. 2013; 47: 268-271
        • McCrory P.
        • Meeuwisse W.H.
        • Aubry M.
        • 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: 250-258
        • McCrea M.
        • Hammeke T.
        • Olsen G.
        • et al.
        Unreported concussion in high school football players: implications for prevention.
        Clin J Sport Med. 2004; 14: 13-17
        • Maroon J.C.
        • Lovell M.R.
        • Norwig J.
        • et al.
        Cerebral concussion in athletes: evaluation and neuropsychological testing.
        Neurosurgery. 2000; 47 (discussion 669–672): 659-669
        • Cernich A.
        • Reeves D.
        • Sun W.
        • et al.
        Automated neuropsychological assessment metrics sports medicine battery.
        Arch Clin Neuropsychol. 2007; 22: S101-S114
        • McCrory P.
        Sport concussion assessment tool 2.
        Scand J Med Sci Sports. 2009; 19: 452
        • Giza C.C.
        • Kutcher J.S.
        • Ashwal S.
        • et al.
        Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology.
        Neurology. 2013; 80: 2250-2257
        • Delaney J.S.
        • Lacroix V.J.
        • Leclerc S.
        • et al.
        Concussions among university football and soccer players.
        Clin J Sport Med. 2002; 12: 331-338
        • Kaut K.P.
        • DePompei R.
        • Kerr J.
        • et al.
        Reports of head injury and symptom knowledge among college athletes: implications for assessment and educational intervention.
        Clin J Sport Med. 2003; 13: 213-221
        • Lovell M.R.
        • Solomon G.S.
        Neurocognitive test performance and symptom reporting in cheerleaders with concussions.
        J Pediatr. 2013; 163: 1192-1195
        • Van Kampen D.A.
        • Lovell M.R.
        • Pardini J.E.
        • et al.
        The “value added” of neurocognitive testing after sports-related concussion.
        Am J Sports Med. 2006; 34: 1630-1635
        • Fazio V.C.
        • Lovell M.R.
        • Pardini J.E.
        • et al.
        The relation between post concussion symptoms and neurocognitive performance in concussed athletes.
        Neurorehabilitation. 2007; 22: 207-216
        • Hamilton M.
        A rating scale for depression.
        J Neurol Neurosurg Psychiatry. 1960; 23: 56-62
        • Hamilton M.
        The assessment of anxiety states by rating.
        Br J Med Psychol. 1959; 32: 50-55
        • Register F.
        Protection of human subjects: Belmont report – ethical principals and guidelines for the protection of human subjects of research. vol. 44. 1979: 23192-23197
        • Lovell M.R.
        • Iverson G.L.
        • Collins M.W.
        • et al.
        Measurement of symptoms following sports-related concussion: reliability and normative data for the post-concussion scale.
        Appl Neuropsychol. 2006; 13: 166-174
        • Williams J.B.
        A structured interview guide for the Hamilton Depression Rating Scale.
        Arch Gen Psychiatry. 1988; 45: 742-747
        • Williams J.B.W.
        • Terman M.
        Structured interview guide for the hamilton depression rating scale with atypical depression supplement (SIGH-ADS).
        New York State Psychiatric Institute, New York2003
        • Shear M.K.
        • Vander Bilt J.
        • Rucci P.
        • et al.
        Reliability and validity of a structured interview guide for the Hamilton Anxiety Rating Scale (SIGH-A).
        Depress Anxiety. 2001; 13: 166-178
        • Lau B.
        • Lovell M.R.
        • Collins M.W.
        • et al.
        Neurocognitive and symptom predictors of recovery in high school athletes.
        Clin J Sport Med. 2009; 19: 216-221
        • Williamson I.J.
        • Goodman D.
        Converging evidence for the under-reporting of concussions in youth ice hockey.
        Br J Sports Med. 2006; 40 (discussion 128–132): 128-132
        • Llewellyn T.
        • Burdette G.T.
        • Joyner A.B.
        Concussion reporting rates at the conclusion of an intercollegiate athletic career.
        Clin J Sport Med. 2014; 24: 76-79
        • Chrisman S.P.
        • Quitiquit C.
        • Rivara F.P.
        Qualitative study of barriers to concussive symptom reporting in high school athletics.
        J Adolesc Health. 2013; 52 (e333): 330-335
        • Konrad C.
        • Geburek A.J.
        • Rist F.
        • et al.
        Long-term cognitive and emotional consequences of mild traumatic brain injury.
        Psychol Med. 2011; 41: 1197-1211
        • Kreutzer J.S.
        • Seel R.T.
        • Gourley E.
        The prevalence and symptom rates of depression after traumatic brain injury: a comprehensive examination.
        Brain Inj. 2001; 15: 563-576
        • Ramanathan D.M.
        • Rabinowitz A.R.
        • Barwick F.H.
        • et al.
        Validity of affect measurements in evaluating symptom reporting in athletes.
        J Int Neuropsychol Soc. 2012; 18: 101-107