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

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Presentation on theme: "Concussion in Females Cynthia L. Boyer, Ph.D Executive Director Bancroft NeuroRehab."— Presentation transcript:

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

2 MRI Views

3 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

4 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

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6 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 Symptoms may last from several minutes to days, weeks, months, or longer in some cases

7 Traumatic Brain Injury Mod Mild Severe Severe GCS ≤ 8 Moderate GCS 9 - 12 Mild GCS 13 - 15 Teasdale et al Lancet 1974; ii: 81-4 Sports concussion ? “Minimal” Glasgow Coma Scale

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10 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

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12 There is NO test to diagnose a concussion Clinical diagnosis based on the following: – Symptoms – Physical Signs – Behavioral Changes – Cognitive Impairment – Sleep Disturbances

13 Diagnosis / Symptoms 8 Observed Dazed, stunned Confusion, forgetful Clumsy/balance issues Speaks slowly Loss of consciousness Mood, behavior, personality changes Reported Headache, pressure Nausea, vomiting Dizzy Blurred vision photo/phono-phobia Foggy, fatigue, hazy Memory/focus issues Feeling down/not right

14 Signs and Symptoms: Sports Medicine

15 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

16 Early versus Delayed Signs Early (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)

17 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

18 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

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20 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

21 Sports Related Concusssions

22 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

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24 StudySport (% of All Injuries) MalesFemales Powell, Barber-Foss Soccer3.9%4.3% Powell, Barber-Foss Basketball2.6%3.6% Powell, Barber-FossBaseball/Softball1.7%2.7% NCAASoccer4.7%4.4% Total % of all injuries3.23%3.75% StudySport (Injuries per 1000 AE) MalesFemales DickSoccer0.3480.578 DickLacrosse0.3340.618 Boden, et al.Soccer0.60.4 NCAASoccer0.440.46 Powell, Barber-FossSoccer0.180.23 Powell, Barber-FossBasketball0.110.16 Powell, Barber-FossBaseball/Softball0.050.1 J. Kelly, J. RosenbergSoccer0.250.24 Total Ave per 1000 AE0.2890.348 Soccer Ave per 1000 AE0.3640.382 Other Ave per 1000 AE0.1650.293

25 In sports played by both genders, girls actually run a higher risk of sustaining concussion 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 U.S. female high school soccer athletes suffered almost 40% more concussions than males In high school basketball, female concussions were nearly 240% higher 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 Female college athletes who play soccer, basketball, softball and hockey also bear higher concussion risks than their male counterparts

26 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)

27 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)

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29 NCAA Injury Surveillance System: 3-year study concussions Covassin, Swanik, Sachs, JAT, 2003) 14,591 reported injuries, 5.9% were classified as Concussions during practices: Female athletes: 167 (3.6%) Male athletes148 (5.2%) Concussions during games: Female athletes:304 (9.5%) Male athletes: 254 (6.4%)

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

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33 Domestic Violence

34 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

35 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

36 Concussion In DV Populations Blow 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

37 Increased Risk for Repeat Injury Reaction time and judgement decreased Reduced ability to respond to surroundings/cues Injury may cause disinhibition/impulsivity

38 Multiple Concussions Injuries accumulate, symptoms increase Leads to increased cognitive, physical, and emotional dysfunction over time Abuser takes advantage of impairments

39 Screening for TBI/Concussion in DV Reduce ongoing abuse Secure effective treatment/cognitive rehabilitation Improve overall outcome

40 Thank you !


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