Concussions in Female Athletes: Risks, Symptoms, and Recovery

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Vivian Kaufman –

Hi, everyone. We’re going to get started. I just want to let you know we are recording this webinar and it will be sent to all participants and registrants after via email, probably the next day or two once we get it uploaded. But thank you all for joining and for coming to this amazing webinar. We are super excited. I’m going to give a little bit of an introduction about TrueSport and who we are before I hand it over to our amazing speaker, Dr. Michele LaBotz. TrueSport is… TrueSport, this is your first time with TrueSport. I just want to give a little bit of an intro.

We are the youth education arm for the US Anti-Doping Agency, and we support athletes, families, coaches, parents, really anyone involved in sport and youth sport with educational tools and resources to provide a positive youth sport experience. We teach on life skills, core values, ethical behavior, both on and off the field. And this is just one facet of what we do at TrueSport. And so, we’re very excited that you are here. And I am going to introduce our amazing speaker now. This is Dr. Michele LaBotz. She is a sports medicine physician and one of our TrueSport experts.

Michele graduated from Dartmouth Medical School and trained in pediatrics at the University of Wisconsin, Madison, and Maine Medical Center before she did a sports medicine fellowship at the University of North Carolina Chapel Hill. On top of being one of our amazing TrueSport experts, she is an associate professor at Tufts University School of Medicine, Medical Director at the University of New England Athletic Training Program, and research associate with the Sports Equity Center at Stanford University. Michele is an amazing doctor, researcher, mother, and human, and we are so excited that she is here today to share her knowledge and expertise in this area. So I’m going to let Michele take it away and yeah, thank you, everyone.

 

Dr. Michele Labotz –

Vivian, thank you for that awesome introduction and thanks to everybody over at TrueSport, Vivian and Betsy and Lisa and everybody for pulling this set together.

It’s an amazing organization. If this is your introduction to it, hopefully you’ll be prompted to dig deeper after our session today. So, I am standing before you as an expert for TrueSport. But other than that besides my interest in caring for young athletes and trying to keep them healthy and participating, I have no financial or other significant disclosures on the information I’m going to share today. And again, thank you to everybody who’s both joining us now in real time as well as those who are going to be watching us asynchronously. And a big thank you to anybody who put questions in ahead of time ’cause that really helped me shape the type of information I’m going to share today.

So, our overview here in terms of what we’re going to cover. So first of all, just make sure we’re all kind of starting on the same page. I’m going to go over some concussion basics. And just to be clear, a lot of what I say today is going to be applicable really to most everybody with a concussion, but we are really going to emphasize those areas where we know that there are differences between boys and girls. And that’s really become a big focus and hot topic within sports medicine. There will be plenty of time for questions and answers at the end.

So just kind of keep in mind as you go through, if there’s anything that comes up and we’ll be happy to to address it. But talking about the basics of concussion, so concussions occur from the way the brain kind of ricochets or kind of ratchets around inside the skull. And sometimes when that happens, it’s pretty obvious. So if there’s a hit directly to the head and that brain kind of bumps around inside the skull, that’s usually kind of pretty evident when that happens. But sometimes things are a bit more subtle, right? And especially if you’re kind of on the sidelines, you may not notice it, but if there’s an impact elsewhere in the body or a sudden change in direction that causes the head to kind of either whip around or kind of move back and forth, that brain is still kind of moving around inside the skull.

And a concussion could still have occurred even if there wasn’t a direct impact to the head. So sometimes that second mechanism can be a bit more subtle and hard to find, or hard to discern when you’re watching on the sidelines. So, a concussion can produce a variety of symptoms. So these are neurologic symptoms or symptoms that happen from a disturbance in the brain. And this is one area where we do see a significant difference between males and females. And so, when I kind of show these highlighted symptoms here, just kind of on your own think or maybe kind of put into the chat, do you think these are symptoms that we tend to see more in boys or more in girls who have sustained a concussion?

So these are kind of symptoms with the way kind of the brain is thinking, concentrating, focusing on stuff. And basically, this is a set of symptoms that we see quite a bit more commonly in boys than we do in girls. But when we look at the symptoms that we see in girls, we see quite a bit more symptoms in what we call the physical domain. So that perception of a headache, that sensitivity to light and noise. There tends to be a little more emotionality along with it. And girls tend to have more difficulties with sleep after concussion than boys do.

