There is conflicting evidence regarding whether females are more adversely affected after concussion than males. Further, recent research suggests that hormonal contraceptive (HC) use may affect symptom severity and duration post-concussion. The objective of this study was to examine the effects of sex and HC use on outcomes following concussion among collegiate varsity athletes. We hypothesized that females would have longer length of recovery (LOR), and that peak symptom severity would be associated with longer LOR in both males and females. Among females, we hypothesized that non-HC users would have longer LOR and higher peak symptom severity than HC users. Ninety collegiate student-athletes were included in this study (40 males, 50 females; 24 HC users, 25 non-HC users). Demographic, injury, and recovery information was abstracted via retrospective record review. LOR was defined as days between injury and clearance for full return to play by team physician. Peak symptom severity score (Sport Concussion Assessment Tool [SCAT] 2 or 3) was used in analyses. Study results revealed that males had shorter LOR than females (F[1, 86] = 5.021, p < 0.05, d = 0.49), but had comparable symptom severity scores. Symptom severity was strongly related to LOR for males (r = 0.513, p < 0.01) but not females (r = −0.003, p > 0.05). Among females, non-HC users demonstrated higher symptom severity than HC users (F[1,47] = 5.142, p < 0.05, d = 0.70). No significant differences between female HC users and non-HC users on LOR were observed. This study provides evidence for differential concussion outcomes between male and female collegiate athletes and between HC users and nonusers among females.
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References
1.
McCroryP., MeeuwisseW.H., AubryM., CantuB., DvořákJ., EchemendiaR.J., EngebretsenL., JohnstonK., KutcherJ.S., RafteryM., SillsA., BensonB.W., DavisG.A., EllenbogenR.G., GuskiewiczK., HerringS.A., IversonG.L., JordanB.D., KissickJ., McCreaM., McIntoshA.S., MaddocksD., MakdissiM., PurcellL., PutukianM., SchneiderK., TatorC.H., and TurnerM. (2013). Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br. J. Sports Med., 47, 250–258.
2.
LangloisJ.A., Rutland-BrownW., and WaldM.M. (2006). The epidemiology and impact of traumatic brain injury: a brief overview. J. Head Trauma Rehabil., 21, 375–378.
3.
CovassinT., SwanikC.B., and SachsM.L. (2003). Epidemiological considerations of concussions among intercollegiate athletes. Appl. Neuropsychol., 10, 12–22.
4.
DaneshvarD.H., NowinskiC.J., McKeeA.C., and CantuR.C. (2011). The epidemiology of sport-related concussion. Clin. Sports Med., 30, 1–17.
5.
KilcoyneK.G., DickensJ.F., SvobodaS.J., OwensB.D., CameronK.L., SullivanR.T., and RueJ.-P. (2014). Reported concussion rates for three Division I football programs an evaluation of the new NCAA concussion policy. Sports Health, 6, 402–405.
6.
ZuckermanS.L., KerrZ.Y., Yengo-KahnA., WassermanE., CovassinT., and SolomonG.S. (2015). Epidemiology of sports-related concussion in NCAA athletes from 2009–2010 to 2013–2014: incidence, recurrence, and mechanisms. Am. J. Sports Med., 43, 2654–2662.
7.
BakerJ.G., LeddyJ.J., DarlingS.R., ShucardJ., MakdissiM., and WillerB.S. (2016). Gender differences in recovery from sports-related concussion in adolescents. Clin. Pediatr. (Phila.) 55, 771–775.
8.
CollinsM.W., GrindelS.H., LovellM.R., DedeD.E., MoserD.J., PhalinB.R., NogleS., WasikM., CordryD., DaughertyM.R., and SearsS.F. (1999). Relationship between concussion and neuropsychological performance in college football players. JAMA, 282, 964–970.
9.
SadyM., VaughanC., and GioiaG. (2011). School and the concussed youth: recommendations for concussion education and management. Phys. Med. Rehabil. Clin. N. Am., 22, 701–719.
10.
McClincyM.P., LovellM.R., PardiniJ., CollinsM.W., and SporeM.K. (2006). Recovery from sports concussion in high school and collegiate athletes. Brain Inj. 20, 33–39.
11.
WilliamsR.M., PuetzT.W., GizaC.C., and BroglioS.P. (2015). Concussion recovery time among high school and collegiate athletes: a systematic review and meta-analysis. Sports Med. 45, 893–903.
12.
ChamelianL., and FeinsteinA. (2006). The effect of major depression on subjective and objective cognitive deficits in mild to moderate traumatic brain injury. J. Neuropsychiatry Clin. Neurosci., 18, 33–38.
