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Factors Affecting Recovery Trajectories in Pediatric Female Concussion
Christina L. Master, MD, FAAP, CAQSM, FACSM • Natasha Desai, MD, FACEP, CAQSM
Multiple studies have shown that females have more difficulty with concussion compared to males. There have been studies that show females have high rates of concussion per athletic exposure, high symptom burden, and longer recovery times. However, the data is conflicting regarding the extent of sex-based differences in concussion making it important to investigate these issues further. There are a number of theories relating to intrinsic differences between the sexes as a possible cause of these differences, including neck strength and hormonal effects. Our original research “Factors Affecting Recovery Trajectories in Pediatric Female Concussion” was an initial attempt to see if sex-based differences occurred in recovery of injury, their recovery times were not significantly different. This
patterns in children with concussion.
Our study 1 examined children with prolonged recovery, defined as greater than 4 weeks. A retrospective secondary analysis of 192 unique subjects with the diagnosis of sport related concussion who presented to our sub-specialty office in a large children’s hospital system was performed. There were 117 males and 75 females, relatively well matched in terms of age, pre-existing conditions, and previous concussions, except that females did have a significantly higher baseline GPA and males did have significantly higher rate of learning disabilities. The main factors examined were time to presentation for specialty care for concussion, the physical exam, symptoms and clinical features, as well as outcomes including the time to return to school and sports participation, normalization of clinical exam and neurocognitive testing.
Similar to prior studies, we found that females had higher symptom scores at initial evaluation and also had a longer time to recovery in We found that females returned to school later (4 vs. 3 days), returned to exercise later (13 vs. 7 days), had neurocognitive recovery later (68 vs. 40 days), had later vision and vestibular (balance) recovery (77 vs. 34 days) and returned to full sport far later (119 vs. 45 days). We also found that the median days to presentation to subspecialty evaluation was significantly longer in females than males, 15 days for females and 9 days for males. When we controlled for time to presentation, examining only the subset of the cohort who presented for specialty concussion care within 14 days, the apparent sex-based differences in outcomes disappeared.
Our finding that females and males who presented within 14 days all outcome measures than the males.
would imply that an extrinsic factor, delay to subspecialty diagnosis and treatment, may be a major contributing factor to prolonged recovery in females rather than intrinsic sex-based differences. In males there was a significant correlation of time to initial presentation and time to recovery. In females, it trended towards the same pattern but did not reach significance.
Our study was not designed to determine the reason for the delay to specialty concussion care for females, but we surmise that differences in sideline medical presence and access to medical support may play a factor. Since athletic training support is a limited resource, at the interscholastic high school level, girls’ sports do not enjoy the protections of Title IX as women’s sports do in college.
We would hypothesize that lack of immediate access to medical coverage on the sidelines at the time of injury for female sports, in practice and competition, may lead to a delay in concussion identification and care as well as subsequent presentation for Author Bios specialty concussion care This may inherently delay appropriate Christina L. Master, MD, is a Professor of Clinical Pediatrics at treatment and thereby potentially delay concussion recovery. the University of Pennsylvania Perelman School of Medicine with Individualized specialty concussion care can mitigate the effects over two decades of experience in clinical pediatrics. Dr. Master of excessive rest or activity in the acute recovery timeframe. As is board-certified in pediatrics and brain injury medicine with research advances and our understanding of the role of rest additional qualification in sports medicine and is a fellow of the and activity modification becomes more refined, the early American College of Sports Medicine. She treats over 800 youth implementation of active recovery approaches such as subsymptom with concussion annually in her outpatient practice. She is cofounding director of Minds Matter, the concussion program for threshold exercise may also improve recovery for those who seek children at CHOP that provides clinical care, community outreach subspecialty sooner rather than later in the recovery process. and conducts research in youth concussion. Her particular Further study is need to investigate this hypothesis. research emphasis has been in furthering our understanding of visual deficits following concussion as a target for intervention There are a few important limitations that should be mentioned. for those with prolonged symptoms in addition to identifying This study examined time to presentation to specialty concussion objective physiologic biomarkers for concussion. care and did not assess time to presentation to the emergency room or primary care and it is possible that improving care at Natasha Desai, MD, is the Associate Chief of Sports Medicine Physicians in the Department of Orthopedics at Columbia those points of care would also improve outcomes for girls. As University Irving Medical Center and the Assistant Team Physician concussion practice continues to evolve, these extrinsic factors may for Columbia University Athletics. Dr. Desai received her BS in be changing even as we speak and there may be changes that have Neuroscience from UCLA in 2005 and her Medical Doctorate already occurred in practice that could already be closing this gap from George Washington University School of Medicine in 2010. in outcomes for girls. Nonetheless, our study highlights the fact She completed residency in Emergency Medicine at The Mount that modifiable extrinsic factors should be considered in addition Sinai Hospital in 2014 and a fellowship in Sports Medicine at the to intrinsic factors when examining sex-differences in outcomes in Children’s Hospital of Philadelphia and University of Pennsylvania in 2015. She is board certified in both Emergency Medicine and concussion. Sports Medicine. She has been involved in numerous research projects focused on mild TBI and concussion. References $1,750 1/2 4C 7.375 x 4.875”
Desai N, Wiebe DJ, et al. Factors Affecting Recovery Trajectories in Pediatric Female Concussion. Clin J Sport Med. 2019 Sep;29(5):361-367
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