Women and Concussion

Most of the concussion literature is devoted to concussion and men, and this literature focuses primarily on American football and ice hockey. Yet women appear to be more prone to sport-related concussion than men, and may manifest with more concussion-like symptoms both at both baseline and post-concussion. There may be both endocrinologic and biomechanical reasons why women’s concussive symptoms are different from men’s, but this remains incompletely understood. There may also be sex-based and gender-based differences in how men and women experience and describe concussion. It is important to understand these distinctions when managing concussion in women.

Protective Equipment

Helmets are designed to prevent catastrophic brain injury such as skull fractures and intracranial hemorrhage. Helmets do not prevent concussion, and are sometimes used as a weapon that may actually lead to a concussive injury. Football helmets are certified by the National Operating Committee on Standards for Athletic Equipment (NOCSAE), and the National Football League has also developed criteria for evaluating football helmets independent of NOCSAE. To mitigate concussion and repetitive head impact exposure, the head needs to be taken out of the game, irrespective of the use of helmets.

Neck Pain Following Concussion

Neck pain and cervicalgia are common following concussion. The cervical spine should be carefully examined in any individual who has sustained a concussion, because neck pain may be a sign of more serious underlying cervical spine injury. Even when a more serious injury has been ruled out, it is noteworthy that the cervical structures are vulnerable to stress and injury at their end range of motion, and such motion occurs commonly in an accelerated fashion with concussion. Further, cervical spine injury may cause faulty proprioceptive input from the upper cervical spine, resulting in vestibular symptoms. Cervicalgia is a source of persistent symptoms following concussion and frequently manifests with dizziness and cervicogenic headache. Individuals with persistent symptoms of cervicalgia or cervicogenic headache may benefit from a combination of physical therapy and vestibular therapy.

Unmasking Neuropsychiatric Disorders Following Concussion

Sometimes concussion is accompanied by an abrupt change in behavior, including psychosis or dementia, but concussion is not necessarily the cause. It is more likely that head injury can sometimes unmask an underlying predisposition to another neuropsychiatric disease that has already begun to manifest, often sub-clinically. Such unmasking may occur as a result of a brain injury superimposed on an already vulnerable brain, or a brain injury that contextually removes the individual from a routine that served as a reliable and dependable structural context. Thus, when abrupt neuropsychiatric manifestations such as psychosis or dementia manifest after concussion, a thorough neuropsychiatric evaluation should be performed, and one should not simply assume that concussion is the cause.

Independent Medical Care

Sport coaches are the primary interface with athletes and have considerable influence over the athletic environment. There is an evolving cultural shift to an athlete-centered approach to sports medicine, meaning that athletes should receive medical care that is completely independent of the influence of the coach. This is an especially important concept when athletic trainers, physicians and other sports medicine personnel are housed in athletics, a space where a coach may have considerable influence. Ultimately, primary health-care providers for athletic teams or organizations should have unchallengeable, autonomous authority for all medical and return-to-play decisions in sport.

Concussion and Pituitary Dysfunction

Pituitary dysfunction is increasingly recognized as a possible complication of concussion. The hypothalamus and pituitary may be susceptible to shearing forces that are common in concussion. The hypothalamic-pituitary axis is critical in adolescent development, and it also plays an important role in normal adult functioning. Pituitary dysfunction can lead to symptoms of depression, lethargy, poor libido, impaired concentration, and decreased problem-solving ability; all of these symptoms are commonly observed in individuals with post-concussion persistent symptoms from other causes. Therefore, in individuals who present with persistent symptoms following concussion, pituitary dysfunction should be considered and managed appropriately.

Concussion Two Weeks Later

Although most individuals recover from concussion within 7 to 10 days, a sizable minority have prolonged concussion symptoms, especially those who also suffered loss of consciousness, post-traumatic amnesia, many acute symptoms, and immediate dizziness. Thus, someone could remain symptomatic from concussion more than two weeks following the injury. At that point, however, the discerning clinician must differentiate prolonged concussion symptoms from the evolution of persistent symptoms from comorbid neurologic conditions or emerging mental health symptoms or disorders. Too often, prolonged or persistent symptoms are not considered in the context of initial concussion injury and symptoms, proper return to activity, or emerging comorbid conditions that can also lead to persistent symptoms.

Multiple Concussions and Retirement from Sport

Retirement from sport is a big decision for any athlete. Currently there are no evidence- or consensus-based guidelines for retirement from sport following multiple concussions. This gap is compounded by the lack of objective biomarkers to guide such decision-making. Current recommendations for retirement center around worrisome neurological findings on exam or brain imaging, prolonged recovery following concussion, low threshold for developing concussion, and shortened time intervals between concussions. Retirement from sport following one (or multiple) concussions should be based on multiple factors, including evidence of neurologic impairment, prolonged recovery, lower threshold for developing concussion, and personal/family concerns.

Acute Concussion in the Emergency Department

Concussion evaluations are very common in the Emergency Department, but there is no standardized protocol to evaluate and manage concussions. Triage to rule out more severe brain injury is becoming more uniform. For example, there are emerging guidelines and biomarkers for when a brain CT scan should be ordered for a suspected intracranial bleed or other brain structural lesion. However, the nuance of concussion diagnosis and management is less uniform, leaving many patients with a diagnosis and no clear plan for management and recovery—and this fallout can negatively impact recovery. Following concussion diagnosis, discharge instructions are key, as delayed concussion management and lack of follow-up can lead to improper early management, which too often leads to prolonged, persistent symptoms.

Concussion and Oculomotor Dysfunction

Oculomotor dysfunction is common following concussion, but is too often not addressed. It is not surprising the oculomotor dysfunction is common following concussion because visual pathways comprise 50% of the brain. Post-concussion oculomotor dysfunction often manifests as convergence insufficiency, and failure to address it can result in prolonged post-concussive symptoms, including headache and dizziness, especially when attempting to read. A detailed oculomotor exam should be performed in all patients diagnosed with a concussion. Oculomotor rehabilitation is an emerging strategy that can be used early in the treatment of patients with post-concussion oculomotor dysfunction.