Females Athletes Require Longer Post-Concussion Recovery

On average, high school athletes with concussion take 1 month to return to play, illustrating that the message that prolonged rest is needed after a head impact is getting through, new research suggests.

However, findings from a cohort study of more than 300 high school athletes who sustained at least one concussion also showed that females and those with a history of previous concussion took longer to return to play.

"Our results show that high school athletes with concussion have a high prevalence of previous concussion — around 33%. Coaches and physicians need to be aware that these individuals may take longer to recover," lead author Toufic Jildeh, MD, Henry Ford Hospital, Detroit, Michigan, told Medscape Medical News.

Jildeh noted that clinicians and coaches should also be aware that female athletes may be more susceptible to concussion.

"We need to be more sensitive to concussion-like complaints in females and they should have a lower threshold for being taken out of the game," he said.

"It has been shown before that females with concussion have reduced visual memory, processing speed, and reaction times vs males with concussion. This fits in with our observations of longer times to return to play for females," Jildeh added.

The findings are published in the July/August issue of Orthopedics.

Hockey, Football, Soccer

The researchers analyzed records of 357 consecutive youth patients who sustained concussions and presented to the Henry Ford Hospital in Detroit between September 2013 and December 2016.

The average age at injury was 15.5 years (age range 14-18 years). In addition, 62% of patients were boys, 6.7% reported a loss of consciousness, and 14.3% reported having had amnesia. The most common sport of injury was football (27.7%), followed by hockey and soccer.

To assist in the management of concussions, neuropsychological testing is routinely implemented primarily using the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) score, which includes a battery of 6 neuropsychometric tests, Jildeh noted.

The score at time of concussion is compared with a previous baseline score from the individual taken at the beginning of the season. If a baseline score is not available, a normative value is used.

"These scores are then used to assess recovery and when a patient is ready to return to play," said Jildeh.

A total of 33% of participants had had a previous concussion, including 30.6% of football players, 48.1% of hockey players, and 33.3% of soccer players.

Among concussions sustained during the study period, hockey players had the highest rate of loss of consciousness and amnesia (10.4% and 15.6%, respectively).

Score Disparities

On average, athletes required 30.4 days of recovery prior to returning to sport. Those who sustained a recurrent concussion had a longer recovery (35.3 days), although this was not statistically significant (P = .77).

In some of the tests used as part of the ImPACT score, different outcomes were found in patients who had recurred concussions, with mean verbal memory and visual memory scores increasing from baseline and visual motor speed and reaction time decreasing with each recurrent concussion.

"What we think is happening is that patients with previous concussion are developing familiarity with the tests when conducted a second or third time, and the verbal and visual memory scores are more susceptible to learning than visual motor speed and reaction times," Jildeh said.

"We believe this is the first study to show a disparity in the various ImPACT scores and, if confirmed in other studies, could mean that visual motor speed and reaction times may be better tools to assess recurrent concussions," he noted.

The results add to other evidence that have suggested that cognitive function worsens with increasing number of concussions, he added.

"Patients with previous concussions had prolonged pathogenesis and increased recovery times, even if that previous concussion happened several years ago," said Jildeh.

The Message Is Rest

Historically, literature has estimated a concussion prevalence of around 4% to 5% in adolescents playing high school sports, but more recent studies have estimated the prevalence to be more like 20%, Jildeh said.

"It also used to be believed that young age may be protective because of the neuroplasticity of the brain in younger people, but this has now been disproven. It is now thought that younger people actually need longer recovery times," he noted

In the past, a large percentage of concussed players would return to play immediately. However, research on long-term adverse effects of concussion have led to a consensus that athletes should rest for 30 days after a concussion, Jildeh said

"This recommendation has received much press attention and coaches, trainers, and parents are starting to take the message on board. This is reflected in our results," he said.

However, "the 30-day mark should be regarded as a baseline for recovery time, with more time for each subsequent concussion," he added.

In- vs Out-of-Clinic

A multivariable linear model showed a significantly longer return-to-play time for the female athletes vs their male counterparts (P < .001) and longer recovery times when concussion was diagnosed in the clinic rather than outside the clinic (P = .046).

"If concussion is diagnosed outside [the] clinic by the coach or trainer straight away after the incident, then treatment can be instigated immediately. If the patient is diagnosed in the clinic this may be a couple of days later and so treatment may be delayed somewhat," Jildeh explained.

Another finding showed that athletes who have suffered concussions have a higher incidence of noncontact lower extremity injuries because of balance issues "which may have implications on the performance, safety, and well-being of individual athletes," he added.

These findings will be the focus of a future study.

Co-investigator Vasilios (Bill) Moutzouros, MD, chief of Sports Medicine at Henry Ford, noted that the concussions are "a pressing issue" and that it's important to limit the number of concussions and head injuries in a young athlete.

He added that younger athletes who experience a concussion early in life are much more likely to experience longer-term effects if they get repeatedly concussed.

Orthopedics. Published July/August 2020 issue. Abstract

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