Athletic Training and Sports Health Care

Original Research 

Baseline Self-report Symptoms and Health-Related Quality of Life in High School Athletes: Influence of Sex and Prior Concussion History

Candace A. Leach, MS, ATC; R. Curtis Bay, PhD; Tamara C. Valovich McLeod, PhD, ATC, FNATA

Abstract

This study aimed to determine whether history of prior concussion is related to self-reported symptoms and headache-specific, health-related quality of life (HRQOL) and whether it is moderated by sex. A cross-sectional design was used to evaluate a convenience sample (N = 3298, 2548 males, 750 females) of healthy, uninjured interscholastic athletes. Participants completed a self-report concussion history questionnaire, symptom scale, and Headache Impact Test (HIT-6). Significant interaction was noted for total symptom score (P = .014), and symptom-positive females reported a significantly higher score than negative females, positive males, and negative males. The interaction between concussion history and sex was insignificant for the HIT-6 (P = .11) but was significant for concussion history (P < .001) and sex (P < .001). Athletes with a concussion history reported a clinically meaningful increase in symptom severity. This information may be useful in understanding the effect of headache on HRQOL. [Athletic Training & Sports Health Care. 2013;5(3):115–122.]

Ms Leach and Dr Valovich McLeod are from the Athletic Training Program, and Dr Bay is from the Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, Arizona.

This research was funded by a grant from the National Headache Foundation.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Tamara C. Valovich McLeod, PhD, ATC, FNATA, Athletic Training Program, Arizona School of Health Sciences, A.T. Still University, 5850 E. Still Circle, Mesa, AZ 85206; e-mail: tmcleod@atsu.edu.

Received: April 02, 2012
Accepted: August 23, 2012
Posted Online: April 17, 2013

Abstract

This study aimed to determine whether history of prior concussion is related to self-reported symptoms and headache-specific, health-related quality of life (HRQOL) and whether it is moderated by sex. A cross-sectional design was used to evaluate a convenience sample (N = 3298, 2548 males, 750 females) of healthy, uninjured interscholastic athletes. Participants completed a self-report concussion history questionnaire, symptom scale, and Headache Impact Test (HIT-6). Significant interaction was noted for total symptom score (P = .014), and symptom-positive females reported a significantly higher score than negative females, positive males, and negative males. The interaction between concussion history and sex was insignificant for the HIT-6 (P = .11) but was significant for concussion history (P < .001) and sex (P < .001). Athletes with a concussion history reported a clinically meaningful increase in symptom severity. This information may be useful in understanding the effect of headache on HRQOL. [Athletic Training & Sports Health Care. 2013;5(3):115–122.]

Ms Leach and Dr Valovich McLeod are from the Athletic Training Program, and Dr Bay is from the Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, Arizona.

This research was funded by a grant from the National Headache Foundation.

The authors have no financial or proprietary interest in the materials presented herein.

Address correspondence to Tamara C. Valovich McLeod, PhD, ATC, FNATA, Athletic Training Program, Arizona School of Health Sciences, A.T. Still University, 5850 E. Still Circle, Mesa, AZ 85206; e-mail: tmcleod@atsu.edu.

Received: April 02, 2012
Accepted: August 23, 2012
Posted Online: April 17, 2013

Participating in recreational activity and organized team sports may result in concussion and traumatic brain injury. Approximately 1.6 to 3.8 million sport-related concussions and traumatic brain injuries occur annually in the United States.1 Immediately following a concussive event, athletes report an increase in self-reported symptoms, cognitive impairments, and postural instability. However, these deficits of concussion gradually return to baseline over several days.2

Recently, concussion researchers have focused on the immature brain of adolescent athletes and the potential effects of a concussion on future brain development.3 Evidence suggests that cumulative impacts or subconcussive blows could result in impairments,4,5 possible long-term cognitive decline,6 and emotional problems.7 Athletes with a history of concussion are thought to be at increased risk for subsequent concussions,5 which may manifest through prolonged symptoms that affect the individual’s health-related quality of life (HRQOL). Testa and Simonson8 described HRQOL as encompassing the physical, psychological, and social aspects of health based on one’s beliefs, values, experiences, and perceptions.