13.
IversonG.L. (2006). Misdiagnosis of the persistent postconcussion syndrome in patients with depression. Arch. Clin. Neuropsychol., 21, 303–310.
14.
MooneyG., SpeedJ., and SheppardS. (2005). Factors related to recovery after mild traumatic brain injury. Brain Inj. 19, 975–987.
15.
McCreaM., GuskiewiczK., RandolphC., BarrW.B., HammekeT.A., MarshallS.W., PowellM.R., Woo AhnK., WangY., and KellyJ.P. (2013). Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. J. Int. Neuropsychol. Soc., 19, 22–33.
16.
MakdissiM., DavisG., JordanB., PatriciosJ., PurcellL., and PutukianM. (2013). Revisiting the modifiers: how should the evaluation and management of acute concussions differ in specific groups?. Br. J. Sports Med., 47, 314–320.
17.
BroshekD.K., KaushikT., FreemanJ.R., ErlangerD., WebbeF., and BarthJ.T. (2005). Sex differences in outcome following sports-related concussion. J. Neurosurg., 102, 856–863.
18.
ColvinA.C., MullenJ., LovellM.R., WestR.V., CollinsM.W., and GrohM. (2009). The role of concussion history and gender in recovery from soccer-related concussion. Am. J. Sports Med., 37, 1699–1704.
19.
HenryL.C., ElbinR.J., CollinsM.W., MarchettiG., and KontosA.P. (2016). Examining recovery trajectories after sport-related concussion with a multimodal clinical assessment approach. Neurosurgery, 78, 232–241.
20.
Preiss-FarzaneganS.J., ChapmanB., WongT.M., WuJ., and BazarianJ.J. (2009). The relationship between gender and postconcussion symptoms after sport-related mild traumatic brain injury. PM R, 1, 245–253.
21.
CovassinT., SchatzP., and SwanikC.B. (2007). Sex differences in neuropsychological function and post-concussion symptoms of concussed collegiate athletes. Neurosurgery, 61, 345–351.
22.
KontosA.P., CovassinT., ElbinR.J., and ParkerT. (2012). Depression and neurocognitive performance after concussion among male and female high school and collegiate athletes. Arch. Phys. Med. Rehabil., 93, 1751–1756.
23.
FrommerL.J., GurkaK.K., CrossK.M., IngersollC.D., ComstockR.D., and SalibaS.A. (2011). Sex differences in concussion symptoms of high school athletes. J. Athl. Train., 46, 76–84.
24.
McCreaM., GuskiewiczK., RandolphC., BarrW.B., HammekeT.A., MarshallS.W., PowellM.R., Woo AhnK., WangY., and KellyJ.P. (2013). Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. J. Int. Neuropsychol. Soc., 19, 22–33.
25.
HenryL.C., ElbinR.J., CollinsM.W., MarchettiG., and KontosA.P. (2016). Examining recovery trajectories after sport-related concussion with a multimodal clinical assessment approach. Neurosurgery, 78, 232–241.
26.
StoneS., LeeB., GarrisonJ.C., BlueittD., and CreedK. (2017). Sex differences in time to return-to-play progression after sport-related concussion. Sports Health, 9, 41–44.
27.
National College Athletic Association. (2017). Sport sponsorhip participation and demographics search [student-athlete data: 2016–2017 overall figures]. http://web1.ncaa.org/rgdSearch/exec/main (last accessed March2, 2018).
28.
MihalikJ.P., OndrakK.S., GuskiewiczK.M., and McMurrayR.G. (2009). The effects of menstrual cycle phase on clinical measures of concussion in healthy college-aged females. J. Sci. Med. Sport, 12, 383–387.
29.
EmersonC.S., HeadrickJ.P., and VinkR. (1993). Estrogen improves biochemical and neurologic outcome following traumatic brain injury in male rats, but not in females. Brain Res. 608, 95–100.
30.
GaspardU.J., RomusM.A., GillainD., DuvivierJ., Demey-PonsartE., and FranchimontP. (1983). Plasma hormone levels in women receiving new oral contraceptives containing ethinyl estradiol plus levonorgestrel or desogestrel. Contraception, 27, 577–590.
31.
MishellD.R., ThorneycroftI.H., NakamuraR.M., NagataY., and StoneS.C. (1972). Serum estradiol in women ingesting combination oral contraceptive steroids. Am. J. Obstet. Gynecol., 114, 923–928.
32.
