Women Are at Higher Risk for Concussions Due to Ball or Equipment Contact in Soccer and Lacrosse

Pediatric Concussions in Contact Sports: A 10-Year Retrospective Analysis of Mechanisms and Associated Symptoms

Background

Concussions make up a significant proportion of sports injuries. This study aimed to describe the mechanisms of injury and associated symptoms of pediatric patients diagnosed with concussions (age range, 4-17 years) from contact sports.

Hypothesis

Mechanisms of injury would differ based on sex and age, with female athletes and younger athletes aged 4 to 11 years sustaining fewer concussions from player-to-player contact.

Study Design

Descriptive epidemiology study.

Methods

The National Electronic Injury Surveillance System was queried for all contact sport concussions presented to United States emergency departments. The sports analyzed included basketball, football, soccer, hockey, rugby, and lacrosse. Descriptive data, mechanisms of injury, and associated symptoms were analyzed for each sport. Differences in the number of concussions sustained by year and sport, the severity of the injury, and associated symptoms were compared using chi-square test, and differences in proportion were calculated for mechanisms of injury stratified by sex and age.

Results

A total of 12,602 youth athletes sustained concussions between 2012 and 2021. Most patients were male (78.5%), with a mean age of 13.48 years. Football concussions were the most common, with 45.32% of the concussions. The mechanism of injury was largely sport-specific, with player-to-player contact the most common overall. Older male athletes were more likely to have concussions from player-to-player contact, whereas younger athletes were more impacted by head-to-ground mechanisms. Symptom presentation was not sport-specific, and headache and dizziness were the most common presentation at 41.2% and 26.2%, respectively.

Conclusion

The most important overall mechanism of injury was player-to-player contact, especially in older male youth athletes, whereas younger athletes were more likely to be concussed due to head-to-ground injuries.

Descriptive Epidemiology of Injuries Sustained in National Collegiate Athletic Association Men's and Women's Lacrosse, 2004-2005 Through 2013-2014 Seasons

Background: Men's and women's lacrosse operate with significantly different rules, equipment, and contact. Previous studies have assessed injury rates (IRs) in either men's or women's lacrosse, but a few studies have compared injury patterns in the National Collegiate Athletic Association (NCAA) men's and women's lacrosse. Purpose: We sought to examine whether there were differences in injury type, mechanism, setting, and time loss in men and women playing lacrosse in the NCAA. Methods: We performed a retrospective case-control study using data collected by the NCAA Injury Surveillance Program (ISP) during a 10-season period (2004-2005 to 2013-2014). The data were assessed for potential differences in injuries between male and female lacrosse players and analyzed to obtain descriptive statistics through calculations of rates, percentages, and confidence intervals (CIs). Main outcomes measured were IRs per 1000 athletic exposures (AEs) and injury rate ratios (IRRs) with 95% CIs. Results: The IRs were 5.19 per 1000 AEs in women's lacrosse and 6.52 per 1000 AEs in men's lacrosse. Men had more injuries overall than women in competitions and practices and in preseason, regular season, and postseason play. Preseason IRs were higher than the regular season, and competition injuries were greater than practice injuries in both sexes. Women had more injuries to the head/face, knee, lower leg, and foot. Sprains, strains, concussions, and contusions were the most common types of injuries in both sexes. Overuse/gradual onset, cartilage, concussion, inflammation, and tendinosis injuries were more common in women than men. Injuries in men resulted in time loss more often than injuries in women. Conclusions: Our retrospective study's findings suggest that there were differences in injury patterns between men's and women's lacrosse. Future prospective research should assess whether these disparities are due to differences in equipment and rules and whether changes to these factors can reduce injuries.

