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Most college varsity athletes who recovered slowly from concussion were able to return to play with an additional month to recover beyond the typical recovery time, an observational study showed.

Of 399 athletes with slow recovery after concussion, 77.6% returned to play within 60 days of injury, reported Thomas Walker McAllister, MD, of the Indiana University School of Medicine in Indianapolis, and colleagues in .

Within 90 days of injury, 83.4% of athletes with slow recovery were cleared for return to play. But at 6 months post-injury, 10.6% had not returned to play.

Slow recovery was defined as 14 or more days for concussion symptoms to resolve, or 24 or more days to be cleared for return to play. Both thresholds were considered typical recovery times for 80% of athletes.

"Although an athlete may experience a slow or delayed recovery, there is reason to believe recovery is achievable with additional time and injury management," McAllister said in a statement. "This is an encouraging message that may help to relieve some of the discouragement that athletes can feel when trying to return to their sport."

"The results of this study provide helpful information for athletes and medical teams to consider in evaluating expectations and making difficult decisions about medical disqualification and the value of continuing in their sport," he added.

The study included 1,751 concussed college athletes who played for teams participating in the NCAA-Department of Defense (DOD) and who had baseline data collected between the fall of 2014 and the spring of 2018. All CARE sites used a common definition of concussion and diagnosis was made by a local team physician.

Participants were evaluated five more times: within 6 hours after injury, 24-48 hours later, when they were asymptomatic, when they were cleared to return to play, and at 6 months. They reported symptoms daily to medical staff for up to 14 days following injury, then weekly if they had not yet returned to unrestricted play.

Mean age was about 19 and 63% of participants were male. Most concussed athletes (79%) played contact sports. Male athletes primarily played football, soccer, and basketball; female athletes played soccer, volleyball, and basketball.

Overall, 80% of the cohort reached asymptomatic or return-to-play timepoints by days 14 and 24, respectively; 399 athletes (22.8%) exceeded those thresholds and were in the slow recovery group. That group included 79 athletes with slow recovery defined by a delayed asymptomatic timepoint only, 71 with a delayed return-to-play timepoint only, and 249 with both.

For the slow recovery group, the median return-to-play time was 34.7 days after injury, compared with 12.8 days in the overall cohort.

Participants with slow recovery were more likely to be female. They also were more likely to be injured in practice, carried a higher symptom burden immediately after injury, and completed fewer post-injury assessments.

"However, once these individuals exceeded the threshold we used to define a slow recovery, these characteristics were not predictors of eventual return to play," McAllister and colleagues observed.

"This raises the possibility that while neurobiological factors related to sex and injury severity are primary drivers of recovery trajectory within the first 4 weeks after injury, additional factors may assume a greater role further out in time from the injury," they added.

A possible complex interaction between neurobiological and psychosocial factors was difficult to assess partly due to missing pre-injury somatic symptom data, "but warrants further investigation," McAllister and colleagues noted.

The study had several limitations, the researchers pointed out. Participants all were varsity college athletes and may not be representative of other age groups or levels of sport. Results also may not apply to other types of mild brain injuries, including civilian or military trauma.

In addition, the asymptomatic timepoint and return to play intervals are not the only indicators of concussion recovery, they acknowledged.

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