Tackling the concussion gender gap head on

 
Balls smashing into each other.

Tackling the concussion gender gap head on

 
Balls smashing into each other.

How concussion affects men and women differently and what that means for physiotherapy treatment is discussed by PhD candidate Shreya McLeod.

There has been an exponential rise in women participating in sport, from amateur to professional leagues.

This rapid increase in participation has seen a concurrent increase in injuries such as sport-related concussions.

In comparable sports, women are twice as likely to sustain a sport-related concussion as men (Kerr et al 2016), most commonly from player-to-player contact or from contact with an object or surface (Rosene et al 2017).

Proposed hypotheses for these sex-based differences include physical and physiological factors (Iverson et al 2017).

Physical factors such as shorter neck dimensions, smaller head mass and narrower neck girth could predispose women to greater head-neck acceleration during impacts (Alsalaheen et al 2019).

Physiological factors such as morphological variations in brain architecture and hormonal fluctuations at the time of injury may have an impact on outcomes (McGroarty et al 2020, Solomito et al 2019).

Women also tend to be more forthcoming in terms of reporting their symptoms, although chronic under-reporting exists (Brown et al 2015).

Symptoms

Following an acute concussive episode, women report greater symptomology and have higher short-term morbidity compared to men in cognitive functioning and reaction time (McGroarty et al 2020, Solomito et al 2019, Stone et al 2017).

Although the evidence is mixed, on average, women take longer to recover compared with men (Iverson et al 2017).

Both sexes report symptoms such as headaches, mental fatigue, concentration difficulties and mood swings (Covassin et al 2018).

Women rate headache, pressure in the head and emotional lability higher than men (Covassin et al 2013).

Other symptoms may include dizziness, fatigue, memory loss, concentrationdifficulties, insomnia, neck pain, irritability, visual disturbances and feeling in a fog (Makdissi et al 2017, Merritt et al 2015).

Cervical spine

Neck pain is commonly reported following concussion, with symptoms closely resembling those of a whiplash injury (Morin et al 2016).

Due to the upper cervical spine’s role in proprioception, a thorough cervical spine examination is warranted if the individual complains of neck pain, headache, cervicogenic dizziness
or a sense of feeling ‘foggy’.

Assessment should include the cervical flexion-rotation test (Ogince et al 2007), segmental palpation, motor control and flexor/extensor endurance (Jull et al 2007, Treleaven et al 2006, Treleaven et al 2003).

In the general population, women are also up to five times more likely to suffer from migraine headaches and, therefore, clinicians should consider the headache presentations of female athletes and offer appropriate management.

Cervical therapies such as exercise and manual therapy have been shown to be effective in treating cervicogenic headache (Hall et al 2007, Schneider 2019).

Shreya McLeod.

A multifactorial approach involving sleep hygiene, education, exercise and stress reduction may also be indicated (Zasler 2015).

Based on examination findings, treatment could target impairments with manual therapy, motor control training or flexor/extensor endurance training.

In addition, as women and men use different strategies to stabilise their heads and have inherent differences in physical parameters (Alsalaheen et al 2019, Caswell et al 2017,
Press & Rowson 2017, Tierney et al 2005), more studies are needed to understand how cervical spine treatments affect both sexes.

Vestibular/oculomotor  

Dizziness is a commonly reported symptom following a concussion (Kerr et al 2016).

Little research has examined sex differences in vestibulo- ocular outcomes post-concussion. 

However, research has shown that adolescent girls perform worse on balance, vestibular and oculomotor function compared to boys, and that early vestibular rehabilitation may be important in female athletes to improve balance and dizziness symptoms and reduce the symptom burden post- concussion (Gray et al 2020).

Autonomic dysfunction Following a concussion, exercise may provoke an individual’s symptoms or indicate intolerance, thought to be due to autonomic dysfunction.

In adolescents and adults, a protocol of sub-symptom threshold aerobic exercise at 80–90 per cent heart rate, five to six times per week, has shown positive results in facilitating recovery (Leddy et al 2019, Leddy et al 2019, Willer et al 2019).

Studies have shown that female athletes prescribed early sub-symptom threshold aerobic exercise reported a reduction in symptoms, compared with male athletes (Leddy et al 2019, Leddy et al 2019, Willer et al 2019).

As individuals work through exercise programs, treatment strategies need to be patient-specific and incorporate multiple systems, including balance and cognitive tasks (Reid et al 2021).

Two recent systematic reviews have shown that in concussed individuals with persistent symptoms, an individualised, active rehabilitation program (comprised of exercise, cervical spine treatment and vestibulo-ocular therapy) can improve symptom scores and increase the likelihood (by three times) of an athlete returning to sport by eight weeks (Reid et al 2021, Carter et al 2021).

Further research is needed to determine whether there are sex differences and the optimal frequency, intensity, time and type dosages of exercise prescription in concussed individuals.

Concussion is heterogeneous in nature and requires input from multiple healthcare practitioners.

Physiotherapists are integral to the multidisciplinary team and possess a unique skill set for guiding individuals from injury (eg, assessment and rehabilitation through to return to function/play).

Due to the inherent physical and physiological differences between men and women, education plays a vital role in recovery.

Further research is required to understand whether men and women respond differently to treatment.

>> APA Sports and Exercise Physiotherapist and APA Musculoskeletal Physiotherapist Shreya McLeod APAM MACP is a consultant with Cricket NSW. Shreya is a PhD candidate at the University of Newcastle, New South Wales, in the identification of concussion in women’s national rugby league. She has a research interest in injury risk reduction, particularly in female contact and collision sports. She is also a lecturer and course coordinator of the undergraduate physiotherapy program at the Australian Catholic University in North Sydney, New South Wales. 