Are Sex Differences in Collegiate and High School Sports-Related Concussion Reflected in the Guidelines? A Scoping Review

Background: Sport-related concussion (SRC) is a common sport injury. Females are participating in sports at increasing rates, and there is growing awareness that female athletes may be more vulnerable to SRC. Objectives: We aimed to identify sex differences in epidemiology, clinical manifestation and assessment of SRC and examine how these relate to the 6th International Conference on Concussion in Sport (ICCS). Methods: We conducted a scoping review of the Medline database and identified 58 studies examining the effects of sex on SRC in collegiate and high school athletes that were written in English and published in a peer-reviewed journal between March 2012 and March 2022. Results: We found that female athletes suffer higher rates of concussion in sex-comparable sports, in particular soccer. Female athletes experience more somatic symptoms-headache/migraine/sleep disturbance-and may take longer to recover from concussion. Sex differences were also identified regarding some aspects of sideline concussion assessment with the Sport Concussion Assessment Tool. Conclusions: Females are at greater risk and experience SRC differently than males; this is mostly likely due to a combination of biomechanical factors, differences in neck musculature and hormonal and social factors. Sex differences are not widely addressed by the 6th ICSS, which informs many sports' concussion protocols.

Premorbid Risk Factors and Acute Injury Characteristics of Sport-Related Concussion Across the National Collegiate Athletic Association: Findings from the Concussion Assessment, Research, and Education (CARE) Consortium

BACKGROUND

Previous sport-related concussion research highlights post-injury characteristics that influence recovery trajectories; however, there is limited information regarding premorbid factors that affect sport-related concussion risk.

OBJECTIVE

We aimed to (a) compare premorbid demographic factors among a large cohort of collegiate student athletes who did or did not sustain a sport-related concussion and (b) assess differences in acute injury characteristics based on biological sex and contact level.

METHODS

We conducted a cohort study of university student athletes from 22 sports enrolled in the Concussion Assessment, Research, and Education (CARE) Consortium study from 2014 to 2021 (n = 1804 student athletes with sport-related concussions; n = 21,702 student athletes without sport-related concussions).

RESULTS

Statistical analyses indicated student athletes who self-identified as Black (odds ratio [OR] = 1.61; 95% confidence interval [CI] = 1.42, 1.81) or multiracial (OR = 1.32; 95% CI 1.10, 1.59) demonstrated greater odds of experiencing sport-related concussions than White-identifying student athletes. Additional findings suggest male athletes (OR = 1.47; 95% CI 1.20, 1.81) and contact sport student athletes (OR = 1.40; 95% CI 1.16, 1.70) may be at increased odds for sport-related concussions if they were previously diagnosed with attention deficit hyperactive disorder. Notable post-injury characteristics across sexes included differences in the incident loss of consciousness (male: 5.9%, female: 2.6%; p < 0.001), post-traumatic amnesia (male: 13.6%, female: 5.1%; p < 0.001), and retrograde amnesia (male: 6.8%, female: 2.8%; p < 0.001). A greater proportion of contact-sport student athletes experienced an altered mental status (52.7%) than limited contact (36.2%) and non-contact (48.6%) [p < 0.001]. Last, student athletes participating at lower contact levels were more likely to have a longer delay in removal from activity following injury (contact: 73.6 ± 322.2 min; limited contact: 139.1 ± 560.0 min; non-contact: 461.4 ± 1870.8 min; p = 0.005).

CONCLUSIONS

The present study provides contemporary pre- and post-sport-related concussion injury characteristics using a considerably sized cohort of collegiate student athletes. These findings support previous work suggesting sport-related concussion results in complex individualized clinical presentations, which may influence management strategies.

Occupational and Environmental Challenges for Women

ABSTRACT

The prevalence of women in the global workforce is increasing. Women increasingly participate in nontraditional employment settings in previously male-dominated industries and manually intensive professions, such as military service, emergency response, health care, aviation, space, agriculture, and technical trades. Limited occupational and environmental hazard data specific to women exist for these work environments. Physiologic and biomechanical differences between sexes create unique workplace challenges specific to women. This article will summarize challenges confronting women working in nontraditional employment and identify strategies to mitigate risk within these populations.

