Caring for Your Brain: Concussions in Female Athletes

Caring for Your Brain: Concussions in Female Athletes

By Dr. Elisabeth Pang, BSc BScKIN MSc DC, Chiropractor & Sport Recovery Specialist

Practical and current evidence-based recommendations for concussion diagnosis and recovery.

 As per the 5th International Conference on Concussion in Sport, a sports-related concussion is a “mild traumatic brain injury (mTBI), caused by a direct blow to the head, face, neck or somewhere on the body with an impulsive force transmitted to the head, resulting in the rapid onset of impairment of neurological function and range of clinical signs and symptoms”.3  While the pathophysiology of a concussion continues to be investigated, at a basic level the signs and symptoms are thought to be the result of a mismatch between the cellular demands of the brain and blood flow to the head.

Incidence of Concussions

“Overall, across all pediatric age ranges (0-17 years), young females have a lower incidence of TBI than young males” 7, however “female athletes are most susceptible to sport-related concussions and experience worse outcomes compared with male athletes”. ” 4. Girls sports that fall into top ten highest rates of concussion include girls soccer, girls lacrosse, girls field hockey, girls basketball and girls softball.

In high school sports, two out of three concussions result from collisions among athletes.  In soccer, concussions typically happen when players collide while heading the ball.  Lacrosse, field hockey, and basketball have the greatest occurrence of concussions from direct impacts, either other players or equipment (i.e. sticks, nets, etc.).  In softball, “about 1 out of 4 concussions happen when an athlete is fielding a batted ball”. 2

Diagnosing Concussions

If a child or adolescent experiences any head trauma while involved in sport, they should be immediately removed from the competition to be assessed for a concussion.  While concussion signs may or may not develop immediately, assessing the athlete is important.  Many studies have concluded that young athletes who were not removed immediately had a greater symptom burden, resulting in a longer recovery time.  On the sidelines, standardized tools such as the SCAT-5 (Sport Concussion Assessment Tool) may be used as an initial evaluation.  However, “they have not been validated as a return to play tool and should not substitute for a thorough clinical examination by a physician”. 6

In a clinical setting, symptom scales (i.e. Post-Concussion Symptom Scale) can provide a better determination of symptom burden.  These scales typically take into account five various domains that can be dysregulated by a traumatic brain injury.  The five domains, with commonly associated concussion symptoms, are:

·       Somatic; headache, fatigue, dizziness, light/noise sensitivity

·       Visio-Vestibular; dizziness, nausea

·       Cognitive; difficulty remembering, difficulty concentrating, fogginess

·       Mood; anxiety, depression, nervousness, irritability

·       Sleep; drowsiness, difficulty falling asleep, sleeping more/less than usual

It must be noted that multiple studies have demonstrated the underreporting of symptoms by young athletes after a concussion.  This is likely due to a variety of reasons, including fear of removal from play and fear of repercussions from coaches/teammates/parents.  Research also demonstrates, however, that female athletes are more likely to report their concussion symptoms compared to their male counterparts.  This tendency in general highlights the need for a thorough examination by a physician and an understanding by an athlete’s support system of how to recognize and manage post-concussive care.

Concussion Recovery

Current management of pediatric concussions is dynamic and multifaceted.  Commonly discussed modifications include:

·       Physical and Cognitive Rest; Modification of physical and cognitive activity is recommended for the first 24-48 hours after injury.  Contrary to previous thought, current research indicates that prolonged rest may be associated with increased symptom burden and longer recovery times.  We must continue to recognize each child’s needs in the recovery process on an individual basis.

·       Aerobic Exercise; Due to it’s benefit of autonomic functions by increasing blood flow to the brain, aerobic exercise has been shown to decrease symptoms burden and reduce total recovery times after a concussion.  The aerobic exercise must be to a graded subsymptom threshold, controlled, and submaximal.

·       Return to Play; Some research shows that younger athletes take longer to recover fully from concussions.  A conservative approach including recognizing the athlete’s individual tolerances and using a physician’s discretion, should be taken.  As per the 5th International Conference on Concussion in Sport, a graduated stepwise return to play process is typically followed. The athlete may only progress to the next step if they were symptom free for 24 hours after completion.  If any symptoms arise, it is suggested that they return to the step prior and re-attempt progression after being symptom-free for 24 hours.  The suggested progression steps are:

1.     Symptom limiting activities,

2.     Light aerobic activity,

3.     Sport-specific activities,

4.     Non-contact activity,

5.     Full contact practice (following medical clearance), and

6.     Full return to sport and normal game play.

·       Return to Learn: One should undertake a slow, gradual return to cognitive load.  Oftentimes, it is recommended that the pediatric population begin with only portions of their class load (in terms of time and cognitive load).  School accommodations must be individualized based on symptom burden.