Headache is considered a hallmark symptom of concussion.3,9,10 In one study, headache was reported as the primary complaint in 40% of participants with concussion,11 whereas another study indicated the number could be as high as 92% of athletes with concussion reporting headache at the time of injury.12 Because headache is prevalent among those sustaining concussion, HRQOL may be effected. Headaches can cause physical pain, as well as mental or emotional problems that may interfere with daily activities and one’s perception of his or her health and well-being.13

A prior history of concussion has also been found to alter symptom reports and HRQOL. Bruce and Echemendia14 noted that athletes with 1 prior concussion reported more symptoms during preseason baselines than did athletes with no concussion history. Register-Mihalik et al15 reported a significant association between endorsed symptoms and prior concussion history in high school and collegiate athletes. Furthermore, several studies have now investigated HRQOL and history of concussive injury and have found lower HRQOL in those individuals with a prior concussion injury.16,17 Collegiate athletes with a self-reported concussion history show decreased scores on the 36-question Medical Outcomes Study-Short Form Health Survey (SF-36) subscales of vitality, bodily pain, and social functioning.16 Similarly, adolescent athletes with a positive self-reported concussion history had significantly decreased scores for the bodily pain, general health perceptions, vitality, and mental health subscales of the SF-36, as well as higher Headache Impact Test-6 (HIT-6) scores, indicating a greater effect of headache on HRQOL.17 Specific to headache, athletes with a self-reported history of at least 1 prior concussion indicated higher headache-related disability compared with their peers with no prior concussion history.15

Sex differences of concussion incidence and symptoms have been debated in the literature. Higher concussion rates have typically been reported in male athletes, but when the analysis is limited to sports in which males and females both participate, females tend to have higher rates of concussion.11,18 The study of differences in concussion sequelae between sexes has yielded mixed results. Covassin et al19 reported no differences in symptoms or neurocognitive test results between males and females at baseline but found that females had significantly decreased visual memory scores at 3 days post-injury and males had higher self-reported sadness and vomiting following concussion. Conversely, Lovell et al20 noted significantly more self-reported symptoms in female athletes compared with male athletes at baseline, but no differences were noted following concussion. With respect to headache, several reports indicated a higher presence of headache in females,21–24 whereas others have reported a higher incidence of headache-related disability25 or effect of headache on HRQOL24 in females compared with males. However, one study reported no sex differences in headache characteristics, including severity, frequency, and duration, in those individuals seeking treatment for chronic headaches.26

Due to the increased attention to measuring the patient’s perspective of HRQOL, it is important to understand how individual characteristics and comorbidity factors in athletes influence the perception of one’s own health status. Therefore, the purpose of this study was to determine whether history of prior concussion is related to self-reported symptoms and headache-specific HRQOL, and whether this relationship is moderated by sex. A secondary objective was to assess the relationship between headache-related symptoms and headache-specific HRQOL.

Method

Participants

Interscholastic high school athletes participating in contact sports from 17 secondary schools (N = 3298; 2548 males, 750 females; age = 15.6 ± 1.6 years; grade level = 10.3 ± 1.1) agreed to participate in the current study. Contact sports included football; wrestling; men’s and women’s volleyball, soccer, and basketball; softball; and baseball. Athletes identified their primary sport and provided demographic information and a concussion history. Athletes were included in the study if parental consent was returned and participant assent was provided. No exclusion criteria were used. On the basis of responses to the concussion history questionnaire, participants were divided into positive (POS) and negative (NEG) concussion history groups for analysis. This research was approved by the university’s institutional review board.

Instrumentation and Procedures

During preseason concussion baseline testing, participant demographics were collected, including sex, age, and grade level. Athletes also completed a concussion history questionnaire, the Sport Concussion Assessment Tool 2 (SCAT2) symptom scale, and the HIT-6.

The concussion history questionnaire asked specific questions about previous concussions or head injuries, the number of concussions, and whether they occurred during participation in organized sports or during other recreational activities. Additional questions were asked using idioms for concussion, such as “ding” or “bell rung.” These terms were used to detect unreported and undiagnosed concussions.27 A yes answer to any of the 6 concussion history questions (Table 1) signified a positive concussion history.