So certainly, you know, anybody can experience these, but when you look at kind of the balance of symptoms from boys compared to girls, these are symptoms that you’ll see more frequently in girls. And so when we talk about concussions, right? So these symptoms, sometimes they happen right away, sometimes they evolve over time, and they oftentimes do change in their nature and severity over time. And for kind of how much kind of focus we’ve been putting on concussion in young athletes, it’s important to remember that the vast majority of times, concussions resolve on their own if you give them a few days or maybe a couple of weeks without any kind of permanent consequences or long-term sequela. Having said that, there are sometimes some symptoms, and we’re going to talk about those a little bit later, that do benefit from some dedicated treatment.

You do need, at least in the United States a healthcare provider does need to be involved in concussion management. And kind of by definition, concussions have normal imaging studies. We typically don’t get imaging studies with concussion, but if there’s an imaging study that was done, there’s any abnormalities, it is not a concussion and that may be an indicator of a more severe brain injury, in which case the stuff we’re talking about today does not directly apply. And then when we talk about getting kids back into the classroom, back into sport, it’s not a one-stop shopping, right? The athletic trainers on the call know this, right?

It’s a progressive kind of return process, and we will be talking about that towards the very end of the session today. So besides symptoms, what other differences are there in regards to kind of boys and girls in concussion and sports? And so one thing I want to just kind of highlight is there are a lot of concussions in our young athletes in the United States, about two million per year. And when you look overall, about half of them happen in American football, right, in tackle football. And although there are some girls that are playing tackle football, for the most part, right, football in the United States is still a male sport.

And even though the rates of participation in American football in young athletes through high school have been declining, excuse me, football rosters typically are quite a bit larger than you see in other sports. And so, there’s two reasons white football is so dominant when we talk about kind of rates of concussion overall. So, one is that practically with most every play, right, there’s intentional kind of contact and collision. It’s an invasion sport. The second thing is that there’s a lot more kids playing football than playing most other sports.

And so that kind of tips the scale in terms of really kind of making football a dominant presence when we are talking about concussion. But when we are looking at sports beyond football, so let’s take out the unique risk of sport, of football for concussion, we start to see where girls are uniquely vulnerable. So, in what we call sex equivalent sports. So sports where the rules are pretty much the same between boys and girls. So in the top here, we’re seeing soccer and then basketball. The third one down, so we typically will compare softball and baseball because there are a lot of similarities there.

And in all of those sports the girls are significantly at higher risk for developing a concussion. When you look at kind of sports where concussions are less frequent, so in the bottom there, for instance, this is in track and field, but it’s also the case with swimming for instance. The rates of concussion are so low that you don’t really see significant differences between boys and girls. But let’s also look at a couple of other sports. So, for the most part, right, in ice hockey, right, there’s not body checking in girls’ hockey. There are again, a lot of girls, especially at the youth level who are playing boys’ hockey, but girls’ hockey, for the most part, there’s no body checking.

And even in spite of that, concussion rates are still higher in girls’ hockey than in boys’ hockey leagues where body checking is allowed. And then in regards to football, right, so flag football, hot topic in sports medicine, a lot of research interest in flag football injury, and in particular concussion injury. But right now, we don’t have high quality data that looks at difference in risk and rates of concussion in boys compared to girls specific in flag or non-tackle football. The other activity that I really kind of want to draw our attention to is competitive cheer. Competitive cheer is a very common source of concussion.

I will tell you personally, several of the most difficult concussions that I have been involved with the treatment have been from competitive cheer. Excuse me. And the thing about competitive cheer is that, you know, they are training acrobatic skills that are typically very similar to what you see in gymnastics, but they oftentimes don’t have the benefit of the protective equipment and the amount of padding that you will see in a well-equipped gymnastics facility. I mean, for goodness sakes, I have seen competitive cheer teams practicing in parking lots, right? And they’re doing their stunts and stuff on hard, you know, gymnasium floors.

So there is multiple reasons why this is a group at increased risk. And not just for concussion, but actually competitive cheer is one of the activities at highest risk for serious and permanent neurologic injury, not only from head injury, but also from neck injury as well. So, competitive cheer is a sport at unique risk for head injuries of all types, not just concussion, but beyond that as well. And let’s look at kind of how concussions occur. So the mechanisms of injury, because that’s also different between boys and girls. So, but overall, boys are at higher risk for getting their concussion from player to player impact.

