Sports Medicine Research: In the Lab & In the Field: Head Case: What Role does Age and Gender Play Following a Concussion? (Sports Med Res)
Friday, June 15, 2012

Head Case: What Role does Age and Gender Play Following a Concussion?

The Role of Age and Sex in Symptoms, Neurocognitive Performance, and Postural Stability in Athletes After Concussion
Covassin T, Bay E. J Neurosci Nurs. 2012 Jun;44(3):124-33.

There is no question that the topic of concussions is currently at the forefront of sports medicine.  As with any injury, a structured approach must be taken regarding recognition, recovery and return to play.  That said, our follow-up and treatment of concussions may need to take into account not only the athlete's age, but their gender as well. The purpose of this study was to examine how sex and age may affect post-concussion symptom reporting, postural stability and neurocognitive testing (NCT).  NCT includes the following areas: visual memory, verbal memory, visual processing speed and reaction time.  Covassin et al. hypothesized that concussed high school athletes would demonstrate 1) more concussion symptoms 2) greater postural instability and 3) greater neurocognitive impairments when compared to concussed collegiate athletes.  The authors also expected female athletes would present with prolonged NCT deficits, more concussion symptoms, and greater postural stability deficits than concussed male athletes. A total of 222 subjects (157 male, 65 female; 150 HS, 72 collegiate) participated in this study all of which met the following inclusion criteria: 14-25y/o, sustained a sports related concussion diagnosed by a sports medicine professional during an academic 2-year span, previously undergone baseline computer-based ImPACT (NCT) testing.  Post-injury, all subjects underwent ImPACT testing at 2, 7 and 14-days after injury.  Post-concussion postural stability was measure through the Balance Error Scoring System (BESS) on days 1, 2, and 3; however, there was no baseline BESS testing performed.  The BESS test is a battery of 6 tests that measures an individual’s static and dynamic posture after sustaining a concussion.  A higher score on the BESS test indicates poorer postural stability. Concussion symptoms were measured through self-reporting completion of a Post-Concussion Symptom Scale obtained during ImPACT testing.  After data analysis, the following items were discovered: NCT performance (verbal memory, visual memory and reaction time) was significantly worse for all athletes 2 days post-injury when compared to baseline.  By day 14, there was no significant difference between baseline scores and follow-up scores.  HS athletes in general performed worse than collegiate athletes in regards to visual and verbal memory, though this finding was not significant.  When regarding subject sex, female athletes collectively performed worse on visual memory and presented more post-concussion symptoms than males.  Concussion symptoms were significantly greater at 7 days post injury when compared to baseline for all groups.  On average, post-concussion symptoms reverted to baseline levels 14-days after injury.  The BESS test illustrated that the HS male athletes exhibit worse postural stability than male collegiate athletes and female collegiate athletes performing worse than female HS athletes.  However, with no baseline data available in terms of the BESS test, it is difficult to quantify the degree to which postural stability has been compromised.

The findings of this study are important for many reasons.  First, this study supports what other research has begun to show, that there is an age/developmental component that needs to be considered when managing concussions.  High school athletes appear to recover at a slower rate than collegiate athletes, especially in regards to visual and verbal memory.  Another key aspect of this study is that sex does appear to play some role in memory recovery as well as concussion symptoms.  While female athletes present with more symptoms, it is quite possible that male athletes may not have been entirely forthright in relaying their symptoms.  Items like returning to play and societal pressures may have hindered truthful reporting in an effort to return to the field faster.  All of these items, from memory deficits, to postural instability and how they differ between the sexes and at different ages are all items that clinicians should begin considering during the concussion management and return to play.  What are your thoughts on the results of this study?  Do they mirror what you are seeing with your athletes?  Are you currently including any form of postural component to your baseline concussion testing?

Written by: Mark Rice
Reviewed by: Stephen Thomas

Related Posts:

Covassin T, & Bay E (2012). Are There Gender Differences in Cognitive Function, Chronic Stress, and Neurobehavioral Symptoms After Mild-to-Moderate Traumatic Brain Injury? The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses, 44 (3), 124-33 PMID: 22555349


Bethany H said...