Persistent Post-Concussive Syndrome

When females are compared to males in a post-concussive state, research shows that typically females have less optimal functioning at the 10-day mark, in addition to the three-month mark.  Typically, “optimal functioning was comparable at 6 months’ between females and males. It should be reassuring to families that most children and adolescents will reach optimal functioning within three to six months after a concussion”.1

Pediatric post-concussion rehabilitation should be guided by a qualified practitioner.  However, this is especially true for the approximately “30% of children and adolescents who exhibit persistent symptoms and deficits past the four-week mark”. 6  Current research demonstrates that “having a history of headaches, learning disability, ADHD, anxiety, depression, and sleep disorders was associated with a greater likelihood of persistent symptoms after concussion following a traumatic brain injury”. 8  These factors should be considered after being diagnosed with a concussion and preparing for both short-term and long-term recovery.

Key Takeaways

Immediate Removal and Assessment: Any pediatric head trauma during sport should result in the athlete(s) being removed from the competition and immediately assessed.  It is important to remember that symptoms are typically underreported and may not present immediately.

How Concussions are Diagnosed: For concussion diagnosis in a clinical setting, in addition to a physical exam, symptom scales are often used to determine the individual's symptom burden.  These scales take into account five domains: somatic (i.e. headache), visio-vestibular (i.e. dizziness), cognitive (i.e. difficulty with concentration), mood (i.e. anxiety) and sleep (i.e. drowsiness).

Early Rest and Activity Modification: Modification of physical and cognitive demands for the first 24-48 hours is recommended.  Then re-assess the symptom burden as more rest may be recommended.  Some research shows prolonged rest may result in increased symptom burden.

The Role of Aerobic Exercise in Recovery: Graded subsymptom threshold aerobic exercise has been shown to improve recovery as it increases blood flow to the brain.

A Gradual Return to Play: A six-step graded return to play process is recommended.  The athlete should be symptom-free for 24 hours after each step prior to progressing.

Recovery Differences in Female Athletes: Females typically take a bit longer to return to optimal functioning.

Risk Factors for Persistent Symptoms: A history of headaches, ADHD, anxiety, and depression has been linked to a greater likelihood of persistent symptoms.

About the Author

Dr. Elisabeth Pang is a chiropractor with over 10 years of experience in the greater Edmonton area. With a Bachelor of Science in Kinesiology and a Master of Sport Science and Rehabilitation, she has provided care for athletes from recreational to world-class. She also enjoys working with the general population in demonstrating how physical activity can benefit their lifestyle. As an active woman and a proud girl mom, she continues to be passionate about females in sport and maintaining healthy minds and bodies in competition.

Learn more

If you have questions or concerns about your child’s recovery, early guidance can make a meaningful difference. Visit Dr. Pang at her Edmonton or Spruce Grove location.

Redefined Health, Edmonton 

Back On Track Health Centre, Spruce Grove 

 

Resources

  1. Beauchamp MH, Tang K, Ledoux A, et al. Optimal Recovery Following Pediatric Concussion. JAMA Netw Open. 2025;8(3):e251092. doi:10.1001/jamanetworkopen.2025.1092
  2. Centers for Disease Control and Prevention. (n.d.). Data on sports and Recreation Activities. Centers for Disease Control and Prevention. https://www.cdc.gov/heads-up/data/index.html
  3.  McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine 2017;51:838-847.
  4.  McGroarty, N. K., Brown, S. M., & Mulcahey, M. K. (2020, July 16). Sport-related concussion in female athletes: A systematic review. Orthopaedic journal of sports medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC7366411/ 
  5. Miriam H. Beauchamp, Vicki Anderson, Linda Ewing-Cobbs, et al. (2024). Early childhood concussion | pediatrics | American Academy of Pediatrics. American Academy of Pediatrics. https://publications.aap.org/pediatrics/article/154/5/e2023065484/199608/Early-Childhood-Concussion
  6. Podolak, O. E., Arbogast, K. B., Master, C. L., et al. (2021, January 21). Pediatric sports-related concussion: An approach to care. American journal of lifestyle medicine. https://pmc.ncbi.nlm.nih.gov/articles/PMC9290185/ 
  7. Valera, E. M., Joseph, A.-L. C., Snedaker, K., et al. (2021). Understanding Traumatic Brain Injury in Females: A State-of-the-Art Summary and Future Directions. Journal of Head Trauma Rehabilitation, 36(1), E1–E17. https://doi.org/10.1097/htr.0000000000000652
  8. Wilson, R., Jackson, J., Birnie, K., et al. (2025, April 5). Predictors of persisting symptoms after concussion in children following a traumatic brain injury: A longitudinal retrospective cohort study. BMJ Paediatrics Open. https://bmjpaedsopen.bmj.com/content/9/1/e003036 

 

 

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