And that’s kind of true across the board for these sports as shown here. Girls although certainly player to player happens quite frequently, but they are more likely to get their concussion from impact with equipment. So whether that be a ball, whether that be, you know, a post or the ground, they’re less likely to have that player to player as a source of their concussive injury. However, when you look at middle school girls, so a lot of concussion-related research is being done at the high school and at the collegiate levels. There’s less data on middle school girls, but some of the more recent data that has come out shows that when we look at that difference in risk between males and females in sport, that in middle school, that difference in risk is greater than it is in high school and college populations.

And we also know or have found that in middle school athletes, that girls are more likely to get their concussions from player to player contact than older athletes are. And that may have to do with just that the skillset is a little bit less well-developed in the younger athletes than they are in the older athletes. The other pattern to keep in mind, and this is true really for all age groups and for boys as well as for girls, is that in most sports, in the most common team sports that young athletes participate in, concussions are more common in competition than they are in practice. The exceptions to that are sports like competitive cheer and gymnastics where they’re kind of trying these new skills and really kind of pushing the envelope in practice whereas competition is usually the well-rehearsed types of events that they’ve been working on. So, we can kind of look at kind of the numbers of differences and kind of see how these occur, right?

Those are pretty easy to observe. But when you start to look at the reasons behind these differences, so why are there these differences? That is a lot harder to study. And that’s an area where there’s a lot that we don’t know. And if I give a talk like this again in a couple of years, I may be able to tell you more or different information, but what I’m going to do is I’m going to share with you kind of what we think and what we know now today in August 2026. So, some of the differences in concussion risk between boys and girls has to do with the way girls are made informed.

And so these first two are pretty well-established. There’s good data to support these as one of the reasons why there’s these differences. So one is that anybody, whether they’re boy or girl, has the diagnosis of anxiety and/or depression, for whatever reason, they are at higher risk for sustaining a concussion. Combine that with the fact that particularly in this younger population, there are far more females, far more girls than boys with a diagnosis of anxiety and depression. And so therefore, right, there’s more girls that are at higher risk.

The other thing that we know is that girls are more likely to recognize and to report symptoms that they experience. And this is true not just for concussion, but it’s true for any type of injury or illness, right? Whether it’s a sprained ankle or a sore throat, a girl is more likely than a boy to kind of recognize and report. And the thinking is that their girls may be more attuned to kind of their internal kind of physical cues than boys are. You know, a lot of different theories for why that might be, but that is a well-recognized pattern. Other potential internal differences that may account for some of that difference in risk between boys and girls, these are less well-studied, but they’ve got, I think, strong theoretical foundation, so I just want to kind of talk about them briefly here.

So one is when you look at, for the most part, the size of the cells in the brain, the size of the neurons in those axons in the brain in girls, they tend to be smaller than in boys. And so there’s some thinking that those smaller cells may be kind of more vulnerable to injury, area of active research. Girls don’t have as large neck muscles or as strong neck muscles as boys do. And so, strong neck muscles act as good shock absorbers and they take kind of reduce the impact that is sustained by the brain and kind of disperses it throughout the musculature and the rest of the body. And so, that may be accounting for some of the differences in concussion.

And there are also these kind of what we call mechanical or technical differences, right? The way girls move and the way they perform their sports-related techniques. And this is an area that has been really well-studied looking at ACL injury risks, so anterior cruciate ligament injury risk. And ACL injuries, far more prevalent in girls than they are in boys. And they’ve come up with some pretty good data to show how these mechanical differences and addressing these differences can help reduce ACL injury risk. Haven’t gotten to that point yet with concussion, but it’s being studied pretty strongly, and there may be data to come on that.

The other types of differences that exist in the athlete experience between boys and girls that may explain the increased risk in girls are things that are external to the girls that are part of kind of the sporting environment rather than something to do with the girls kind of themselves. And so one of these, I find this first point really to be pretty disturbing in that although girls may be more likely to report symptoms of concussion, they are less likely to be removed from play once they do report it as compared to their male peers. So it tells me that there’s some education that needs to be done. The other thing that has been shown is that rules are enforced a little bit differently. Officiating may be a little more lax, not universally, but in any settings for girls’ sports as they are for boys’ sports.

