Differences in Symptom Reporting Between Males and Females at Baseline and After a Sports-Related Concussion: A Systematic Review and Meta-Analysis.
Brown DA, Elsass JA, Miller AJ, Reed LE and Reneker JC. Sports Med. 2015; [Epub ahead of print].
Take Home Message: Females are more likely to report concussion-related symptoms at baseline testing than males. However, following a concussion there are no differences in symptom reporting between male and female athletes.
To evaluate a concussion, clinicians need to understand factors that influence the prevalence of symptoms at baseline testing and after a concussion. For example, if males and females report concussion-related symptoms differently at baseline testing and after concussions then they may need different criteria to determine severity and recovery. Therefore, Brown and colleagues completed a systematic review and meta-analysis to determine if a difference exists between sexes with regards to self-reporting individual symptoms in high school and college athletes. The authors identified 21 studies from a pool of 195 studies that the authors originally identified by an electronic search and a manual review of reference lists from included articles. Articles were included if: (1) patients self-reported symptoms at any time, (2) high school and/or collegiate athletes were included (3) the concussion occurred as a result of sport activity, (4) symptom reporting was separated by sex, and (5) the article was written in English. All studies were screened for inclusion and study quality by 2 independent reviewers. The Quality of Cohort Studies, version II was used to assess the quality of each study. The 2 primary outcomes extracted from each study were the prevalence of symptom reporting and total symptoms score (calculated by adding each symptom severity on a Likert scale). Overall, all studies included were of either good (17) or acceptable (4) quality. Women were 43% more likely to report any symptoms at baseline than males. Specifically, women were more likely to report at baseline a difficulty concentrating, problems with hearing/vision, headaches/migraines, emotional disturbances (e.g., depression, nervousness, irritability), and energy/sleep disturbances. Post-concussion, no difference existed between males and females with regards to reporting all symptoms; however, women were 45% less likely to report confusion. With regards to total symptom score, females had higher total symptom scores on 2 different scales at baseline and after a concussion but these differences were small and unlikely clinically relevant.
Overall, the data presented in this study can be helpful to clinicians when evaluating a concussion and determining recovery. Interestingly, females were more likely to report symptoms at baseline; however, this difference did not persist following a concussive event. This can help clinicians during baseline and initial concussion assessment. The higher initial symptom reporting could be caused by normal hormonal changes during the menstrual cycle. If this is true then clinicians should be aware of this and may also want to consult the athlete’s use of contraceptives as this may impact the number and severity of symptoms reported. It should be noted that the current systematic review could not account for past concussion history of these populations. A history of concussion could also impact these reported symptoms. Ultimately, clinicians should consider individual differences in baseline concussion symptom reporting, the individual’s concussion history prior to sport participation, phase of menstrual cycle, and contraceptive use. The authors also suggest that it may be helpful to ask females to complete baseline testing twice (pre-menstruation and during menstruation). This will better equip clinicians to decipher the changes that occur following a concussive event.
Questions for Discussion: When looking at baseline concussion symptom reporting, do you consider the athlete’s reported menstrual activity? How do you feel this impacts your clinical-decision making following a potential concussion?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban