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