And again, we’re talking about primarily kind of that youth level. We’re not talking about kind of the collegiate and the highest level, but rule enforcement seems to be different between boys and girls. And again, these first two are areas where there’s a pretty good data set to support these as contributing to some of the differences that we see. In addition, there is a lot of variability in kind of resource availability for sports teams, you know, across the country. But oftentimes, girls’ sports teams are less well-resourced than boys’ sports teams are.

So particularly when you get down into kind of that youth and kind of, you know, volunteer coach level, oftentimes the coaches for girls’ sports aren’t quite as experienced as those who are coaching boys’ sports. When there’s an athletic trainer available on site, so in schools, for instance, oftentimes they are spending a lot of their energy and time on the male athletes. So in football, or in fall, for instance, the athletic trainers are typically on the sidelines during football practice and during games and not so much for kind of field hockey and soccer. And the other thing is, and again, this has to speak to kind of resources, this is not universally true, but there are trends across the country that oftentimes both protective equipment when it is provided to athletes as well as training facilities just are not of the same standard for many girls’ programs as they are for boys’ programs. So again, the thinking is this combination of kind of these external differences may be contributing to some of that difference in risk as well.

So, let’s kind of move on now and talk about, you know, you’re on the sideline and you see a hit occur and you kind of go, “Oh my goodness, did a concussion just occur?” Right? And you can kind of see everyone kind of, you know, look at each other and kind of wonder what’s going on. And it can be hard to sort out. As a physician, it can sometimes be hard to sort out and can be really difficult in folks without medical training. A couple years ago, one of the concussion study groups released this concussion recognition tool. And in that resource page that you’re going to get a link to at the end, there is a link to this concussion recognition tool.

And again, it’s designed for people without a medical background. And it’s really straightforward kind of assessment for the sideline in terms of trying to kind of figure out what your degree of suspicion is for a concussion. And so it lists kind of things to look out for that may prompt you to think that we should be calling 911 or other kind of clues, questions, symptoms that may suggest that a concussion did occur for that athlete. And again, this is something not just for girls, right? This is kind of across the board. And if you think a concussion occurred, it gives kind of initial guidance for when there is a suspected concussion.

And so if it is a concussion, first and foremost, right, the athlete has to be removed from play and put into an area where they’re not likely to get hit on the head again. So in some sports, right, that means you really don’t want them standing right on the sidelines. And the current standard is that if there is a suspected concussion, you do not return the athlete to play the same day, right? Even if that concussion happened at the beginning of the game and at the beginning of the second half, they’re begging to be put back in because they insist that they feel better, even if their symptoms are completely resolved, they don’t go back. They are at higher risk for an additional injury or for making that first injury significantly worse.

So don’t go back to play the same day as a suspected concussion. If the athlete program has access to a licensed athletic trainer, that’s usually their first point of contact. And in the US currently, right, all states kind of require some involvement with a healthcare provider before returning to school-based activity. And when the athletes come to our healthcare providers, what we want to do is we want to try to clench the diagnosis, kind of really kind of figure out whether or not a concussion occurred. We want to see if there are any symptoms or opportunities for treatment where we can kind of help kind of with the resolution by pointing them down different treatment opportunities.

And then finally when the time is right to clear them back for full participation. And so, when athletes and families kind of come into the office with a suspected concussion, I mean, important to remember, there are no definitive tests. Boy, life would be so much easier if we had a definitive test for concussion. There are some blood tests and there are some fancy imaging studies that are part of research, but they’re not ready for prime time. They are not ready for patient care yet. They might be down the road, but not today. And so, typically what we’re looking for is we want to hear the history of the type of injury, so that brain perturbation that we kind of talked about earlier and then those neurologic signs and symptoms.

So we’re kind of looking at the symptom checklist, which is pretty much the same as the symptom checklist on that concussion recognition tool. And if the pieces fit, then we make the diagnosis of a concussion. We then kind of go through our examination. So we do what’s called a neurologic examination. And typically even in athletes who are significantly kind of impaired or impacted by their concussion, that examination is typically pretty normal, but sometimes it’s not. So sometimes we can see some findings that are amenable to specific treatment.

