Influence of Self-reported Fatigue and Sex on Baseline Concussion Assessment Scores

Background: Baseline concussion assessments are advocated to provide an objective preinjury point of comparison for determining the extent of postconcussion neurological deficits and to assist with return-to-activity decision making. Many factors, including testing environment, proctor availability, and testing group size, can influence test accuracy and validity; however, it is unknown how self-reported fatigue affects test scores. Purpose: To investigate the influence of self-reported fatigue and patient sex on baseline concussion assessment scores. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Participants included 494 healthy Division I college student-athletes (221 women, 273 men; mean +/- SD age, 20.0 +/- 1.3 years). During preseason baseline testing, participants were asked to rate their fatigue on a scale from 0 to 100 based on how they normally feel and function each day (0, completely exhausted; 100, completely awake and alert). Each participant then completed a multimodal baseline concussion assessment, including a graded symptom checklist (number of symptoms endorsed and total symptom severity score), Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), and CNS Vital Signs computerized neurocognitive testing. Multiple linear regressions tested whether self-reported fatigue and sex predicted baseline concussion examination scores. Results: Athletes with higher self-reported fatigue levels (ss = -0.014, P < .01) and female athletes (ss = -0.216, P < .01) reported more total symptoms. Being male (ss = 0.856, P < .01) increased the likelihood of endorsing zero symptoms versus any symptoms by a factor of 2.40. Women also had significantly higher SAC scores (ss = 0.569, P < .001), BESS scores (ss = -2.747, P < .001), and CNS Vital Signs summary scores (ss = 4.506, P < .001). SAC, BESS, and CNS Vital Signs scores were not predicted by fatigue level (P > .05). Conclusion: Female athletes and fatigued athletes endorsed more symptoms and higher symptom severity at baseline. Using total symptom endorsement and total symptom severity scores as part of the postinjury management is a common practice. The current data suggest that levels of reported exhaustion can influence concussion assessment scores meant to represent a healthy baseline and likely would interfere with postinjury assessment scores.