References


1.    Kerr, Z.Y., et al., Concussion symptoms and return to play time in youth, high school, and college American football athletes. JAMA pediatrics, 2016. 170(7): p. 647-653.
2.    Rosene, J.M., et al., Comparison of concussion rates between NCAA Division I and Division III men’s and women’s ice hockey players. The American Journal of Sports Medicine, 2017. 45(11): p. 2622-2629.
3.    Iverson, G.L., et al., Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med, 2017. 51(12): p. 941-948.
4.    Alsalaheen, B., et al., Women and men use different strategies to stabilize the head in response to impulsive loads: implications for concussion injury risk. Journal of Orthopaedic & Sports Physical Therapy, 2019(0): p. 1-26.
5.    McGroarty, N.K., S.M. Brown, and M.K. Mulcahey, Sport-related concussion in female athletes: A systematic review. Orthopaedic journal of sports medicine, 2020. 8(7): p. 2325967120932306.
6.    Solomito, M.J., H. Reuman, and D.H. Wang, Sex differences in concussion: a review of brain anatomy, function, and biomechanical response to impact. Brain Injury, 2019. 33(2): p. 105-110.
7.    Brown, D.A., et al., Differences in Symptom Reporting Between Males and Females at Baseline and After a Sports-Related Concussion: A Systematic Review and Meta-Analysis. Sports Med, 2015. 45(7): p. 1027-40.
8.    Stone, S., et al., Sex Differences in Time to Return-to-Play Progression After Sport-Related Concussion. Sports Health, 2017. 9(1): p. 41-44.
9.    Covassin, T., et al., Sex differences in sport-related concussion long-term outcomes. International journal of psychophysiology, 2018. 132: p. 9-13.
10.    Covassin, T., et al., The management of sport-related concussion: considerations for male and female athletes. Translational stroke research, 2013. 4(4): p. 420-424.
11.    Makdissi, M., et al., Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. British journal of sports medicine, 2017. 51(12): p. 958-968.
12.    Merritt, V.C., A.R. Rabinowitz, and P.A. Arnett, Injury-related predictors of symptom severity following sports-related concussion. Journal of clinical and experimental neuropsychology, 2015. 37(3): p. 265-275.
13.    Morin, M., P. Langevin, and P. Fait, Cervical Spine Involvement in Mild Traumatic Brain Injury: A Review. Journal of Sports Medicine, 2016. 2016: p. 1590161.
14.    Ogince, M., et al., The diagnostic validity of the cervical flexion–rotation test in C1/2-related cervicogenic headache. Manual therapy, 2007. 12(3): p. 256-262.
15.    Jull, G., et al., Retraining cervical joint position sense: the effect of two exercise regimes. J Orthop Res, 2007. 25(3): p. 404-12.
16.    Treleaven, J., G. Jull, and N. LowChoy, The relationship of cervical joint position error to balance and eye movement disturbances in persistent whiplash. Man Ther, 2006. 11(2): p. 99-106.
17.    Treleaven, J., G. Jull, and M. Sterling, Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error. Int J Phys Med Rehabil, 2003. 35(1): p. 36-43.
18.    Hall, T., et al., Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. journal of orthopaedic & sports physical therapy, 2007. 37(3): p. 100-107.
19.    Schneider, K.J., Concussion part II: Rehabilitation–The need for a multifaceted approach. Musculoskeletal science and practice, 2019.
20.    Zasler, N.D., Sports concussion headache. Brain injury, 2015. 29(2): p. 207-220.
21.    Caswell, S.V., et al., Characterizing verified head impacts in high school girls’ lacrosse. The American journal of sports medicine, 2017. 45(14): p. 3374-3381.
22.    Press, J.N. and S. Rowson, Quantifying head impact exposure in collegiate women's soccer. Clinical journal of sport medicine, 2017. 27(2): p. 104-110.
23.    Tierney, R.T., et al., Gender differences in head-neck segment dynamic stabilization during head acceleration. Med Sci Sports Exerc, 2005. 37(2): p. 272-9.
24.    Gray, M., et al., Female adolescents demonstrate greater oculomotor and vestibular dysfunction than male adolescents following concussion. Physical therapy in sport, 2020. 42: p. 68-74.
25.    Leddy, J.J., et al., Early subthreshold aerobic exercise for sport-related concussion: a randomized clinical trial. JAMA pediatrics, 2019. 173(4): p. 319-325.
26.    Leddy, J.J., et al., A Preliminary Study of the Effect of Early Aerobic Exercise Treatment for Sport-Related Concussion in Males. Clin J Sport Med, 2019. 29(5): p. 353-360.
27.    Willer, B.S., et al., Comparison of rest to aerobic exercise and placebo-like treatment of acute sport-related concussion in male and female adolescents. Archives of physical medicine and rehabilitation, 2019. 100(12): p. 2267-2275.
28.    Reid, S.A., J. Farbenblum, and S. McLeod, Do physical interventions improve outcomes following concussion: a systematic review and meta-analysis? British Journal of Sports Medicine, 2021.
29.    CARTER, K.M., A.N. PAUHL, and A.D. CHRISTIE, The Role of Active Rehabilitation in Concussion Management: A Systematic Review and Meta-analysis. Medicine & Science in Sports & Exercise, 2021. 53(9): p. 1835-1845.

 

 

 

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