We’ll talk about that in a minute. Or sometimes we see findings that make us think, hm, this might not be a concussion. This might be something different, maybe something more severe. And if we’re suspecting something more severe, that’s when we will order an imaging test, either a CAT scan or an MRI. But if all things are kind of really pointing to a concussion, you really don’t need to do any of the imaging. It’s a clinical diagnosis. And so once we’ve made that clinical diagnosis, right? So back in the old days, I don’t know how long some of you had been in this business, but I’ve been in long enough to kind of see things evolve significantly, right?

We used to think that we, you know, helped concussions heal by keeping the brain quiet and just kind of letting it kind of settle down and kind of simmer down on its own. So rest in these quiet dark rooms, et cetera, et cetera. No screens, no friends. And we now know that we really weren’t doing patients much of a favor with those recommendations because a lot of those recommendations have really been turned on their head, pun intended I guess, with some of the research that has come out over the past couple years. So let’s talk about that. You know, we used to think that you had to recover from a concussion before you got back to normal activity, right?

But now we know that getting back to normal activity, getting back into your normal routines and your normal schedule is an important part of concussion treatment. That the longer we keep these kids in isolation, right, the longer they stay out of school, the longer the symptoms are going to tend to persist, and the higher risk they are for kind of some of these prolonged kind of post-concussion types of situations. The other thing that has changed is that we used to say, “Oh my goodness, if you’re doing something and it makes your symptoms worse, you need to stop and maybe try again in a day or two.” And we now know that it is okay and even expected that symptoms are going to increase a little bit when initially returning to either physical or mental activity after a concussion. And so some guidance that we oftentimes give is, you know, we’ll kind of rate symptoms on this 10-point scale. And we say that if symptoms go up by one or two points on the 10-point scale, it’s okay.

And acceptable means you’re tolerating the activity. If it goes up more than that then you need to kind of back it down or kind of put things aside. So for example, if there’s a headache, that’s a three out of 10 to get started and you’re kind of doing your math homework and the headache goes up to a five out of 10, you’re okay. Continue on with doing what you’re doing. But if the headache goes up to an eight out of 10, it’s too much. You need to back it down or think about trying again tomorrow. And that’s true both for cognitive, for mental activity, as well as for the early phases of return to physical activity.

So let’s talk about a couple of these kind of key changes in a little more detail. So for physical activity, and this is where there is really strong research that has come out the past couple years, that getting started with low-intensity physical activity, ideally within a day or two of the concussion can be very helpful in terms of symptom recovery. And this is so different from what we used to say. Excuse me. So when we’re talking about low-intensity activity, we’re just talking about movement. We’re talking about walking with your friends or maybe a yoga or Pilates class.

And again, okay if the symptoms go up a little bit, but if they go up a lot, it means you’re not ready yet and you need to kind of back it down. For getting back into school, right? So, hopefully those days of kind of athletes with concussion having these prolonged absences and sometimes missing whole semesters for school, hopefully that those days are over. So we know that if we can get athletes back into the rhythm of kind of going to school, whether or not they’re actually able to tolerate the classroom work, but getting back into the social environment and the habit of going to school and not being isolated alone at home is a very important part. Ideally getting them back within two to three days after the injury.

And we’re going to talk about return to school again in a little more detail. Particularly for girls, staying socially engaged is very important, especially in terms of kind of trying to prevent post-concussion depression, which can be really common. Concussions can be really isolating injuries. They’re invisible. And a lot of times people feel like, or athletes feel like there’s kind of now this barrier between them and their teammates or their classmates. And so, encouraging them within common sense parameters to engage with family and friends, right?

So you don’t want to kind of start off by going to a loud concert or to the school dance, but lower key activities. And some guidance that I would often times give is that, you know, if you’re going to go and, you know, spend time, you know, at a family reunion or something, okay to do it as tolerated, but you have to have an out so that if things get a little too severe, if the symptoms really kind of start ramping up too much, you have to be able to back away and remove yourself from the activity in some way, shape, or form. But otherwise, maintaining some degree of social engagement is key. And a very important part of that now is actually screens, right? Even if they’re sitting right next to each other, right, the communication is oftentimes happening via screens.

