Gender Differences in Concussion

The lack of attention to gender differences has been a problem in the medical field. This difference needs be taken into consideration when working with athletes recovering from traumatic brain injury because of physiological and chemical differences which impacts how you should manage concussions. Improper management of concussion may result in serious long-term or lifelong disability, risk of coma, or in extreme cases death.


Traumatic brain injury (TBI) commonly occurs in high-contact sports for both male and female athletes. However, when comparing the research between male and female athletes, female athletes suffer more concussions than men. Even in sports where the rules are the same for both sexes, such as basketball or soccer, female athletes experience or report a greater number and severity of symptoms and a longer duration of recovery than male athletes. A 2007 study of college athletic injuries shows that female softball players experience concussions at twice the rate of their male baseball counterparts. In some sports, such as women’s hockey where intentional body checking is prohibited for women, they still experience more concussions.


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Game concussion rate by gender. The figure compares game concussion injury rates in basketball and soccer (similar rules and equipment) and ice hockey (similar equipment but different rules—no body checking allowed in women’s game). In all three activities, the women’s sports showed absolute rate values that were higher than their male counterparts and in two cases, (basketball and soccer), these rates were statistically higher.


At first this difference was attributed to women being more honest or forthcoming about their injuries to their medical staff. However, view of female athletes being more culturally accepting of injury is slowly being reconsidered as studies prove that women are not just more vocal about their pain, but are being injured in sports at higher rates than men. Based on research, there are two reasons for this occurrence:

    1. Biomechanical Differences: Differences in the musculature in the cervical spine and less developed neck muscles. Studies have shown that neck size and strength may play a role in determining concussion rates and the comparatively weaker neck muscles in women may be causing less head stability in females during an impact of fall.
    2. Physiological Differences:Hormonal differences in women and men. Studies have shown that estrogen appears to be a protective factor in male, but it exacerbates the injury in female. Moreover,  the menstrual cycle is a predictor of the outcomes after a concussion. Women who are injured during the luteal phase, the last two weeks of the cycle, are more vulnerable to concussions and have worse symptoms than women who are injured during the follicular phase.

Although female athletes may face more concussions than male athletes, there are simple things that can be done to help reduce the rates of concussion. Pre-season testing and erring on the side of caution both after an impact and during return to play will help reduce second impact syndrome. Strength training, especially focused on the neck muscles may contribute to reducing the forces experienced by the head. With proper concussion management, an athlete can recover from a concussion and be able to return to play and life functions.

Managing Assessment Variances Within Sports Medicine Teams

Athletic Therapists (ATs) are commonly the first medical providers or health care professionals available onsite to evaluate any injuries that may occur during a competition or practice. They are not only crucial during competition, but also post competition during the injury management and return-to-play decision-making process. Athletic Therapists work closely with the Team Physician in order to provide the most effective therapeutic interventions and rehabilitation of injuries. Their goal is to return an athlete to competition as quickly and as safely as possible. Not only do they play a key role in injury identification, evaluation, and management, but are also critical at the sideline for screening for concussions to mitigate the risk of permanent brain damage.


One of the challenges faced by an Athletic Therapist is determining whether an athlete should be removed from activity for further evaluation after a suspected hit to the head. Although even a decade ago it was acceptable to “shake it off” and return to play, new legislations in Canada and the US and standard guidelines require athletes to be removed from competition or practice if a concussion is suspected. To properly determine the risk an Athletic Therapist should complete a post-injury assessment and compare it to a test done on the same athlete at the beginning of the season. In some sports leagues, there are multiple Athletic Therapists tending to multiple teams. A reality is that a post-injury test may not be completed by the same person who did the pre-season assessment. It is important for sports medicine teams to try to manage assessment variances in order to provide the best possible information for making return-to-play decisions.


Managing variability through diversification 

The post-injury assessment includes a series of questionnaires, checklists, and physical testing that is identical to the pre-season test. A concussion can impact brain function in a variety of ways and because of the nature and physical demands of a sporting event an evaluation of concussion-related symptoms can be challenging. For example, an athlete may show concussion-like symptoms if they are dehydrated or have performed a strenuous activity, however this does not mean that the athlete will also demonstrate balance or neurocognitive impairments. Therefore it is important that an Athletic Therapist, his/her team and the team physician are all using a comprehensive battery of tests to assess brain function. Relying on any one type of test for the monitoring and decision making regarding return to play for an athlete provides an incomplete picture of the severity and breadth of the brain injury.


Managing variability through calibration meetings 

Assessment variances also happen when training and communication is limited between therapy teams. It is possible to estimate and to some degree calibrate inter-rater (tester 1 vs. tester 2) reliability. For example, when testing balance at the beginning of the season, teams can grade athlete balance errors individually and after the test is complete they can compare scores. While this provides a crude measurement, it will provide insight into how much agreement exists and provides an opportunity for coaching and education. Weekly “calibration” meetings may also help - short dedicated discussions can happen and ATs can discuss why they chose the specific values they did. Where disagreements appear, the collective unit can help form some rules to help ensure calibration in the future.


