Concussion in Females Cynthia L. Boyer, Ph.D Executive Director Bancroft NeuroRehab

Concussion in Females

Cynthia L. Boyer, Ph.DExecutive Director

Bancroft NeuroRehab

MRI Views

About Your Brain

• Freely floating within the cerebrospinal fluid• Moves at a different rate than the skull in collisions• Collision between the brain and skull may occur

– On the side of the impact (coup)– On the opposite side of the impact (contracoup injury)

• Acceleration-deceleration may result in stretching of the long axons and in diffuse axonal injury

What is a Concussion? A concussion ( or mild traumatic brain injury) is a

complex physiological process affecting the brain, induced by traumatic biochemical processes secondary to direct or indirect forces to the head.

Disturbance of brain function is related to neurometabolic dysfunction rather than structural brain injury and is typically associated with normal structural imaging findings

Concussion may or may not involve a loss of consciousness

What is a Concussion?

Results in a constellation of physical, cognitive, emotional, and sleep-related symptoms• Symptoms may last from several

minutes to days, weeks, months, or longer in some cases

Traumatic Brain Injury

ModMild Severe

Severe GCS ≤ 8Moderate GCS 9 - 12Mild GCS 13 - 15

Teasdale et al Lancet 1974; ii: 81-4

Sports concussion

?

“Minimal”

Glasgow Coma Scale

Current Diagnosis of Concussion

• Does not require LOC• Does not require a direct blow to the head• Does not require amnesia• CT/MRI likely to be normal

• There is NO test to diagnose a concussion• Clinical diagnosis based on the following:

– Symptoms – Physical Signs– Behavioral Changes – Cognitive Impairment – Sleep Disturbances

Diagnosis / Symptoms8

Observed Dazed, stunned Confusion, forgetful Clumsy/balance issues Speaks slowly Loss of consciousness Mood, behavior,

personality changes

ReportedHeadache, pressureNausea, vomitingDizzyBlurred visionphoto/phono-phobiaFoggy, fatigue, hazyMemory/focus issuesFeeling down/not right

Signs and Symptoms:Cognitive Physical Emotional Sleep

Feeling slowed down Headache Irritability Sleeping more than usual

Difficulty concentrating

Dizziness Sadness Trouble falling asleep

Mentally foggy Fatigue/drowsiness More Emotional Sleeping less than usual

Difficulty remembering

Fuzzy or blurred vision Nervousness

Difficulty thinking clearly

Sensitivity to noise or light

Anxiety

Balance problems

Having no energy

Nausea or vomiting

Sports Medicine

Meehan WP 3rd, d’Hemecourt P, Comstock RD. High school concussions in the 2008-2009 academic year: mechanisms, symptoms, and management. Am J Sports Med. 2010;38(12):2405–2409; and Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes 2005-2010. Br J Sports Med. 2012;46(8):603–610

Early versus Delayed SignsEarly (immediate)

• Alteration in consciousness or memory loss (retrograde or post-traumatic amnesia)

• Disorientation• Poor coordination or

balance

Delayed (late presentation)

• Eating or sleeping disorders

• Behavioral changes• Poor academic

performance• Psychological

sequelae (anxiety, depression)

Metabolic Abnormalities

• Potassium, glutamate and glucose are immediately released from affected brain cells

• Calcium enters these disturbed cells• Neurotransmitter release occurs with loss of

autoregulation on the affected area• Decreased cerebral blood flow

Pathophysiology of Concussion

Neuronal Disruption

Potassium Efflux, Release of Glutamate

Increased Potassium Efflux

Increased Demand for ATP and Glucose

“Metabolic Crisis”Lactate accumulates; decreased cerebral blood flow

Multiple Concussions• Each subsequent concussion - requires less force• Post Concussion Vulnerability

– A second blow sustained before recovery results in worsening metabolic changes within the neuron