And here’s where there’s like this middle ground that can sometimes be really hard to figure out in that you want them to engage in screens so they feel like they’re able to kind of communicate with family and friends. This is how schoolwork is getting done a lot of times these days. But boy, if you spend too much time, you start going down the rabbit hole of, you know, doom scrolling and hours on social media, you get into that isolation situation. So again, kind of that middle ground in terms of that limited but appropriate screen time to make sure that they’re staying connected and getting done what needs to get done. But let’s now talk a little more specifically about some of those findings that we find on physical exam that may benefit from some additional treatment.

So one area is these kind of balance and visual issues. So, a concussion can kind of interfere with the way the eyes and the ears, so the ears are kind of our organs of balance, but the ways the eyes and the ears kind of communicate with the brain. And this is more common in females than in males. And sometimes in the medical literature, you’ll hear this referred to as VOMS, V-O-M-S symptoms, and that refers to vestibular and oculomotor symptoms. Excuse me. And the symptoms that you’re kind of typically seeing with this can be miserable. I feel so bad for athletes who have these balance and visual issues because oftentimes their symptoms are more severe.

They oftentimes have significant difficulties getting back in to school. There’s oftentimes quite a bit of difficulty with reading. And oftentimes these symptoms result in prolonged concussions symptomatology. So, the bad news is that this tends to be a more problematic set of symptoms for many athletes with concussion. But the good news is that there is some treatment that is available. So, there are specific, what we call oculomotor and balance exercises. So, we do those assessments in the office, kind of seeing how the eyes move and checking their balance, both with the eyes open and with the eyes closed.

And if there are issues, there are specific rehabilitation exercises that they can do for that that can be very helpful. That’s oftentimes either with a physical therapist or with an athletic trainer, excuse me. Sometimes the physician may decide that a home-based program and there’s some online resources that can be helpful for that. And these athletes oftentimes benefit significantly from academic accommodations, right? If the eyes aren’t working well together, really hard to read, really hard to kind of move your eyes back and forth from a computer screen to the teacher.

And so for these athletes, I typically would advise as much as possible, get information into the brain through the ears rather than through the eyes. So books on tape, lectures, you know, having parents even read to the athletes. Sometimes parents kind of welcome that opportunity. And one thing that I have learned the hard way is to let families know that as they begin treatment for these symptoms, the symptoms will often get worse before they get better. And if the athlete isn’t expecting it, they oftentimes lose confidence or faith in the process and kind of walk away from treatment that can be very, very helpful.

So I’ve learned to kind of let them know ahead of time that that may very well be the case. But this is really a very miserable set of symptoms for athletes with concussion, and I do feel badly for those that come in with them. As mentioned before, right, depression, anxiety, more common in females than in males. And we are kind of looking for, I mean, we all kind of know what the symptoms of depression and anxiety are. And this is an issue not only for those who had a diagnosis beforehand, but maybe even were just predisposed to depressive thinking or anxious thinking.

And sometimes a concussion is enough that kind of just kind of tips them over. And so, the treatment for that is some of the things we’ve already mentioned, physical activity, social interaction, particularly important, making sure that they are doing the things they need to sleep well if they’re not sleeping well, right? Concussions can be very difficult to recover from if you’re not getting good sleep. If it’s a little more severe counseling either with a school-based counselor or a mental health professional. And if things are particularly severe or prolonged, then sometimes we will think of a trial of an SSRI or other type of medication.

And certainly, right, as always if there is thoughts of self-harm or suicidality those require immediate medical attention. Neck issues. So things that cause a concussion can be very similar to things that can cause kind of a whiplash and kind of bother the muscles or the joints of the neck. So these athletes will oftentimes experience kind of pain or stiffness of the neck, or sometimes they’ll get these headaches that kind of start in the back and kind of wrap around the head as well. The treatment for this is oftentimes some manual work, again, either with your licensed athletic trainer, physical therapist.

In some areas, there are some chiropractors who sometimes can be very good at this type of manual work as well. And then finally attention issues. And this is actually one area where, at least in my experience, it seems like boys are more prone to developing this than girls are, where after the concussion, the parents say or that we hear from the teachers that, “Geez, it’s like he has ADHD.” You know, difficulty with the concentration and that type of thing. The treatment for this is the same school-based accommodations that they will make for students with ADHD. And then physical activity, especially kind of well-time physical activity before periods of expected concentration, so before they sit down to do the homework for the night can be very helpful.