Managing variability with routine 

Variability can also appear as a result of intra-rater (tester 1 vs tester 1) reliability issues. For example, grading a balance video in the morning, and then watching and grading the same video in a different setting in the afternoon can generate some significant variances. With the challenges and pressures that Athletic Therapists face during a sporting event combined with subjective concussion testing, a consistent routine and method can help improve intra-rater reliability. To begin, the trainer needs the support needed from his/her therapy team to focus exclusively on the concussion assessment at hand instead of  attempting to split his/her attention between the test and the active game. Reducing situational interference (distractions from the surrounding environment) and following a consistent testing structure or methodology every time can also help.


Managing variability with objectivity 

Technology has enabled us to collect objective measurements where subjective grading used to take place. In his Sensorimotor Physiology lab at UBC, PhD candidate Harrison Brown developed a way to use technology to reduce variances in balance testing. He specifically looked at the balance test done in concussion assessments. By analyzing the movement of athletes performing the test and by introducing motion sensors, he was able to develop an algorithm which can objectively score an athlete's balance. “Now it doesn’t matter whether my grandma is doing the test, my favourite doctor is or both; they’re both going to get the same score.” His technology has increased the test-retest reliability of the concussion gold-standard balance test from between 40-60% reliability to over 91% reliability.

Physical and Emotional Effects of Concussion

Post-concussion syndrome is a collection of physical and emotional symptoms that are present after a head injury or trauma has occurred. These symptoms can last from days, to weeks or months. The concussion symptoms listed below vary depending on the individual and the severity of the injury. The symptoms of this type of brain injury may be worse for individuals who have had a history of concussion. Others may experience a less severe effect due to proper management once the concussion has occurred.


Physical symptoms:

  • Headache or pressure in the head (the most common symptom)
  • Nausea or vomiting
  • Double or blurred vision
  • Hearing loss and/or tinnitus - ringing noise in the ears
  • Reduced sense of smell and taste
  • Sensitivity to light and noise
  • Difficulty with concentration and balance

Emotional/behavioural symptoms:

  • Easily irritable and sometimes aggressive
  • Depression
  • Having disturbed sleep and feeling constantly tired
  • Reduced sex drive
  • Changes in appetite
  • Lack of energy and motivation
  • Sudden outbursts of emotion or mood swings


It is important to know that these symptoms may not be present or obvious at the time of the injury. The symptoms of traumatic brain injury may be delayed from 24 hours to a week. Therefore, it is crucial to be aware of how your body is changing physically and emotionally after a direct bump, blow, or jolt to the head.

Concussion Basics

What is a Concussion?

The occurrence of concussion, a type of traumatic brain injury (TBI), has risen dramatically over the past 10 years and is nowadays considered a major cause of disability in Canada and the US. This type of brain injury is caused by a direct bump, blow, or jolt to the head or an indirect blow to the body that causes the brain to rapidly move back and forth within the skull. Concussions can occur during a fall, accident, household or work mishaps and commonly in high-contact sports such as football, rugby, hockey, and soccer. Indications of a concussion usually reflect a functional disturbance to the brain and may include physical (e.g. headaches, nausea), cognitive (e.g. difficulty with concentration or memory), emotional (e.g. irritability, sadness), and ‘maintenance’ (e.g. sleep disturbances, changes in appetite or energy levels) symptoms. Standing balance is also a common indicator of concussion, whereby concussed individuals suffer from a distinct lack of postural stability. Improper diagnosis of these indicators and management of concussion may result in serious long-term or lifelong disability, risk of coma, or in extreme cases death.

What Should I Do If I Have a Concussion?

Never ignore a collision to the head - it is always better to miss one game than the whole season and to be safe than sorry. If you believe you have a concussion, informing your coach or athletic therapist/trainer is the first step in order to evaluate whether or not you have a concussion. If a more severe injury is suspected, they will send you to the hospital for further examination and diagnosis to understand the severity of the brain injury. Even though there are currently no validated medical treatments for concussions, the recommended recovery method is by giving your brain a rest, both physically and mentally. Rest includes limiting exercise and activities that require thinking or mental concentration such as schoolwork, reading, and using a computer or mobile device. Before returning to play, it’s crucial to receive a clearance from a medical professional even if you no longer feel the symptoms of a concussion anymore. Returning to sport too soon will increase the risk of having a second concussion that could lead to permanent or fatal brain damage.

How Do I Prevent a Concussion?

Do what you love and love what you love. If participating in sport is an activity that you enjoy, don’t let the increased chance of receiving a concussion prevent you from doing something that you enjoy. Concussion risk can be reduced by playing by the rules, wearing the proper equipment for the sport and wearing the equipment properly, learn and use the proper techniques of your sport, and practicing good sportsmanship.