Young females seek specialist concussion help later than males, study finds

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© Mike Bain

Female athletes seek specialist medical treatment later than male athletes for sports-related concussions, according to researchers.

Doctors say this delay may cause them to experience more symptoms and longer recoveries.

The findings have particular relevance for horse-related pursuits, given the well-recognised risk of concussion and the high rates of female participation.

Researchers from the Sports Medicine Program at the Children’s Hospital of Philadelphia reported their findings in the Clinical Journal of Sports Medicine after analyzing the electronic health records of sports participants aged 7 to 18.

The study raises the question of whether, in American youth and high school sports, inequities in sideline medical and training support are contributing to delayed identification and specialized treatment of concussion for female athletes.

“There is speculation in the scientific community that the reasons adolescent female athletes might suffer more symptoms and prolonged recoveries than their male counterparts include weaker neck musculature and hormonal differences,” says senior author Christina Master, a pediatric and adolescent primary care sports medicine specialist with the hospital’s Center for Injury Research and Prevention.

“We now see that delayed presentation to specialty care for concussion is associated with prolonged recovery, and that is something we can potentially address.”

Dr Master and her team analyzed the records of 192 individuals aged between 7 and 18 who were diagnosed with a sports-related concussion and were seen by a sports medicine specialist.

Females took longer to present to specialist care and had longer recovery trajectories than males. The median number of days to presentation for a sub-specialty evaluation was 15 for females with a sports-related concussion and 9 for males.

This delay is important, since time to presentation for specialized care greater than 1 week has been described as a factor associated with prolonged recovery.

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Five distinct outcomes indicating return to pre-injury function were measured to determine “recovery” in this group of athletes.

By looking at average-days-to-recovery for female and male patients across these outcomes, researchers found that females returned to school later (4 days versus 3 days for males), returned to exercise later (13 days versus 7 days), had neurocognitive recovery later (68 days versus 40 days), had later vision and vestibular (balance) recovery (77 days versus 34 days) and returned to full sport far later (119 versus 45 days).

Importantly, when researchers limited the analysis to those female and male patients who presented to the specialty practice for evaluation within the first 7 days of injury, the differences between males and females on all outcomes disappeared.

In sports where females sustain the highest rates of concussion – specifically soccer, basketball, and cheerleading – there is generally less sideline medical coverage for games and inconsistent athletic training coverage for practice because they are categorized as moderate-risk sports.

In contrast, many high school leagues require athletic training coverage at all football, ice hockey and men’s basketball practices and games.

“It is possible that the lack of athletic training coverage at the time of injury may affect the time to concussion recognition during the first critical hours and days after injury,” Master says.

“This period is a window of opportunity where specific clinical management, such as immediate removal from play, activity modification and sub-symptom threshold exercise is correlated with more rapid recovery.”

Those who study concussion in children have been investigating why some take longer to resolve than others so they can identify those concussions early and implement appropriate management plans to hopefully prevent persistent post-concussion symptoms.

This study builds on that knowledge and suggests a tangible cause and solution: close the gap in athletic training and medical coverage between female and male sports.

Repeat concussion risk

Meanwhile, in other research reported by the hospital this year, doctors found that 1 in 6 children aged 5 to 15 who has a concussion will go on to experience a repeat concussion within two years.

Several characteristics of the initial concussion predict an elevated risk of subsequent concussions, including an increased number of symptoms and longer recovery time.

Researchers identified, through review of electronic health records, 536 children aged 5 to 15 who had an initial visit for a concussion at the hospital location between July 1, 2012, and June 30, 2013.

A subsequent review of their electronic health records over the following two years found that 8% of patients were diagnosed with a second concussion within the first year, and 16% had a second concussion within two years, including 3% who were diagnosed with two additional concussions.

The risk of repeat concussion among 12 to 15-year-olds was almost twice as high as that of 9 to 11-year-olds, but this increased risk may simply be related to their increased exposure to sports and recreational activities.

“Knowing a child’s increased risk for repeat concussions can help families make better decisions about their child’s health,” says Master, who was co-lead on this study.

“We know that having a lot of symptoms or a long recovery time from your initial concussion are associated with a subsequent concussion within a couple of years. By looking at the number of symptoms and length of recovery, clinicians can give families data on which to make informed decisions about future risk.”

Patients who experienced more than 10 symptoms had twice the risk of repeated injury compared to patients with fewer than two symptoms.

The risk of concussion did not vary by how patients got their initial concussion, suggesting that all concussions, regardless of cause, contribute to an individual’s overall burden of concussion and risk of subsequent injury.

“This is one of the first studies to quantify the risk of a subsequent injury given a first concussion,” said Dr Matt Breiding of the Centers for Disease Control and Prevention.

“We hope that clinicians will pay particular attention to these findings since repeat concussions can have real consequences for a young person’s health and development. The results of this study can aid a clinician in discussing the risk of further injury with patients and their parents.”

The findings were reported in the Journal of Pediatrics.

Desai et al, “Factors Affecting Recovery Trajectories in Pediatric Female Concussion.” Clin J Sports Med, 2019 Sep;29(5):361-367. DOI: 10.1097/JSM.0000000000000646.

E. Curry, PhD, MPH, et. al. “Risk of Repeat Concussion Among Patients with a Concussion at a Pediatric Care Network.”  Journal of Pediatrics. Online May 14, 2019.

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