– This concept is distinct from “second impact syndrome”• The concussed brain is less responsive to usual neuron

activation• Prolonged dysfunction may result from premature cognitive

activity or vigorous physical activity

Is a functional, not structural issue

Sports Related Concusssions

Epidemiology: Girls Sports

Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958–963; Castile L, Collins CL, McIIvain NM, et al. The epidemiology of new versus recurrent sports concussion among high school athletes 2005-2010. Br J Sports Med. 2012;46(8):603–610; and Marar M, McIIvain NM, Fields SK, et al. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(4):747–755

Study Sport (% of All Injuries) Males FemalesPowell, Barber-Foss Soccer 3.9% 4.3%Powell, Barber-Foss Basketball 2.6% 3.6%Powell, Barber-Foss Baseball/Softball 1.7% 2.7%NCAA Soccer 4.7% 4.4%

Total % of all injuries 3.23% 3.75%

Study Sport (Injuries per 1000 AE) Males FemalesDick Soccer 0.348 0.578Dick Lacrosse 0.334 0.618Boden, et al. Soccer 0.6 0.4NCAA Soccer 0.44 0.46Powell, Barber-Foss Soccer 0.18 0.23Powell, Barber-Foss Basketball 0.11 0.16Powell, Barber-Foss Baseball/Softball 0.05 0.1J. Kelly, J. Rosenberg Soccer 0.25 0.24

Total Ave per 1000 AE 0.289 0.348Soccer Ave per 1000 AE 0.364 0.382Other Ave per 1000 AE 0.165 0.293

In sports played by both genders, girls actually run a higher risk of sustaining concussion

U.S. female high school soccer athletes suffered almost 40% more concussions than males

In high school basketball, female concussions were nearly 240% higher

Female college athletes who play soccer, basketball, softball and hockey also bear higher concussion risks than their male counterparts

Gender Differences

• Mechanism: surface or ball contact (F) vs direct contact (M)

• Physical Differences: Neck/Upper body strength; Hormones

• Behavioral: Reporting Differences• Signs / Symptoms:

Amnesia & confusion (M)↑ Symptom score & higher rxn times (F)

Female athletes endorsed a significant number of mild baseline symptoms as compared to male athletes:

• Headache, nausea, fatigue, need more sleep, drowsiness, sensitive to noise, sadness, nervousness, more emotional, difficulty concentrating, visual problems.

• Effect sizes ranged from .13 (Sleep) to .40 (Emotional)

Covassin, Swanik, Sachs, Kendrick, Schatz, Zillmer, Kaminaris, (BJSM, 2007)

NCAA Injury Surveillance System: 3-year studyconcussions Covassin, Swanik, Sachs, JAT, 2003)

14,591 reported injuries, 5.9% were classified asConcussions during practices:

Female athletes: 167 (3.6%) Male athletes 148 (5.2%)

Concussions during games:Female athletes: 304 (9.5%) Male athletes: 254 (6.4%)

Menstrual Phase as Predictor ofOutcome After Mild Traumatic BrainInjury in Women (2013)Kathryn Wunderle, BA; Kathleen M. Hoeger, MD, MPH; Erin Wasserman, BA;Jeffrey J. Bazarian, MD, MPH

Domestic Violence

Statistics

• 36% of DV survivors sustain injuries to head, neck or face

• More than 90% of all injuries secondary to DV involve the head, neck, face

• 74-77% of DV survivors had symptoms of TBI

Representative Sample

• 92% hit on the head, most more than once• 83% hit on head and shaken• 8% hit on the head > 20 times in the past year

Concussion In DV PopulationsBlow to the head

with any object

Falling and hitting your

head

Pushed against the

wall or other solid object

Strangled

Punched in the face

Strenuous shaking of

body

Use of firearms

Near drowning

Increased Risk for Repeat Injury

• Reaction time and judgement decreased

• Reduced ability to respond to surroundings/cues

• Injury may cause disinhibition/impulsivity

Multiple Concussions

• Injuries accumulate, symptoms increase

• Leads to increased cognitive, physical, and emotional dysfunction over time

• Abuser takes advantage of impairments

Screening for TBI/Concussion in DV

• Reduce ongoing abuse

• Secure effective treatment/cognitive rehabilitation

• Improve overall outcome

Thank you !