I have noticed similar things in some of my athletes. During my clinical rotation at a high school last year, we included balance testing in our post-concussion evaluation. What I noticed throughout the course of the season was that our male athletes (especially our soccer players) seemed to be drastically "feeling better" (symptom-wise) much quicker than the females, but when we had them perform the balance testing, they had not improved any from their initial balance score immediately post-concussion

Alyson said...

This is a good study to allow for clinicians to better they clinical treatment for athletes of different ages. This article definitely open up the eyes of the reader to not only notice different injury courses athletes take, but also notice the different presentation of concussion, and how your should tailor your treatment protocols to that specific athlete. If you have seen 1 concussion you have treated 1 concussion. The timeline may be the same, or the symptoms overall could correlate to another case, but because it is a different individual, it is hard to say that you can treat them the same as the concussed soccer athlete vs the concussion football athlete. Different mentalities, different genders, and ages possibly. This article allow for a great reference to base your clinical practice on, but also to notice those possible correlations between different presentation of s/s, and treat accordingly. I agree with the point of the males not describing as many s/s because of the social stigma of being the tough guy. It was really interesting to read on how males don't recover as fast in the postural control, and females have more trouble with visual memory than males. I have seen the postural control first hand in my clinical experience. It would be interesting to see how many previous concussions each of these athletes had and if that correlates to their s/s check list and complaints. Also, developing a study that could get baseline BESS scores would be excellent.

This is an area of study that is very interesting and has a great future. We treat daily injuries (sprain, fx) differently because of age and gender, and growth of body, why shouldn't be consider those factors to better treat our concussed athletes? Great future of this area.

Suzy Frame said...

Thanks for this information. I understand that concussions are a huge aspect to sports medicine and it is a growing problem that doctors are having to deal with. Thanks also for the comments before me. I found them all very interesting. Can anyone tell me if clinical trials for concussions are very common?

Jane McDevitt said...

Yes, clinical trials are very common in concussion research. Concussion clinical trials may be slightly different then what you would typically think of clinical trials. We don't give some people concussion and some people we spare! However we will look at their concussion history or follow them during their concussion care. Concussion clinical trials help evaluate evaluation tools and equipment, develop possible prognostic tests, assess if there are genetic association with concussions, and like this study see if there are any gender difference for more individualize care. There are many different ways we use clinical trials for concussion research.

Jeffrey Driban said...

You can also look for clinical trials related to concussions on (a great resource):

Chip said...

I found this information intriguing, thanks for posting. It's interesting that the male collegiate athletes did better on the BESS post-concussion than the HS athletes, but it was the opposite for the females. All the other information pointed to younger athletes taking longer to recover, so I found this to be interesting. It's also good to see that other people have noticed that males may be downplaying their symptoms, as this is something I've noticed(football anyone?). As for baseline BESS testing: It's something we did as part of our concussion baselines during PPE's before school started. If you're going to assess someone's balance as part of a concussion assessment, why wouldn't you have a baseline?

TJ said...

Just a quick question regarding the statement: "Concussion symptoms were significantly greater at 7 days post injury when compared to baseline for all groups." Does this mean that their symptoms were still present and had worsened or is it that they were greater in the sense that they were less symptomatic?

I am not entirely surprised by the results and let me try to articulate my reasoning behind this. Males develop at a later age than females, therefore I would expect that when comparing college age and high school males they are at different developmental stages. A more developed male should out perform the high school aged male if the condition (concussed) is the same. Similarly, females in high school are at a different developmental stage than collegiate females; however, I am led to believe that the opposite result may come from the further preparation that a collegiate female's body has with regard to preparing for childbirth. Therefore, the differences would lend to the better performance toward the high school aged female athlete. I am interested on others' thoughts about this line of thought.

I volunteered to help with PPE's at a local high school and that was the first year that they had included the BESS test as a baseline. I am unsure as to what NCT they had performed. I think that postural stability should definitely be looked at for return to play.

I am interested in further developments in this area because I will be working with the high school aged population at my clinical rotation.

Thanks for posting this article.

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