Sports- and physical activity-related concussion and mental health among adolescents: Findings from the 2017 and 2019 Youth Risk Behavior Survey

This study examined the association between self-reported sports- or physical activity-related concussion and symptoms of depression and suicidal behaviors (suicidal ideation, having a suicide plan, and suicide attempts). This study used data from the 2017 and 2019 Youth Risk Behavior Survey (YRBS), a biennial, school-based, nationally representative survey of U.S. students in grade levels 9 to 12 (N = 14,496). Multivariate logistical regression models assessed the association between self-reported sports-or physical activity-related concussions and suicidal behaviors among students, controlling for a range of demographic and psychosocial variables. Altogether, 13.6% of students reported a sports-or physical activity related concussion in the past 12 months. Among youth, sports-or physical activity related concussions were significantly associated with greater odds of symptoms of depression, suicidal ideation, making a suicide plan, and suicide attempts compared to other youth who did not experience sports- or physical activity-related concussion. Findings highlight increased risk for adverse mental health outcomes among students with sports-or physical activity related concussions. Providing resources for students to engage in physical activity and sports teams may help prevent the onset of depression and suicidal behaviors; however, resources must also be available to monitor any concussions related to these activities to provide support for student emotional well-being.

Neurodevelopmental Disorders and Risk of Concussion: Findings from the National Collegiate Athletic Association Department of Defense Grand Alliance Concussion Assessment, Research, and Education (NCAA-DOD CARE) Consortium (2014-2017)

Evidence suggests neurodevelopmental disorders (NDs) may be associated with an increased incidence of concussion, but no studies have cross-sectionally and longitudinally assessed the associations of NDs and sex with concussion in collegiate athletes. We sought to assess the odds and relative risk (RR) of concussion in athletes self-reporting a diagnosis of attention deficit/hyperactivity disorder (ADHD), learning disability (LD), and ADHD+LD. Data from the Concussion Assessment, Research and Education (CARE) Consortium (2014-2017) were used to evaluate the likelihood of concussion for male and female athletes with ADHD, LD, and ADHD+LD, relative to controls. Odds ratios (ORs) of concussion history prior to enrollment and relative risk ratios for incurring a concussion following enrollment, with and without concussion history were calculated for all groups. Athletes with self-reported diagnosis of ADHD, LD, and ADHD+LD were more likely to report a single concussion (OR range = 1.528 to 1.828) and multiple concussions (OR range = 1.849 to 2.365) prior to enrollment in the CARE Consortium, irrespective of sex compared with control athletes. While enrolled in CARE, male athletes with ADHD, LD, and ADHD+LD had greater risk of incurring a concussion (RR range = 1.369 to 2.243) than controls, irrespective of concussion history. Male athletes with ADHD+LD with concussion history (RR = 2.221) and without concussion history (RR = 1.835) had greater risk of incurring a concussion than controls. These results suggest NDs may be associated with increased odds of single and multiple concussions, irrespective of sex. However, when we accounted for concussion history, it appears only male athletes with ADHD+LD had greater risk than respective controls. There were no significant differences between females and males with ADHD, LD, or ADHD+LD for either odds of concussion history or risk for incurring concussion.

Epidemiology of Concussions in National Collegiate Athletic Association (NCAA) Sports: 2014/15-2018/19

BACKGROUND

Updated epidemiology studies examining sports-related concussions (SRCs) are critical in evaluating recent efforts aimed at reducing the incidence of SRCs in National Collegiate Athletic Association (NCAA) sports.

PURPOSE

To describe the epidemiology of SRCs in 23 NCAA sports during the 2014/15-2018/19 academic years.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

SRC and exposure data collected in the NCAA Injury Surveillance Program were analyzed. Injury counts, rates, and proportions were used to describe injury characteristics by sport, event type (practices, competitions), injury mechanism (player contact, surface contact, equipment/apparatus contact), and injury history (new, recurrent). Injury rate ratios (IRRs) were used to examine differential injury rates, and injury proportion ratios (IPRs) were used to examine differential distributions.