When talking about concussion recovery, right, it’s a little bit different from a lot of other things in medicine. So you go to the doctor for strep throat and you get antibiotics or you break your arm and you’re in a cast. And generally speaking, right, the trajectory is good, right? You’re on your way to healing. But for concussion it can be really different. It can be up, down, all around, good days interspersed with bad days, and it can be really difficult for families and athletes to kind of be convinced that they’re heading in the right direction.

And in those cases, on these repeat visits or as we’re following them through the course of their concussion, keeping an eye on their symptom scores, not just the amount of symptoms, but the severity of symptoms, their ability to progress through their return to learn and return to academic process can give us a sense that they’re heading in the right direction. But it can be really a rocky road in ways that many other medical conditions are not. So, let’s here now kind of talk a little more about kind of getting back into school. So this return to learn progression. And there’s two things that we really want to achieve with this.

So one is, so remember before I said kind of return to normalcy is an important part of concussion management and treatment. And the rhythm and the process of going to school, not staying isolated at home, but going to school is an important part of return to normalcy. So even if the athlete can’t tolerate sitting in the classroom there is a progression for getting the athlete from kind of protected environments in school. So sometimes that’s quiet time in the library or a lot of schools now kind of have these quiet rooms for athletes with concussion to work as they kind of gradually progress back into the classroom environment. So that’s important for kind of their social engagement.

And again, that return to this kind of sense of normalcy that is so, so important. The other part of return to learn then is the academic and cognitive part, right? ‘Cause when all is said and done, this athlete should be back to their prior level of academic achievement. And as you can see kind of through these steps here, right, it’s really kind of this common sense progression of kind of doing a little bit more as the athlete progresses. Especially kind of middle school and high school, they might find that they progress more rapidly in some subjects as compared to the others.

And typically the return to learn kind of captain in a school district is either the school nurse or the guidance counselor, sometimes it’s the teacher, is the athlete that you’re working with doesn’t have that type of resource in their school or if they’re homeschooled or what have you. In that resource page at the end, there is a wonderful handout in terms of how to develop and implement a return to learn program if your athlete doesn’t have access to that already in their academic setting. And then in a similar fashion, getting back to sport is not kind of a one and done. It is a multi-step process. So this is from the Centers for Disease Control.

And this is the standard progression. And at best, each step takes at least one day. So from the time they get back to a little bit of physical activity, it’s at least six days for return to full sport in a contact collision situation. And so initially that initial return to kind of light physical activity that we talked about, ideally within a day or two of the concussion. And once they tolerate that okay, then light aerobic exercise where you’re getting the heart rate up a little bit, you’re kind of getting a little bit of sweat and then progressing into higher intensity and sports-specific skills and drills, but still without contact, right?

So doing things on their own or with a team as long as they’re not putting themselves at risk for another contact or another head injury. But you’ll notice that I kind of put these asterisks here, and that’s because that’s where things change a little bit before we kind of give them permission to return to potential contact. So, the three things that we look for return to contact sport, for clearing them back to full contact activity is the athlete needs to be symptom-free at rest. They need to remain symptom-free both during and after high intensity physical activity. And I document that by either, you know, talking to a reliable source, either oftentimes the athletic trainer or maybe the parent, that type of thing.

But have they been doing high intensity activity? And if so, are their symptoms staying away? And then number three is return to their prior level of school performance or kind of their academic or cognitive kind of thinking abilities. And for that, I’m typically kind of getting information directly from the school, either from the school nurse or the guidance counselor or the athletic trainer, but I want to see that there is some indication that their brain is back to thinking like how it was before. And once these three points have been satisfied they then get a clearance note for return to full contact practice.

And it is important. And athletic trainers tell me they get all sorts of pushback from parents on this, but there needs to be at least one full contact practice before being able to get back into the game. And a couple reasons for that. So first of all, that full contact practice that allows the athlete to kind of see where their skillset is at, particularly if they’ve been out for a little while. And it gives them a chance to get that confidence back, right? If you are not playing in a contact sport with full confidence, you’re going to get hurt.

And so, that’s important from the athlete’s perspective. It’s also important for the coach to see what the athlete is doing because they have to make some decisions based on performance and really what’s best not just for the athlete, but for the team overall. And so, there are some gaps or deficits that have developed needs to be addressed before putting them back into a game situation. But once they’ve had full contact practice and kind of remediated any issues that have developed, then they’re able to return to play. So, a minimum of six days oftentimes takes a bit longer than that for most athletes.

