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However, heterogeneity in study design, participants, and recovery outcomes has led to mixed findings. Further work is needed to evaluate potential differences by sex and to investigate the role of related characteristics, such as sport contact-level, in recovery timelines. This study aimed to investigate whether concussion recovery trajectories differ by sex, considering a priori clinical and demographic covariates, and accounting for the sequence of recovery outcomes. Our secondary question was whether sport contact-level modifies the relationship between sex and time to outcomes. Using data from the Ivy League\u2013Big Ten Epidemiology of Concussion Study, we included SRCs reported across five academic years; 2015\u20132020 (February 2020). We used Cox proportional hazards regressions to estimate associations between sex and time from injury to three outcomes: (1) symptom resolution, (2) return to academics, (3) return to full play, accounting for measured confounders.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>Among 1160 SRCs (male, n\u2009=\u2009667; female, n\u2009=\u2009493) with complete data, median age overall was 20\u00a0years (25th-75th percentiles:19\u201321), and most occurred among athletes playing high-contact sports (78.0%). Males were slightly more likely to complete symptom resolution over time compared to females (HR\u2009=\u20091.18, 95%CI\u2009=\u20091.05\u20131.33), but results were attenuated in fully adjusted models (HR 1.13, 95%CI\u2009=\u20090.99\u20131.29). Similarly, the HR of full academic return for males compared to females was 1.22 (95%CI\u2009=\u20091.07\u20131.38), but was attenuated in fully adjusted models (HR\u2009=\u20091.11, 95%CI\u2009=\u20090.97\u20131.28). The HR of full return to play for males compared to females was 1.14 (95%CI\u2009=\u20091.02\u20131.28), and was attenuated after adjustment (HR\u2009=\u20091.06, 95%CI\u2009=\u20090.93\u20131.20) as well. The interaction between sex and playing a high\/low-contact sport was not statistically significant across models, though differences were apparent.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>Among a cohort of collegiate athletes with SRC, recovery timelines appeared similar between male and female athletes, adjusting for measured confounders. Differences by sex, considering sport contact-level, were evident and may be important clinically and in future studies. This study used robust methods, accounting for nesting in the sequence of RTP outcomes. Results inform concussion management protocols and planned qualitative work to further elucidate how collegiate athletes experience concussion recovery.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Key Points<\/jats:title>\n                <jats:p><jats:list list-type=\"bullet\">\n                  <jats:list-item>\n                    <jats:p>Heterogeneity in study design, participants, and recovery outcomes has led to mixed findings in determining differences in recovery trajectories after concussion by sex.<\/jats:p>\n                  <\/jats:list-item>\n                  <jats:list-item>\n                    <jats:p>We found that having longer time to symptom resolution, and also the sequence of having academic return before symptoms resolve and longer time to academic return were confounders in the relationship between sex and RTP timelines. Time to sequential recovery outcomes appeared similar between male and female athletes, adjusting for observable confounders. Further differences by sex were evident when considering contact-level, and may be important to consider clinically and in future research.<\/jats:p>\n                  <\/jats:list-item>\n                  <jats:list-item>\n                    <jats:p>Results indicate that differences in concussion recovery trajectories by sex may be largely attributed to and driven by differences in sports with a men\u2019s or women\u2019s team only, such as football, and this should be explored further.<\/jats:p>\n                  <\/jats:list-item>\n                <\/jats:list><\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s40798-024-00742-4","type":"journal-article","created":{"date-parts":[[2024,7,29]],"date-time":"2024-07-29T18:03:32Z","timestamp":1722276212000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Associations of Sex and Sport Contact-Level with Recovery Timelines Among Collegiate Athletes with Sport-Related Concussion"],"prefix":"10.1186","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3760-2158","authenticated-orcid":false,"given":"Bernadette A.","family":"D\u2019Alonzo","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0026-5052","authenticated-orcid":false,"given":"Andrea L. 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The study was performed in accordance with the standards of ethics outlined in the Declaration of Helsinki. All participants provided informed consent.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics Approval and Consent to Participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for Publication"}},{"value":"Bernadette A. D\u2019Alonzo has no competing interests. Andrea L.C. Schneider reports being an Associate Editor at the journal <i>Neurology<\/i> outside of the submitted work. Ian J. Barnett and Christina L. Master have no competing interests. Douglas J. Wiebe reports\u00a0providing consulting services on the topic of concussion\/TBI epidemiology to the NCAA. Andy Peterson reports textbook royalties from McGraw-Hill. Other named Ivy League-Big Ten Study Investigators report no competing interests.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"86"}}