RESULTS

A total of 3497 SRCs from 8,474,400 athlete-exposures (AEs) were reported during the study period (4.13 per 10,000 AEs); the competition-related SRC rate was higher than was the practice-related SRC rate (IRR, 4.12; 95% CI, 3.86-4.41). The highest SRC rates were observed in men's ice hockey (7.35 per 10,000 AEs) and women's soccer (7.15 per 10,000 AEs); rates in women's soccer and volleyball increased during 2015/16-2018/19. Player contact was the most prevalently reported mechanism in men's sports (77.0%), whereas equipment/apparatus contact was the most prevalently reported mechanism in women's sports (39.2%). Sex-related differences were observed in soccer, basketball, softball/baseball, and swimming and diving. Most SRCs reported in men's sports (84.3%) and women's sports (81.1%) were reported as new injuries.

CONCLUSION

Given the increasing SRC rates observed in women's soccer and volleyball during the latter years of the study, these results indicate the need to direct further attention toward trajectories of SRC incidence in these sports. The prevalence of equipment/apparatus contact SRCs in women's sports also suggests that SRC mechanisms in women's sports warrant further investigation. As most SRCs during the study period were reported as new injuries, the prevalence of recurrent SRCs in men's and women's ice hockey is also noteworthy.

Systematic review and meta-analysis of sex-based differences for concussion incidence in soccer

OBJECTIVE

To compare concussion incidence in male and female soccer players due to the specific concussion-causing activity.

METHODS/DATA SOURCES

PubMed, EMBASE, and Cochrane Library were searched for studies published between January 2000 and February 2020. Search terms included 'sex,' 'gender,' 'sex differences,' 'brain injury,' 'sports,' 'athletes,' 'incidence,' 'epidemiology,' 'symptoms,' and 'injury rate.' Studies that contained data on concussion incidence in soccer and featured comparisons by sex and soccer activity were included. Studies that were not written in English, contained data on non-sports-related concussions, or were conference abstracts were excluded.

RESULTS

Six studies were included in this meta-analysis, each of which contributed the number of concussions in males and females for a specific soccer activity. Concussion incidence rates were calculated using athlete-exposures as the denominator and a rate ratio was measured by dividing the concussion rate among female soccer players by the rate among male soccer players. Female soccer players were shown to have a greater rate of concussions from heading [1.65 (95% CI: 1.35, 2.03, p < 0.001)] and goalkeeping [1.63 (95% CI: 1.22, 2.17, p = 0.001)]. There were 3 studies comparing sex differences for general play. While the pooled rate ratio was statistically significant [1.51 (95% CI: 1.12, 2.04), p = 0.007], this result was largely driven by 1 study.

CONCLUSION

Concussion incidence rates were significantly higher in female soccer players compared to male players while heading. There is also some evidence to suggest that the incidence is higher for female goalkeepers. Soccer coaches and health care providers need to recognize this sex difference when coaching or treating players.

Sports- and Physical Activity-Related Concussions, Binge Drinking and Marijuana Use among Adolescents: The Mediating Role of Depression and Suicidal Ideation

BACKGROUND

Although past studies have examined the adverse impact of sports- and physical activity-related concussions (SPACs) on health and mental health outcomes, there is a dearth of research investigating the association between SPACs and binge drinking and marijuana use.

OBJECTIVE

The objective of this study is to examine the cross-sectional association between SPACs and binge drinking and marijuana use among adolescents and whether symptoms of depression and suicidal ideation mediate this association.

METHODS

Data for this study came from the 2017 and 2019 National Youth Risk Behavior Survey. An analytic sample of 17,175 adolescents aged 14-18 years (50.2% male) was analyzed using binary logistic regression.

RESULTS

Of the 17,175 adolescents, 13.7% engaged in binge drinking and 19.3% used marijuana 30 days preceding the survey date. Approximately one in seven (14.1%) adolescents had SPACs during the past year. Upon controlling for the effects of other factors, adolescents who had SPACs had 1.74 times higher odds of engaging in binge drinking (AOR = 1.74, p<.001, 95% CI = 1.47-2.06) and 1.42 times higher odds of using marijuana (AOR = 1.42, p<.001, 95% CI = 1.24-1.62) than those who did not have SPACs. Symptoms of depression and suicidal ideation explained 12% of the association between SPACs and binge drinking, and 19% of the association between SPACs and marijuana use.

