What is the difference?
In addition to suffering from a higher incidence of concussion, evidence exists to suggest that female athletes also suffer from a greater number of symptoms, more severe symptoms and also a longer duration of symptoms. In 2005, a study from the USA was among the first to highlight female concussion symptom disparities. It reported that female athletes had a wider range of symptoms and greater drops in cognitive performance. Evidence continues to support this notion but caution has also been expressed before drawing absolute conclusions. This is because women suffer more frequently with symptoms such as migraines unrelated to concussion or head impacts. This leads to the suspicion that reports can overestimate the severity and duration of symptoms directly attributable to concussion.
The reliance on patients to self report symptoms to manage recovery has also been discussed as a possible explanation for gender differences. As with much of the research conducted within the female concussion space, evidence from high school athletes has shown that females are more open about reporting symptoms. This could account for differences seen in symptom duration.
Of course, neither of these two considerations remove the incidence of concussion in and of itself. Furthermore, a recent review study examining results from 25 papers continued to point to an increased burden amongst female athletes (McGroarty et al 2020). One such athlete to understand the severity of concussion is former Northern Ireland and Crystal Palace football (soccer) player, Freya Holdaway. Freya was forced to retire from football in 2020 after suffering from 3 concussions in the space of 18 months. The first she describes as the “classic egg but it wasn't too sore”. The second however she classed as “a bit more sinister”.
After coming off, she passed the initial pitch side tests, but while walking back to the bench she began to feel unwell. She passed out and suffered two pitchside seizures. Freya missed the remainder of the season and the following pre season so she could focus on her recovery - a period of roughly 4 months. Once back playing with Crystal Palace in the FA Women’s Championship, another concussion forced her to question her future. Palace is not fully professional so Freya had to work as well as maintain a high level sporting career. Weeks after the third concussion she continued to struggle. “My ears were ringing and I ended up taking a month off work because looking at a laptop for eight hours a day was giving me excruciating headaches. It got to the point where I was sleeping for 12 hours, that's just not like me but at the same time I clearly needed it."
As the Covid Pandemic forced the UK into lockdown, the time out of the game enabled Freya to take an extended break from the game. "That break from not heading a ball in training or games, it's difficult to explain, but I started feeling so much better.
"I felt more settled and my head was in a good place. It was the best I felt in two years. In hindsight I wasn't really ok before that, but at that point in time not being ok became my normal”.
A four year study assessing the differing consequences of concussion between males and females has recently been published. It had 986 subjects (45% female) who presented to a concussion clinic in the USA. The vast majority of cases were sport related (83% females, 90% males). The results showed that females not only suffered a greater range of concussion symptoms, but that the symptoms were also more severe. In fact, of the 22 listed symptoms, females reported 21 of them and of these, suffered greater severity 91% of the time (20 out of the 22 symptoms). The difference in severity was also stark: Female severity scores (via the Global Severity Index) were 77% higher than those seen in males.
It is also interesting to note that more males suffered from a loss of consciousness (17% versus 9% in females). Male evaluations took place 6 days following the injury whilst female evaluations were at 9 days post injury (median values). Yet despite a longer recovery period between injury and evaluation and a lower proportion of one of the most dramatic symptoms, this study still saw greater symptom prevalence and severity amongst female subjects. The authors highlight that these differences in symptom distress levels may influence variations in recovery and therefore the need to examine sex specific management of post concussion treatments.
The research gap
Despite general increases in knowledge regarding concussion, much of the research remains male focused. Comparison studies are available, but many pull data from high school and college aged females. This means most of the subjects are still going through developmental stages prior to full maturation and adulthood. Therefore drawing conclusions about the causes, diagnoses and treatments to apply to elite adult female athletes could be problematic.
Whilst it is widely accepted that more research is needed into female concussion, consensus does exist that the incidence of concussion amongst female athletes is higher than in their male counterparts. However, the answer to the key question of ‘why?’ remains unanswered. It is fundamentally important that this question is given significant focus, as, until we know why female concussion is more prevalent, credible strategies to mitigate prolonged injury will remain elusive.
The rules of the game
Concussion isn’t limited to sports that males and females play with the same rules, but as has been mentioned within this article, the instances of concussion in those sports are significantly higher in females. Rule changes have been passed across sports at junior levels to protect younger players from the effects of head impacts. As female sporting participation grows, the authorities may want to consider adapting rules to help protect female players.
Rules are constantly being updated to protect player safety. International governing bodies such as World Rugby have examined tackle rules with the aim of reducing direct blows to the head. Soccer has moved to allow concussion substitutes and in 2020 the AFL made an almost immediate change to protect players' heads following the Shaun Burgoyne sling tackle on Geelong’s Patrick Dangerfield. However, at present it doesn’t seem to have had much impact in terms of helping to protect females and improving the statistics related to the over indexing of female concussion.
An area that does need immediate attention is concussion protocols. Although these are continuously under review by national and international governing bodies’ medical panels, increasing evidence points to the need for sex based guidelines. This will hopefully ensure individuals are given the support they need, particularly in terms of prolonged symptom duration amongst female athletes. In many instances, the standard 14 day break from the sport might not suffice. By increasing the recovery window for female players, it could reduce the pressure to return to play, allowing for enhanced recovery.