Published on: July 7, 2017
by Peter Keating for ESPN:
Every 4 years or so, some of the world’s most prominent scientists gather to synthesize and summarize the latest in brain-injury research. Since first meeting in 2001, the assemblage, called the Concussion in Sport Group, has grown in size and influence. When members gathered in Berlin last October, Jiri Dvorak, then FIFA’s chief medical officer, said they worked on behalf of some 1 billion professional and amateur athletes. Of the dozen sessions at the conference, not one was dedicated to sex or gender. Researchers made 24 oral presentations during the meetings; one focused on female athletes. Among the 202 research abstracts, nine, or less than 5 percent, studied women specifically. “Gender hasn’t been a hot, hot topic,” says one member of the Concussion in Sport Group.
Hot or not, the facts the conference could have displayed are shocking. Women suffer more concussions than men in the sports that both play, with an injury rate 50 percent higher, according to the most recent research. Female athletes with brain trauma tend to suffer different symptoms, take longer to recover and hold back information about their injuries for different reasons than males. Anyone involved in sports should have a grasp of these key facts. Yet the leading national and international guidelines for understanding sports concussions and returning injured athletes to play ignore key differences in how women and men experience brain injuries.
Here’s what’s even more stunning: All of that information was public knowledge eight years ago, when ESPN The Magazine first looked at the subject of concussions and female athletes (“Heading for Trouble,” March 23, 2009)-and all of it is still true. The latest studies continue to find that women get brain injuries more often in sports also played by men. But research into why and how is lagging to nonexistent, as are efforts to reverse the trend. Which means millions of female athletes are putting their brains at risk unnecessarily.
“More and more of the athletes I have seen over time are young women, and I’ve found they get less information about concussion from their coaches, and from the media too, than men,” says Jill Brooks, a clinical neuropsychologist who runs Head to Head Consultants in Gladstone, New Jersey, and who in 2004 conducted one of the earliest research reviews of sex issues in brain injury. “They are struggling to deal with their particular symptoms and often not being taken as seriously as they should be. The sports world is much more accepting of girls and women as athletes but still gives the topic of their concussions short shrift.”
FEMALE SPORTS SCIENTIS
TS pioneered the initial research into sex, gender and concussions more than a decade ago. Dawn Comstock, a professor of epidemiology at the Colorado School of Public Health and a 4-foot-11 former rugby player, started tracking injuries among high school athletes in 2004 and began reporting sex differences in brain injury in 2007. In May 2016, she told the House Energy and Commerce Subcommittee on Oversight and Investigations: “In gender-comparable sports, so sports that both boys and girls play, by the same rules, using the same equipment, on the same fields, like soccer and basketball, girls have higher concussion rates than boys.” Tracey Covassin, professor of kinesiology at Michigan State and a certified athletic trainer, has been studying college sports since 2003, with similar results.
But when it comes to looking deeper into the experience of concussions among female athletes specifically, researchers for the most part have been uninterested, unwilling or unfunded. The frontier of knowledge has been stuck for years in epidemiology-studies, again and again, of who encounters a health problem in the general population and when, rather than how and why it strikes a particular group. “There’s a huge gap in the science of brain injury,” says Angela Colantonio, director of the Rehabilitation Sciences Institute at the University of Toronto. “There has been a lack of explicit consideration given to sex and gender. We’re just starting to scratch the surface.”
In the 2017 Consensus Statement on Concussion in Sport, which 36 of the scientists who met in Berlin published in April, and which runs more than 7,000 words, “gender” never appears and “sex” only once. It’s just one item on a laundry list of factors, such as age, genetics and mental health, that the document notes “numerous studies have examined” for their potential impact on how athletes heal from concussions. The consensus statement doesn’t actually evaluate what such research has discovered about the effects of sex or gender, except to say there’s “some evidence” that teenagers “might be” most vulnerable to persistent symptoms, “with greater risk for girls than boys.”
Several Europe-based contact-sport federations fund the meetings of the Concussion in Sport Group. FIFA, the International Federation for Equestrian Sports, the International Ice Hockey Federation, the International Olympic Committee and World Rugby split the costs of the Berlin conference, totaling approximately 250,000 euros (about $284,000), according to two sources at the group. Any of those organizations could be threatened if evidence emerges that it should have managed repetitive blows to the head better among particular kinds of athletes, such as adolescents or repeat concussion victims-or females. And the 30 co-authors of the consensus statement who filed conflict of interest disclosures declared 132 potential entanglements among them. All of which has some brain-injury research advocates concerned that the authors might have hedged their conclusions to avoid exposing their patrons to financial or legal liability. “The statement is extremely disappointing,” says Katherine Snedaker, a clinical social worker in Norwalk, Connecticut, and founder of the research and advocacy group Pink Concussions, who attended the Berlin conference. “But a major problem with concussion research is that very few people conduct it who don’t have a stake in its outcome. I think these folks didn’t want to see their names used in lawsuits.”
Even one of the consensus statement’s co-authors echoes this criticism. “A lot of intelligent brains have been added to the committee,” says Robert Cantu, professor of neurosurgery at Boston University and a founding member of the Concussion in Sport Group. “But I think some are so happy to be part of all this, sometimes they don’t look hard enough at the research. And you’ve got to ask if that serves as a huge protective force for the organizations who put up the money to fund the meetings.”
“We reviewed the literature on clinical recovery from concussion,” says Grant Iverson, a professor of physical medicine and rehabilitation at Harvard Medical School and co-author of the consensus statement. “We examined many predictors and modifiers. Sex was one of them.”
But when it comes to women specifically, the group has a particularly egregious history. Its third consensus statement, published after parleys in Zurich in 2008, included two ambiguous sentences about whether sex or gender influences the likelihood or severity of concussion risk. Four years later, again after meetings in Zurich, the fourth consensus statement also devoted two sentences to females-the same two sentences. Those sentences even cited the same three sources. From 2008 to 2012, women’s participation in sports grew rapidly, rising 13 percent in the NCAA alone. Public interest in concussions also exploded, as the NFL crisis reached full tilt. And during those years, about 300,000 females aged 19 or under went to U.S. emergency rooms with sports- or recreation-related brain injuries. Yet the international consensus found nothing new to learn or say.
“The topics we focus on, we go into pretty thoroughly,” says one researcher in the group. “Other material, we pretty much don’t touch at all. Which is how stuff slides from one year to the next, not only unchanged but not updated.”
“It was a cut-and-paste job, down to the footnotes,” says neuropsychologist Brooks, who attended two earlier international consensus conferences but was not invited to Berlin.
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