Nicole D. Reams, MD, on the Role of Gender on Concussion

No doubt gender affects the incidence of concussion, recovery duration, and post-concussion outcomes, but to what end? To better understand how gender affects concussion, we caught up with Nicole D. Reams, MD, after her session at the American Academy of Neurology’s Sports Medicine Conference.

Dr Reams is a sports neurologist and the associate director for the Sports Concussion Program at NorthShore University HealthSystem in Glenview, Illinois. She is also an independent neurologic consultant for the Chicago Bears, Chicago Fire, Northwestern University Athletics, Dominican University Athletics, Chicago Lions Rugby, and Rockford Ice Dogs.

Here are her answers to our burning questions. 

NEUROLOGY CONSULTANT: How does gender influence concussion? Does concussion affect women differently than men?

Nicole Reams: Yes, gender influences concussion in the following ways:

• Regarding incidence, women appear to be more likely than men, in matched sports, to sustain concussion.
• Women have higher reported concussion-like symptoms at baseline than their male counterparts, which is an interesting point to consider when providers examine a post-injury symptom score: Consider whether the individual may have a high baseline burden of symptoms or whether all reported symptoms are truly concussion-related. Remember that concussion symptoms are non-specific.
• Women experience a higher total symptom score post-concussion than men.
• There is variable evidence that women have a longer duration of symptoms following concussion.

NEURO CON: Incidence of concussion has been rising among women. What do you think has attributed to this increased incidence?

NR: The reason for increased concussion incidence in women is unknown, but there are several hypotheses. The first is that neck size and strength may play a role, with women displaying lower flexor and extensor strength, head mass, head-neck segment length, and neck girth compared with men, which may contribute to higher peak linear and rotational acceleration when the head is contacted.

The second hypothesis is that women’s hormones may play a role, with women in the luteal phase (high progesterone) at the time of their concussion experiencing worse outcomes. Lastly, it may not be that there is truly a higher incidence in women, but rather women are more likely to report concussions: Studies have shown that more male athletes are unlikely to report symptoms of concussion.

Non-concussed women are also more likely to experience migraine and autonomic dysfunction. These conditions can exacerbate after concussion and have been postulated for the female/male difference in symptom scores and recovery rates (though more direct studies are needed).

NEURO CON: Are the treatment regimens different for girls vs boys and women vs men?

NR: There are not different established treatment regimens or return-to-play regimens at this time for girls vs boys or women vs men. Some neurocognitive testing has found gender differences in baseline and post-concussion strengths and weaknesses, so often this testing is compared with age- and gender-matched normative databases when an individual’s own baseline data is not available. This allows for more accurate interpretation of the data so that we do not overcall an abnormality that may be normal for that gender. From a treatment perspective, evidence has not yet led us to different protocols.

NEURO CON: What clinical knowledge gaps exist when it comes to concussion? How are the gaps being bridged?

NR: There are so many knowledge gaps! To name a few:

• How do we know if it is truly concussion? We have no reliable objective diagnostic test for concussion and have to rely on clinical experience and testing to make this call, which is not always right.
• How do we know when it is no longer concussion? We make athletes participate in graded return to exertion protocols to try to test for evidence of continued neurometabolic dysfunction, but there is not much evidence to guide us. More advanced imaging techniques suggest that there may be neurometabolic and cerebrovascular alterations that last weeks, or longer, beyond symptom recovery. The relevance of this finding at this time is unknown. The concern is that this identifies a continued window of vulnerability, but this is not yet clear.
• How many concussions is too many, who is at risk for long-term consequences from concussion, and how do we screen? Our knowledge is limited at this time regarding the risk for neurodegenerative consequences like traumatic encephalopathy syndrome (the clinical counterpart to chronic traumatic encephalopathy), so it is very difficult to counsel patients regarding their risk, especially when they desire to return to active contact or collision athletics.

NEURO CON: What is your key take-home message for neurologists and sports medicine specialists?

NR: Concussions are largely treatable, recoverable injuries when acknowledged acutely, removed from harm, allowed appropriate rest followed by gradual reintroduction of cognitive and then physical exertion. Individuals with prolonged symptoms, complicated injuries, or history of multiple concussions should be seen by a neurologist or sports medicine provider experienced in the treatment of concussions for opportunities for adequate treatment intervention, education and counseling.