Concussion History Study Questionnairea

Table 1: Concussion History Study Questionnaire

The SCAT2 symptom scale is a 22-item scale in which patients grade their daily symptoms on a 7-point Likert scale, with 0 = absence of the symptom, 1 to 2 = mild presence, 3 to 4 = moderate presence, and 5 to 6 = severe presence. Specific directions, such as “Think back to the last few weeks, what are the normal symptoms you feel on a daily basis? Please rate those typical symptoms on the daily self-report symptom list.” were provided to ensure that symptoms were reported for a typical day. The total symptom score (TSS) of the SCAT2 was used in the current study and is the sum of all severity scores for each symptom present on a daily basis. The maximum possible score is 132 points. We also specifically reviewed the severity scores of the 2 headache-related symptoms: headache and pressure in the head. Graded symptom checklists, similar to those used in the SCAT2, have sensitivity and specificity of 0.89 and 1.0, respectively, at the time of injury.28

The HIT-6 is a 6-item questionnaire used to quantify the severity of the athlete’s headaches and the effect of headaches on the athlete’s daily life in the areas of pain, social functioning, role functioning, vitality, cognitive functioning, and psychological distress29 (Table 2). The questionnaire uses a never, rarely, sometimes, very often, and always scale for grading severity, activity limitations, emotional compensations, and concentration abilities affected by the athlete’s headaches. Answers are awarded point values of 6, 8, 10, 11, or 13, respectively. The score range is 36 to 78, with higher scores indicating a greater effect on headache-specific HRQOL. Scores can be interpreted using 4 groupings that indicate the severity of headache effect on the athlete’s life. Scores of ⩽49 points reflect little or no impact, scores of 50 to 55 points reflect some impact, scores of 56 to 59 reflect substantial impact, and scores of ⩾60 points reflect severe impact. A score change of 5 points represents a clinically meaningful change, whereas a change of 3 points is labeled as noteworthy.29 The HIT-6 has shown good reliability and validity in both adult and adolescent populations.24,30 The HIT-6 has reliability (Pearson r = 0.60 to 0.71) and construct validity when compared to the SF-36.30 Piebes et al24 found good test–retest reliability (rs = 0.72) for the HIT-6 total score among adolescents.

Questions Included on the Headache Impact Test-6

Table 2: Questions Included on the Headache Impact Test-6

Statistical Analyses

Participants were grouped into POS or NEG concussion history based on their self-report responses. The independent variables were group (POS versus NEG) and sex (male versus female). The dependent variables were the TSS and the HIT-6 total score. A separate 2 × 2 analysis of variance was conducted for each dependent variable. Pearson correlation was used to assess the relationship between the 2 headache-related symptoms (headache, pressure in the head) and the HIT-6 total score. A secondary analysis was conducted to determine whether any of the dependent variables predicted concussion group assignment (POS versus NEG concussion history). Separate zero-order correlations were performed for males and females. A simultaneous logistic regression analysis was also performed for both males and females. Analyses were calculated using SPSS Statistics, version 19 (IBM Corporation, Armonk, New York). Alpha (2 tailed) was set at .05.

Results

Demographic data for each group are shown in Table 3, with approximately 50% of participants being in the POS group. Table 4 provides the percentage of male and female athletes who reported a concussion history in each primary sport. Participants reporting a concussion history had a significantly higher TSS than those without a concussion history. A significant interaction was noted for TSS (P = .014), with POS females reporting a significantly higher score (18.3 ± 18.5) than NEG females (10.2 ± 13.5), POS males (11.8 ± 13.7), and NEG males (6.6 ± 9.9). POS males also reported a significantly higher TSS than NEG males (Table 5). Athletes with a concussion history reported more symptoms and higher HIT-6 scores than those without prior concussions.

Demographic Data for Each Study Group, Concussion History, and Sex

Table 3: Demographic Data for Each Study Group, Concussion History, and Sex

Primary Sport Within Each Participant Group, Concussion History, and Sex

Table 4: Primary Sport Within Each Participant Group, Concussion History, and Sex

Baseline Symptom Score for Each Headache-Related Self-report Symptom and Total Symptom Score

Table 5: Baseline Symptom Score for Each Headache-Related Self-report Symptom and Total Symptom Score

The interaction between concussion history and sex for HIT-6 scores was not significant (P = .11), but significant main effects were noted for group (P < .001; POS = 46.6 ± 7.8, NEG = 43.8 ± 6.8) and sex (P < .001; females = 46.4 ± 8.1, males = 44.9 ± 7.2).

