Association of Sex and Age with Mild Traumatic Brain Injury-Related Symptoms: A TRACK-TBI Study

Harvey S. Levin, Nancy R. Temkin, Jason Barber, Lindsay D. Nelson, Claudia Robertson, Jeffrey Brennan, Murray B. Stein, John K. Yue, Joseph T. Giacino, Michael A. McCrea, Ramon Diaz-Arrastia, Pratik Mukherjee, David O. Okonkwo, Kim Boase, Amy J. Markowitz, Yelena Bodien, Sabrina Taylor, Mary J. Vassar, Geoffrey T. Manley, Opeolu AdeoyeNeeraj Badjatia, M. Ross Bullock, Randall Chesnut, John D. Corrigan, Karen Crawford, Sureyya Dikmen, Ann Christine Duhaime, Richard Ellenbogen, V. Ramana Feeser, Adam R. Ferguson, Brandon Foreman, Raquel Gardner, Etienne Gaudette, Luis Gonzalez, Shankar Gopinath, Rao Gullapalli, J. Claude Hemphill, Gillian Hotz, Sonia Jain, C. Dirk Keene, Frederick K. Korley, Joel Kramer, Natalie Kreitzer, Chris Lindsell, Joan MacHamer, Christopher Madden, Alastair Martin, Thomas McAllister, Randall Merchant, Amber Nolan, Laura B. Ngwenya, Florence Noel, Eva Palacios, Ava Puccio, Miri Rabinowitz, Jonathan Rosand, Angelle Sander, Gabriella Satris, David Schnyer, Seth Seabury, Xiaoying Sun, Arthur Toga, Alex Valadka, Kevin Wang, Esther Yuh, Ross Zafonte

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


Importance: Knowledge of differences in mild traumatic brain injury (mTBI) recovery by sex and age may inform individualized treatment of these patients. Objective: To identify sex-related differences in symptom recovery from mTBI; secondarily, to explore age differences within women, who demonstrate poorer outcomes after TBI. Design, Setting, and Participants: The prospective cohort study Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) recruited 2000 patients with mTBI from February 26, 2014, to July 3, 2018, and 299 patients with orthopedic trauma (who served as controls) from January 26, 2016, to July 27, 2018. Patients were recruited from 18 level I trauma centers and followed up for 12 months. Data were analyzed from August 19, 2020, to March 3, 2021. Exposures: Patients with mTBI (defined by a Glasgow Coma Scale score of 13-15) triaged to head computed tomography in 24 hours or less; patients with orthopedic trauma served as controls. Main Outcomes and Measures: Measured outcomes included (1) the Rivermead Post Concussion Symptoms Questionnaire (RPQ), a 16-item self-report scale that assesses postconcussion symptom severity over the past 7 days relative to preinjury; (2) the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5), a 20-item test that measures the severity of posttraumatic stress disorder symptoms; (3) the Patient Health Questionnaire-9 (PHQ-9), a 9-item scale that measures depression based on symptom frequency over the past 2 weeks; and (4) the Brief Symptom Inventory-18 (BSI-18), an 18-item scale of psychological distress (split into Depression and Anxiety subscales). Results: A total of 2000 patients with mTBI (1331 men [67%; mean (SD) age, 41.0 (17.3) years; 1026 White (78%)] and 669 women [33%; mean (SD) age, 43.0 (18.5) years; 505 (76%) White]). After adjustment of multiple comparisons, significant TBI × sex interactions were observed for cognitive symptoms (B = 0.76; 5% false discovery rate-corrected P =.02) and somatic RPQ symptoms (B = 0.80; 5% false discovery rate-corrected P =.02), with worse symptoms in women with mTBI than men, but no sex difference in symptoms in control patients with orthopedic trauma. Within the female patients evaluated, there was a significant TBI × age interaction for somatic RPQ symptoms, which were worse in female patients with mTBI aged 35 to 49 years compared with those aged 17 to 34 years (B = 1.65; P =.02) or older than 50 years (B = 1.66; P =.02). Conclusions and Relevance: This study found that women were more vulnerable than men to persistent mTBI-related cognitive and somatic symptoms, whereas no sex difference in symptom burden was seen after orthopedic injury. Postconcussion symptoms were also worse in women aged 35 to 49 years than in younger and older women, but further investigation is needed to corroborate these findings and to identify the mechanisms involved. Results suggest that individualized clinical management of mTBI should consider sex and age, as some women are especially predisposed to chronic postconcussion symptoms even 12 months after injury..

Original languageEnglish (US)
Article number3046
JournalJAMA Network Open
StateAccepted/In press - 2021
Externally publishedYes

ASJC Scopus subject areas

  • Medicine(all)


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