Concussions in the Female Athlete

Introduction

Female athletes are more likely to sustain sport-related concussion than male athletes when playing equivalent sports. Studies on middle-school to high-school females demonstrate that female athletes are at a higher risk of sustaining a concussion than their male counterparts. A landmark study in 2017 by Schallmo et al. was the first to report both gender differences and sport-specific differences in concussion. Despite significant educational efforts, athletes continue to underreport concussion symptoms. This chapter will discuss the evolving evidence surrounding gender differences in concussion, current trends, and future directions.

Clarifying Terms

Since 2001, an international conference involving multidisciplinary experts has convened every 4 years to create an expert, consensus-based approach on how to review, discuss, and study concussion as it relates to sports. Following each meeting, this group has produced a consensus paper with guidelines on the definitions, diagnosis, evaluation, and management of concussion.

It is important to note the evolution of the term, “sport-related concussion (SRC)” versus “concussion.” Concussion is a broad term applied to immediate and transient symptoms of traumatic brain injury (TBI). Between the fourth and fifth International Conference on Concussion in Sport, SRC was more precisely described as, “a traumatic brain injury that is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces with several common features that help define its nature”. ^, A consistent goal of the International Conference on Concussion in Sport is to streamline SRC definition, eliminating designation of severity ratings of concussion (i.e., mild vs. complex).

This definition is incredibly important not only for the clinician but also for the patient to understand. Important points from the Consensus Statement for the definition of SRC include the following:

• SRC is an injury occurring as an induction of biomechanical forces.

• SRC can be caused by a direct blow to the head, face, neck, or elsewhere in the body (i.e., whiplash-type mechanism).

• SRC is a short-lived impairment of neurologic function, which resolves spontaneously. Special note should be taken, as both signs and symptoms can evolve over a period of minutes to hours.

• SRC results in many neuropathologic changes, but the more acute signs and symptoms manifest as a very functional change/disturbance versus a true structural change. This means that no abnormality is seen on a standard neuroimaging study, such as a magnetic resonance imaging or a computed tomographic scan.

• SRC may or may not involve loss of consciousness.

• SRC signs and symptoms will resolve over time with a “sequential course”; however, they can be prolonged in some cases.

• To clinically define a head injury as an SRC, the signs and symptoms need to be defined outside influences such as drug, alcohol, or medication use; other injuries; and/or other comorbidities.

The understanding of concussion is further complicated by it being largely a clinical diagnosis rather than a diagnosis based on an abnormal imaging study or a laboratory result. Additionally, concussive symptoms, which help form the clinical diagnosis, are graded on a spectrum of severity from 1–6, rather than on black-and-white answers of yes or no.