Significant correlations (P < .01) were found between the HIT-6 total score and headache (r = 0.52), the HIT-6 total score and pressure in the head (r = 0.46), and headache and pressure in the head (r = 0.68) among the entire sample. Participants reporting typical daily symptoms of headache and/or pressure in the head reported significantly greater HIT-6 scores, indicating a greater effect of headache on HRQOL.

The zero-order correlations among the male participants indicated that both the TSS (R = 1.04, P < .001) and the HIT-6 total score (R = 1.26, P < .001) were significant predictors of concussion history group. This finding was similar in the female group, with the TSS (R = 1.02, P < .001) and the HIT-6 total score (R = 1.45, P < .001) being predictive of concussion history group. The simultaneous regression analysis resulted in the TSS and the HIT-6 total score as being significant predictors (P < .01) of concussion history group in both male and female participants.

Discussion

In the current study, athletes with a concussion history reported significantly more symptoms and significantly higher HIT-6 scores than those without prior concussions. In addition, female adolescent athletes reported significantly higher TSS and HIT-6 scores than male adolescent athletes. Although the aforementioned findings were statistically significant, the clinical interpretation of the scores suggests that the differences in the TSS between sex and concussion history groups may be clinically significant. However, the differences in the HIT-6 scores may not be clinically meaningful, as all groups fell into the little to no impact severity category, and scores between groups were lower than the 5 points needed to demonstrate clinical meaningful differences.

Females commonly report more symptoms than males in studies of concussion and in other areas of medicine. In a study by Lovell et al,20 high school females reported significantly more symptoms at baseline than males. In another study of typically recurring or weekly symptoms in healthy adolescents aged 11 to 17 years, females reported more symptoms than males; symptoms included headache, fatigue, and dizziness.31 In a study of high school and collegiate athletes with concussion, significantly more self-reported symptoms were found among female athletes compared with male athletes.32 This has also been noted in a mixed high school and collegiate athlete population, with female athletes endorsing more concussion-related symptoms than their male counterparts; however, the authors suggest the difference in symptom endorsement may not be clinically meaningful (females = 2.09 ± 2.90, males = 1.88 ± 2.81).15 In addition, it has been reported that there is no significant difference between baseline symptom reporting and sex.19 In that study of 79 athletes with concussion, no differences between sex were identified at baseline. Although Covassin et al19 presented 2 years of data and had numbers of male and female participants (41 males, 38 females) similar to the our study, the sample size was small, perhaps underpowering the analysis.

Whether sex differences in symptom reports exist following sport-related concussion is debated within literature. In a recent study of athletes with concussion, Frommer et al33 found individual symptom differences between sexes, but found no significant differences in symptoms endorsed, symptom resolution, or return to play between sexes. Covassin et al19 reported similar findings between sexes following a concussion, with no significant differences noted in total symptoms, but individual symptom differences were seen. Also noted in the literature is a trend toward increased symptom reporting by females following a concussion20 and significant differences in total symptoms endorsed between sexes.32

In the current study, we also noted greater self-reported headache symptoms among the female athletes. Our data are similar to the data of other studies, which suggest that females report more headaches than males.22,24,31 These sex differences have also been noted in the headache literature, with several studies suggesting higher headache symptom reports among females.21–24,34,35 In one study of college-aged adults,34 females were more likely to report pain from headaches, compared with males. Similarly, Fichtel and Larsson22 identified that adolescent females reported a significantly higher number of headaches and a higher perception of headache-related health concerns compared with adolescent males. Furthermore, the patient experience following headache has also been found to be different between sexes, with females reporting a higher frequency of headache-related disability and reporting more likelihood of seeking medical services for the headache.25 Although some researchers have suggested sex differences, including the menstrual cycle, are responsible for these variations, Mihalik et al36 found that the menstrual cycle had no effect on endorsed symptoms or total symptoms in healthy collegiate females. Therefore, hormones or the menstrual cycle may not affect symptom severity reports among female athletes. One suggested possibility for the noted sex differences is that females may be more open to reporting symptoms or may be more attentive to symptoms that require medical attention than males.25

