Stratification of recovery from concussion using an objective multi-factorial approach to neurocognitive and motor performance assessment

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To characterise neurologic impairment and recovery associated with concussion in youths and young adults using the Cleveland Clinic Concussion application (C3 app).


Retrospective observational study


Concussion clinic at an academic medical centre


181 student-athletes aged 14–20 diagnosed with concussion by a Cleveland Clinic physician were included.


C3 data were collected pre-season and at least once post-injury. At least one clinical examination by a physician was obtained to characterise clinical impairments. Individuals were stratified into two groups based on recovery time: typical <21 days (n=97) or protracted 21+ days (n=84).

Outcome measures

The following modules of the C3 app were administered across groups: 1) Graded symptom checklist (GSC); 2) Standardised Assessment of Concussion (SAC); 3) Trail Making Test; 4) Simple and Choice Reaction Time; 5) Processing Speed Test; 6) Biomechanical quantification of balance during the BESS.

Main results

At baseline, both groups performed similarly on all modules. However, significant differences were evident at 21 days post-injury in the protracted recovery group with worse performance in: simple and choice reaction time (p<0.001), Trail Making Test B (p=0.01), Biomechanical quantification of BESS (p<0.05), and GSC (p=0.0001). No difference between the groups at 21 days was found in BESS error scores, SAC or processing speed.


An approach that utilises objective and quantitative measures to characterise multiple aspects of neurocognitive and motor function are more sensitive than traditional measures of concussion assessment. These new outcomes provide value in the stratification of patients and their potential time to recovery.

Competing interests

JLA and SML have authored intellectual property associated with the mobile application presented in this study. The remaining authors declare no competing interest.

Competing interests


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