CONCLUSIONS

Understanding the association between SPACs and substance use and mental health could contribute to early identification of adolescents who may engage in substance use.

Why are female soccer players experiencing a concussion more often than their male counterparts? A scoping review

BACKGROUND

The risk of concussion is particularly high in female soccer players. There is no consensus as to why female soccer players are at an elevated risk.

OBJECTIVE

To synthesise current evidence investigating reasons for the increased concussion rate in female soccer players.

SOURCES

Searching of six databases (MEDLINE, Scopus, CINAHL, SportDiscus, Web of Science and the Cochrane Library) and grey literature was performed between 13/07/2020-31/07/2020. Keywords were concussion-related terms, terms relating to female football/soccer and terms relating to the mechanism/cause. No constraints were placed on publication date and quantitative or exploratory studies meeting inclusion criteria were eligible. Exclusion criteria were studies not published in English and qualitative studies.

RESULTS

Several hypotheses were identified to explain increased concussion rates in female soccer players, these include, reduced neck strength/anthropometrics, increased head acceleration, increased ball-to-head concussions, differences in hormones and brain structure/function, and reduced visual awareness.

CONCLUSION

Promising ideas/reasons have been identified for increased concussion rates in female soccer players. Despite hypothesis generation there is scarce high-level evidence which is required to guide injury prevention and/or rule changes to protect female soccer players. The level of evidence for included studies is level 2-3 with most being observational cross-sectional or cohort studies.

Endocrine Responses to Sport-Related Brain Injury in Female Athletes: A Narrative Review and a Call for Action

Sport-related brain injury (SRBI) occurs when a blow to the head causes the brain to move back and forth in the skull, and can lead to neuroendocrine dysfunction. Research has shown that males and females experience and recover from SRBI differently, yet most of what is known regarding diagnosis, treatment, and recovery of SRBI is based on male normative data even though females meet or exceed incidence numbers of SRBIs compared to those of males. Females also have been known to have worse outcomes and a greater number of symptoms following SRBI than males. Research is limited as to why females have worse outcomes, but sex hormones have been suggested as a potential reason. SRBI may cause a dysregulation of the hypothalamic–pituitary–gonadal (HPG) axis, which is responsible for regulating the sex hormones estrogen and progesterone. Initial research has shown that SRBI may suppress estrogen and progesterone, and the concentration of these sex hormones could be indicative of injury severity and recovery trajectory. This review discusses the sex-specific differences in SRBI and also the future direction of research that is needed in order to identify the repercussions of SRBIs for female athletes, which will eventually lead to better clinical treatment, sideline care, and recovery profiles.

Association of Sex With Adolescent Soccer Concussion Incidence and Characteristics

Importance

Because of the negative consequences of concussion, considerable research efforts have been directed toward understanding the risk factors for sport-related concussion (SRC) and its outcomes to better inform strategies for risk reduction. Girls are suggested to have an increased risk of concussion, warranting exploration into sex-dependent variations in concussion presentation and management, with the potential that this information might inform sex-specific rules directed toward risk reduction within sports.

Objective

To compare sex-associated differences in epidemiology and concussion management in adolescent soccer players within a prospective, longitudinal high school injury surveillance project.

Design, Setting, and Participants

This prospective, longitudinal cohort study assessed male and female soccer athletes from all high schools in the Michigan High School Athletic Association (MHSAA) during academic years 2016-2017 to 2018-2019.

Exposures

Sport-related concussion captured in the MHSAA Head Injury Reporting System.

Main Outcomes and Measures

Outcomes included details regarding each documented SRC event, including injury mechanism, immediate management, and return-to-play time. Multiple comparisons were made between male and female athletes regarding SRC risk, mechanism, short-term management, and outcomes.