Several factors, including sex, symptom reports, and past or recent injury, can have a substantial effect on an individual’s HRQOL. One study35 evaluated the effect of headache and musculoskeletal pain HRQOL and found that females reporting pain conditions scored significantly lower on all 8 subscales of the SF-36, a generic measure of HRQOL. In addition, reports of headache were associated with lower physical functioning, perceived role related to physical functioning, and bodily pain in males and vitality, social functioning, mental health and perceived role related to emotional functioning in females.35 Sex differences in HRQOL have also been noted in adolescents, with female athletes reporting lower HRQOL on the vitality and mental composite score of the SF-36 and the happiness subscale of the Pediatric Outcomes Data Collection Instrument.37 Sex differences in HRQOL are speculated to be the result of one’s sensitivity to his or her own condition and the ability to recognize and report symptoms and the effect of symptoms on one’s health status.35,38 Some studies have noted that males tend to report greater effects on physical domains of HRQOL, whereas females tend to report greater effects on psychological or emotional aspects of HRQOL.35,39

The effects of prior concussions on symptom reports and other outcomes have been studied in different athletic populations. Bruce and Echemendia14 found that individuals with 2 or more concussions reported significantly more symptoms at baseline than did individuals without a history of concussion. In addition, collegiate athletes with a positive concussion history were more likely to report headache than were those with no concussion history.40 Because headache is a well-documented symptom of concussion,11,12,14 it may affect the HRQOL of those with a positive concussion history.

With respect to prior injury, Valovich McLeod et al41 found that adolescent athletes with a self-reported history of recent injury (within 1 week) demonstrated lower scores on the SF-36 subscales that affected physical functioning, pain, and social functioning and lower scores on the Pediatric Outcomes Data Collection Instrument for global HRQOL. In addition, moderate effect sizes on several subscales and composite scores were noted, indicating that some nonsignificant differences may still have clinical implications that warrant further evaluation.

Research of the athlete with concussion has evaluated how self-reported, sport-related concussion history affects the HRQOL of collegiate athletes,16 with results indicating that the collegiate athletes’ perception of bodily pain, vitality, social functioning, and headache were negatively affected by a history of sport-related concussion. In adolescent males, Valovich McLeod et al17 found that those individuals with a self-report history of sport-related concussion reported significantly lower HRQOL on several subscales of the SF-36 and a significantly greater effect of headache-specific HRQOL, as measured by the HIT-6. Of particular interest, these domains of HRQOL were depressed, even though the injury was not present at the time of evaluation and the athletes were participating fully in their sport, similar to the current investigation.

It is important to note that other contributing factors, including comorbid conditions, can alter HRQOL and baseline symptoms. Bingefors and Isacson35 found that headache was more commonly reported in individuals who also reported symptoms related to depression and anxiety. Similarly, Piland et al42 noted that higher baseline self-report symptom scores were found in those with a history of concussion, fatigue, physical illness, and orthopedic injury. Therefore, understanding all the potential influences related to symptom reports and HRQOL is important.

Although our study contributes to knowledge regarding headache symptom and HRQOL differences between sexes based on concussion history, we do acknowledge the limitations of our research. A medical history was not obtained for participants, and no exclusion criteria were used. Therefore, some participants may have had underlying comorbid conditions (eg, anxiety, depression) that appeared as daily symptoms on the SCAT2 symptom scale, mimicking concussion-like symptoms. However, all participants had completed a preparticipation physical examination and were cleared to participate by a physician in their respective contact sport. Although data collection was part of a preseason baseline test session, the timing of sessions may have been different at each high school. In addition, although we instructed the athletes to think back to the past few weeks and report their typical daily symptoms, the athletes may have reported current symptoms.

Although self-reported medical history may seem unreliable, both self-reported concussion history and self-reported symptoms are used within the medical literature. Self-reported medical history is commonly used throughout both the medical and dental literature as a reliable source of information.43,44 Without a current medical standard for concussion diagnosis, researchers must depend on self-reported concussion history. Thus, self-reported history is commonly used in concussion research, especially when retrospectively assessing prolonged symptoms and effects of concussion.7,16,17 Including words such as “dinged” or “bell rung” in self-report assessments can help athletes identify their prior concussion history.27 Because of the widespread use of self-report histories, healthy adolescents have been described as reliable when reporting symptoms with a Likert-type grading scale.21

As concerns regarding adolescent concussion rise, additional research is needed. For example, determining relationships between specific symptoms, such as the relationship between visual disturbances and headache, could benefit concussion management. Several symptoms—visual disturbances, auditory problems, and neck pain—are closely related to headache and its possible causes. Another area of research that may benefit adolescent concussion management is the effect of daily symptoms on school performance following a concussion and the role of cognitive rest in alleviating symptoms.

