Female Athletes and Concussions Jeanne Brown, MS, ATC-L OakLeaf Concussion Clinic Eau Claire, WI

2012- Marar M, Comstock RD – Am J Sports Med Concussions (male and female) account for 13.2% of all injuries (1.6 – 3.8 million) per year…..epidemic proportions according to the CDC 2012- Marar M, Comstock RD – Am J Sports Med Indications are that this number would be lower if all injuries that occur were actually considered as reportable (i.e. – minor injuries like mild ankle sprains that did not result in time lost of play are not included in the data)

For the Female Athlete: Fewer overall than males, but increasing over time Games riskier than practices Higher rates for females in comparable sports and greater percent of total injuries Much sex similarity, and modest sex difference shown so far in risks, symptoms and effects

Role of hormones:

Physical Risks for Female Athletes Anatomy -Smaller head than male counterpart -Weaker neck muscles, less neck mass Females have a higher incidence of headache and/or migraine making them more susceptible to concussion Style of play: - Not anticipating blows - Head not on a swivel

Ethical Risks for Female Athletes: Illegal Play is a Risk Factor for female athlete concussions: - 6.4% of all HS sports related injuries were related to illegal play - 14% in girls’ basketball - 11.9% in girls’ soccer - Concussions 25.4% d/t illegal play compared to 10.9% in males - Injuries to head/face 32.3% d/t illegal play compared to 13.8% in males

Girls are becoming more aggressive and assertive in the way they play………………. Good news for the game and the coaches…. Bad news for injuries This will prevent them from reporting as they imbibe in the culture of playing at all cost and playing for ‘the team’. They are concerned about not being tough enough and about losing their position on the team. They know the implications of sustaining a concussion – (they may lose weeks).

Or…… are females just better reporters?

The Role of the ATC - The first line of defense for the injured athlete….. Provides immediate care of the athlete and … Provides intermediate follow-up care of the athlete Knows the athlete as well as anyone providing care May be determining RTP decisions

Consider these numbers: (HCP initial Assessment of Concussion) 94% - by ATC’s 59% - by PCP < 3% - by Specialists (neurologist, NeuroPsy) 63% - by 2 qualified HCP 87% - by ATC’s and PCP 7% - by ATC and Orthopod

TIPS FOR ASSESSING THE CONCUSSED ATHLETE -

SUSPECT A CONCUSSION…. Consider the sport and it’s rate of concussion blow or hit to the head or body and whiplash potential signs of a blow or hit to the head (bumps, lumps, bruises) 3rd or 4th period/quarter implications

A thorough exam: Complete History / Mechanism of Injury Balance Testing CGS (alone with the athlete/no parent) Neuro-psych testing VOR testing

Preliminary evidence (separate slides below?): Symptoms for females tend to be neurobehavioral and somatic in nature Females report more symptoms than males Females have greater sensitivity to subtle symptoms Females report more drowsiness and fatigue

Preliminary Evidence cont…. Females in general more likely to suffer from migraine before concussion which predisposes them to concussion, and they tend to have more headaches after they have recovered from concussion Elevated risk of mental health disorders: mood disorders, depression, sadness, irritability, anxiety (estrogen?) Auditory sensitivity and acuity: hence more phonophobia and tinnitus

Migraine (Physical SX) Clusters of Symptoms: Neuropsychiatric - More emotional -Sadness -Nervousness -Irritability Cognitive Symptoms -Attention Problems -Memory dysfunction -”Fogginess” -Fatigue -Cognitive slowing Sleep Disturbance -Difficulty falling asleep -Sleeping less than usual Migraine (Physical SX) -Headaches -Visual Problems -Dizziness -Noise/Light sensitivity -Nausea

Treatment Spectrum: Every concussion is unique SF at rest, SF under exertion, Passing NP test and VOR/Balance tests for Clearance considerations Treat according to symptoms : (4 clusters) Vestibular therapy if dizziness symptoms after 3 weeks Neck ROM exercises in conjunction with rest Neck Strengthening exercises with exertion Medications PRN : Aleve, Tylenol, and/or Excedrin Migraine as OTC meds; Amantadine or Amitriptyline as RX meds Academic accommodations: see handout Include social interactions via multi- media

Treatment of Symptoms (based on cluster): Emotionality SSRIs Escitalopram (Lexapro) Sertraline (Zoloft) Therapy Somatic Symptoms Headaches Prophylaxis Propranolol* Verapamil* Amitriptyline* Escitalopram (Lexapro) Sertraline (Zoloft) Vestibular Therapy Cognitive Symptoms Neurostimulants Amantadine* Methylphenidate* Atomoxetine (Strattera)* Sleep Disturbance Melatonin Trazodone

Prevention: EDUCATION! Rule changes necessary to protect the athlete Teach and coach: head on a swivel, anticipation of a blow Neck strengthening Headgear?

Neck Strengthening Video by UWEC

Summary The rate of concussions in females is high and on the rise Consider the possibilities especially in high-risk sports (soccer, lacrosse, basketball, hockey) Do a thorough assessment Treat according to cluster of symptoms Consider prevention parameters The Athletic Trainer’s role is paramount in the assessment, treatment, and return-to-play decisions

Handouts available with resources

Thank you Justin Greenwood Diane Wiese-Bjornstal and the Tucker Institute of Research: University of Minnesota UWEC ATEP staff UWEC ATEP students who helped with the video portions of this presentation