Female Athletes and Concussions

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

2. 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

3. 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

7. Role of hormones:

8. 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

9. 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

10. 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).

11. Or…… • are females just better reporters?

12. 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

13. 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

14. TIPS FOR ASSESSING THE CONCUSSED ATHLETE -

15. 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

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

17. 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

18. 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

19. Clusters of Symptoms:

20. 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

21. 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

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

23. Neck Strengthening • Video by UWEC

24. 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

25. Handouts available with resources

26. 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