Conclusions

In this investigation, adolescent athletes with a self-reported concussion history and female athletes reported a significantly higher symptom severity score compared with peers and male athletes without concussion. However, the effect of these symptoms on headache-specific HRQOL, although statistically significant between groups, fell within the scoring category of little to no impact. Future studies should continue to evaluate these and other patient-report outcomes to further identify factors that lower HRQOL and to determine the effect of concussion on headache-specific and general HRQOL in athletes of all ages.

Implications for Clinical Practice

Clinicians should understand that concussion may not only affect the individual’s participation in sports, but can also affect other aspects of his or her life, such as HRQOL. The use of patient-report outcomes scales to measure HRQOL during follow-up assessment of athletes with concussion can provide valuable information about the patient perspective. Understanding the relationship of HRQOL and symptom presentation may also be important to appropriately treat athletes with concussion.

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Concussion History Study Questionnairea

Have you ever had a concussion or head injury
  While playing a sport?
  While participating in a recreational activity?
Have you ever been knocked out
  While playing a sport?
  While participating in a recreational activity?
Have you ever had your “bell rung” or been “dinged”
  While playing a sport?
  While participating in a recreational activity?

Questions Included on the Headache Impact Test-6

When you have headaches, how often is the pain severe?
How often do headaches limit your ability to do usual daily activities, including household work, work, school, or social activities?
When you have a headache, how often do you wish you could lie down?
In the past 4 weeks, how often have you felt too tired to do work or daily activities because of your headaches?
In the past 4 weeks, how often have you felt fed up or irritated because of your headaches?
In the past 4 weeks, how often did headaches limit your ability to concentrate on work or daily activities?

Demographic Data for Each Study Group, Concussion History, and Sex

VARIABLEMEAN ± STANDARD DEVIATION
POS FEMALE (n = 249)NEG FEMALE (n = 501)POS MALE (n = 1416)NEG MALE (n = 1132)
Age (yrs)15.59 ± 1.1615.57 ± 1.4315.52 ± 1.6515.49 ± 1.59
Grade level10.36 ± 1.0810.31 ± 1.1310.29 ± 1.0710.23 ± 1.09

Primary Sport Within Each Participant Group, Concussion History, and Sex

SPORTNO. OF PARTICIPANTS PER SPORT (%)
POS FEMALENEG FEMALEPOS MALENEG MALE
Baseball/softball85 (34.1)148 (29.5)210 (14.8)153 (13.5)
Basketball49 (19.7)93 (18.6)138 (9.8)138 (12.2)
Football3 (1.2)687 (48.5)462 (40.8)
Golf3 (0.2)2 (0.2)
Gymnastics/cheer5 (2)19 (3.8)
Hockey4 (0.3)2 (0.2)
Not specified1 (0.4)19 (3.8)13 (0.9)22 (2)
Othera1 (0.2)7 (0.5)4 (0.3)
Soccer72 (28.9)123 (24.6)157 (11.1)147 (13)
Swim/dive7 (1.4)4 (0.3)7 (0.6)
Track/cross country3 (1.2)4 (0.8)8 (0.6)15 (1.3)
Volleyball31 (12.5)84 (16.8)19 (1.3)21 (1.9)
Wrestling3 (0.6)166 (11.7)159 (14)
Totalb249 (100)501 (100)1416 (100)1132 (100)

Baseline Symptom Score for Each Headache-Related Self-report Symptom and Total Symptom Score

SYMPTOMMEAN ± STANDARD DEVIATION
POS FEMALENEG FEMALEPOS MALENEG MALE
Headache1.51 ± 1.52a0.94 ± 1.130.94 ± 1.23b0.59 ± 0.98
Pressure in the head0.98 ± 1.34a0.44 ± 0.880.65 ± 1.03b0.37 ± 0.77
Total symptom score18.3 ± 18.5a10.2 ± 13.511.8 ± 13.7b6.6 ± 9.9

10.3928/19425864-20130417-02

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