The Role of Age and Sex in Symptoms, Neurocognitive
Performance, and Postural Stability in Athletes After Concussion
Performance, and Postural Stability in Athletes After Concussion
Covassin T, Bay E. J Neurosci Nurs. 2012
Jun;44(3):124-33.
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?
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
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
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.
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?
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.
You can also look for clinical trials related to concussions on clinicaltrials.gov (a great resource): https://clinicaltrials.gov/ct2/results?term=concussions
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?
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.