McCroryP., MeeuwisseW., JohnstonK., DvorakJ., AubryM., MolloyM., and CantuR. (2009). Consensus statement on concussion in sport: The 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. J. Athl. Train., 44, 434–448.
33.
NilssonC.G., LähteenmäkiP., and LuukkainenT. (1980). Levonorgestrel plasma concentrations and hormone profiles after insertion and after one year of treatment with a levonorgestrel-IUD. Contraception, 21, 225–233.
34.
CohenJ. (1988). Statistical Power Analysis for the Behavioral Sciences, 2nd ed. Lawrence Earlbaum Associates: Hillsdale, NJ.
35.
National Collegiate Athletic Association (2017). Sport Sponsorship, Participation and Demographics Search [2012–2013] overall figures. http://web1/ncaa.org/rgdSearch/exec/main (last accessed March2, 2018).
36.
McCreaM., HammekeT., OlsenG., LeoP., and GuskiewiczK. (2004). Unreported concussion in high school football players: implications for prevention. Clin. J. Sport Med., 14, 13–17.
37.
McCroryP., MeeuwisseW.H., DvořákJ., EchemendiaR.J., EngebretsenL., Feddermann-DemontN., McCreaM., MakdissiM., PatriciosJ., SchneiderK.J., and SillsA.K. (2017). 5th International Conference on Concussion in Sport (Berlin). Br. J. Sports Med., 51, 837–837.
38.
BarnesB.C., CooperL., KirkendallD.T., McDermottT.P., JordanB.D., and GarrettW.E. (1998). Concussion history in elite male and female soccer players. Am. J. Sports Med., 26, 433–438.
39.
CollinsC.L., FletcherE.N., FieldsS.K., KluchuroskyL., RohrkemperM.K., ComstockR.D., and CantuR.C. (2014). Neck strength: a protective factor reducing risk for concussion in high school sports. J. Prim. Prev., 35, 309–319.
40.
TierneyR.T., SitlerM.R., SwanikC.B., SwanikK.A., HigginsM., and TorgJ. (2005). Gender differences in head-neck segment dynamic stabilization during head acceleration. Med. Sci. Sports Exerc., 37, 272–279.
41.
GennarelliT.A., SeggawaH., WaldU., CzernickiZ., MarshK., and ThompsonC. (1982). Physiological response to angular acceleration of the head, in: Head Injury: Basic and Clinical Aspects. Grossman, Roberg, and GildenbergP.L., (eds). Raven Press: New York, pps. 129–140.
42.
NiemeierJ.P., PerrinP.B., HolcombM.G., RolstonC.D., ArtmanL.K., LuJ., and NersessovaK.S. (2014). Gender differences in awareness and outcomes during acute traumatic brain injury recovery. J. Womens Health, 23, 573–580.
43.
SheardM. (2009). Hardiness commitment, gender, and age differentiate university academic performance. Br. J. Educ. Psychol., 79, 189–204.
44.
SmithF. (2007). “It's not all about grades”: accounting for gendered degree results in geography at Brunel University. J. Geogr. High. Educ., 28, 167–178.
45.
SafranD.G., RogersW.H., TarlovA.R., McHorneyC.A., and WareJ.E. (1997). Gender differences in medical treatment: the case of physician-prescribed activity restrictions. Soc. Sci. Med., 45, 711–722.
46.
YardE.E., and ComstockR.D. (2009). Compliance with return to play guidelines following concussion in US high school athletes, 2005–2008. Brain Inj. 23, 888–898.
47.
ChoiJ.C., ParkS.K., KimY.-H., ShinY.-W., KwonJ.S., KimJ.S., KimJ.-W., KimS.Y., LeeS.G., and LeeM.S. (2006). Different brain activation patterns to pain and pain-related unpleasantness during the menstrual cycle. Anesthesiol. J. Am. Soc. Anesthesiol., 105, 120–127.
48.
FillingimR.B., MaixnerW., GirdlerS.S., LightK.C., HarrisM.B., ShepsD.S., and MasonG.A. (1997). Ischemic but not thermal pain sensitivity varies across the menstrual cycle. Psychosom. Med., 59, 512–520.
49.
WunderleK., HoegerK.M., WassermanE., and BazarianJ.J. (2014). Menstrual phase as predictor of outcome after mild traumatic brain injury in women. J. Head Trauma Rehabil., 29, E1–E8.
50.
BrotfainE.E., GruenbaumS., BoykoM., KutzR., ZlotnikA., and KleinM. (2016). Neuroprotection by estrogen and progesterone in traumatic brain injury and spinal cord injury. Curr. Neuropharmacol., 14, 641–653.
