Differences
in Symptom Reporting Between Males and Females at Baseline and After a Sports-Related
Concussion: A Systematic Review and Meta-Analysis.
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].
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.
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.
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.
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?
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
Related Posts:
Brown, D., Elsass, J., Miller, A., Reed, L., & Reneker, J. (2015). Differences in Symptom Reporting Between Males and Females at Baseline and After a Sports-Related Concussion: A Systematic Review and Meta-Analysis Sports Medicine, 45 (7), 1027-1040 DOI: 10.1007/s40279-015-0335-6
I think it is important to understand your athlete and the point they are at in their life. If concerns arise about a female athlete than they need to be addressed. Certain symptoms can be exacerbated with menstruation but I do not think the athlete or the concussion should be treated any differently. It may prolong symptoms which would prolong recovery but once the athlete is asymptomatic the return to play progression should be standard.
Christina, thanks for the comment! The authors of the article seem to be particularly concerned about the baseline test results b/c the post-concussion symptoms did not differ between males and females. I agree that we need to know our athlete and the factors that could influence their baseline test results (e.g., sleeping habits, performance in a group test setting, phase in menstral cycle). By understanding out patient during baseline testing we can hopefully ensure we have a good reference when evaluating a concussion, which will help us ensure we are treating our patients consistently.
I think as clinicians we need to first understand if males do not report symptoms at baseline for a specific reason. Since concussions have become such a heavy topic and athletes know about concussion protocols now, they could be nervous to report baseline symptoms because they might think it could sit them out. As clinicians we should take it upon ourselves to make sure our male athletes understand that the baseline helps us diagnose concussions in the future and reporting symptoms that they feel commonly should be reported. They should understand that reporting can only help them, rather than hurt them.
I think that not only do we need to know the athletes but also we need to stress how important it is to give an accurate baseline report. The baseline gives us something to go off of to make a clinical decision about their health. We need to explain that by reporting their symptoms they are only helping themselves and we only want to help them and keep them safe/healthy.
Ryan and Sarah,
Wonderful comments, thank you! I am interested in what forms of testing are you both using? We are all in agreement that baseline testing in critical in understanding the extent of an injury, but as you both eluded to, there are way that athletes attempt to throw off the clinician for fear of not being able to return to play. Paper and pencil tests seem to be the easiest for an athlete to "throw" as I have experienced myself. Are either of you using computerized testing which could be more difficult for athletes to "throw the test"?