Results

A total of 43 741 male and 39 637 female soccer athletes participated in MHSAA soccer during the 3 consecutive academic years of study (2016-2017: n = 751 schools; 2017-2018: n = 750 schools; and 2018-2019: n = 747 schools). During the 3 years of surveillance, 1507 of the 83 378 soccer athletes (1.8%) were reported to have SRC during soccer participation, including 557 boys (37.0%) and 950 girls (63.0%). Documented SRC risk in female soccer participants was greater than in male soccer participants (risk ratio, 1.88; 95% CI, 1.69-2.09; P < .001). Male soccer athletes most often sustained SRC from contact with another player (48.4%), whereas SRCs in female soccer players recorded in the Head Injury Reporting System were most often from nonplayer contact events (41.9%; P < .001). Adolescent male soccer players with a documented SRC were more likely to be removed from play on the day of injury (odds ratio, 1.54; 95% CI, 1.15-2.06; P = .004). Although the overall median time to return to play was 11 days (interquartile range [IQR], 7-15 days), male athletes typically returned 2 days earlier than female athletes (median, 10 [IQR, 7-14] days vs 12 [IQR, 7-16] days; Peto test P < .001).

Conclusions and Relevance

In this cohort study, sex-associated differences were revealed among adolescent soccer athletes in SRC risk, mechanism of injury, immediate management, and outcomes in injuries documented in a statewide injury reporting system. Thus, consideration might be given to sex-specific approaches to participation and concussion management in the sport.

A Promising Subject-Level Classification Model for Acute Concussion Based on Cerebrovascular Reactivity Metrics

Concussion imaging research has primarily focused on neuronal disruption with lesser emphasis directed toward vascular dysfunction. However, blood flow metrics may be more sensitive than measures of neuronal integrity. Vascular dysfunction can be assessed by measuring cerebrovascular reactivity (CVR)-the change in cerebral blood flow per unit change in vasodilatory stimulus. CVR metrics, including speed and magnitude of flow responses to a standardized well-controlled vasoactive stimulus, are potentially useful for assessing individual subjects following concussion given that blood flow dysregulation is known to occur with traumatic brain injury. We assessed changes in CVR metrics to a standardized vasodilatory stimulus during the acute phase of concussion. Using a case control design, 20 concussed participants and 20 healthy controls (HCs) underwent CVR assessment measuring blood oxygen-level dependent (BOLD) magnetic resonance imaging using precise changes in end-tidal partial pressure of CO₂ (PETCO₂). Metrics were calculated for the whole brain, gray matter (GM), and white matter (WM) using sex-stratification. A leave-one-out receiver operating characteristic (ROC) analysis classified concussed from HCs based on CVR metrics. CVR magnitude was greater and speed of response faster in concussed participants relative to HCs, with WM showing higher classification accuracy compared with GM. ROC analysis for WM-CVR metrics revealed an area under the curve of 0.94 in males and 0.90 in females for speed and magnitude of response respectively. These greater than normal responses to a vasodilatory stimulus warrant further investigation to compare the predictive ability of CVR metrics against structural injury metrics for diagnosis and prognosis in acute concussion.

Heading in the Right Direction: A Critical Review of Studies Examining the Effects of Heading in Soccer Players

The practice of heading in soccer has become a public concern because of the potential for subconcussive impacts to cause cumulative concussive-like effects; however, experimental evidence for this hypothesis has been mixed. This systematic review used pre-defined search parameters to assess primary literature that examined changes in cognitive, behavioral, structural, and/or biological processes after acute heading exposure in youth and young adult soccer players. The findings were synthesized into a concise and comprehensive summary of the research following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) format, and suggestions for standardization of acute heading protocols are described. A total of 1189 articles were considered for this review, with 19 articles meeting all of the inclusion criteria for full analysis. An attempt was made to identify methods with significant sensitivity and reliability by grouping studies based on their outcome measures. Because of lack of standardization across intervention types and data collection protocols, no sensitive and reliable methods could be identified conclusively to assess the effects of acute heading exposure in soccer players. Based on this review, there is not enough evidence to either support or refute the potential of effects of subconcussive events from acute soccer heading exposure. Recommendations for standardization of acute heading exposure studies based on the included literature are discussed. Standardization is required to better understand the impact of acute heading exposure in soccer players, while allowing for the development of guidelines that mitigate any potential risks and allowing athletes to remain active and develop their skills.