So, let’s kind of spend our last couple minutes here just talking about prevention right? As a pediatrician, right, I initially trained in pediatrics. This is so important. But unfortunately, this is another area where particularly for girls, we don’t have a lot of data that a lot of these early studies were done for good reason in football because that’s where a lot of the concussions occur. But we’re not kind of getting some of that more specific information that we need. So remember I said at the beginning about neck not being as strong in girls as for boys, and the role of the neck muscles is kind of good shock absorbers.

And there’s some data that shows that and a lot of these studies have been in soccer and with heading in soccer, is that by strengthening the neck, you do reduce the force that a brain sees with some of these impacts, but there’s not good data that it actually reduces the risk of concussion. So, my take on it is that anything we can do to reduce forces across the brain is probably a good idea. And strengthening neck muscles is probably going to help with your heading skills as well. It’s a good idea whether or not data over the longer term shows a significant impact on concussion risk. Looking at rule changes, and this is one area that kind of breaks my heart a little bit in that rule changes have been shown to be really effective in boys’ hockey and football in terms of reducing concussion risk.

But it’s really a mixed bag for girls. So, when they implement fair play programs, which in boys’ programs have been shown to be effective in reducing concussions, no effects for girls. There has been some improvement. There was some rule changes where they were actually able to enforce rules more effectively in karate. Did reduce risk for concussion in younger girls less than 18, but didn’t have an impact on older adults. And then when they implemented some of the heading restrictions in youth soccer there was a study that showed that maybe it increased the proportion of injuries that were concussions.

There’s some difficulties with the study, so I wouldn’t kind of take that one to the bank just yet. There was a lot of education about concussions where maybe people were just kind of more aware that concussions were going on. But there definitely was not a distinct decrease in concussions. And now that you understand why, how concussions happen from the brain moving inside the skull, right, when you put something on the outside of the head, whether it’s a helmet or whether it’s other headgear, it’s really hard to kind of reduce the way the brain is moving around inside. So, there is some data that particularly in lacrosse and soccer, that some of the headgear may reduce some of the risk.

But they, helmets are very important at reducing more serious head trauma in sports like football and equestrian and snow skiing. And the most important part of helmets kind of doing their job well is good fit. And there’s some good data and there’s a really good article on the TrueSport site about the role of fit in helmets in young athletes. The other area is kind of eyewear and mouth guards. They don’t really appear to be effective in reducing concussion risk. There’s some data that has kind of come and gone on that, but they’re very effective at reducing eye and dental injury, and still worth their while, even if they’re not helping us with concussion.

And then finally, educating coaches makes them better at recognizing concussion, but it doesn’t seem to reduce the risk of concussion in their players. And then when we talk about kind of technical instruction, again, kind of going back to what we saw with the ACLs some of that technical instruction particularly with heading in soccer, may improve the performance, but doesn’t really seem to have a direct impact on concussion occurrence. So, prevention is still kind of this area where again, if I give this talk in a year or two, maybe I will be able to share additional information, but really there’s a lot we don’t know in this range. So, a couple of my take-home messages, right, just remembering that in many sports, girls are about two or more times higher for concussion risk as compared to boys, that these risk factors are hardly variable, but keep tuned ’cause more data to come. Getting them back into physical activity and back into school sooner rather than later, ideally within a couple days are really important for kind of minimizing the risk of these prolonged symptoms.

It is okay if symptoms go up with activity both mental and physical activity, particularly in those early stages. And remember, prevention is just a challenge, but keep tuned because again, more data is going to be coming down the road without a doubt. So you may have noticed that I did have some footnotes throughout this. Here are my references if you are interested. We have our TrueSport team who is happy to engage at any point, and certainly if any questions emerge after this, don’t hesitate to put it out either through social media or through TrueSport.

And now I welcome any questions that you may have. The QR code on the left goes to a feedback form and those additional concussion resources can be found on the QR code on the right. So once again, thank you so much everybody for your attendance tonight. Really appreciate it.

 

Vivian Kaufman –

Yeah. Thank you, everyone. Thank you so much, Michele. That was amazing. And we have a few questions in the Q&A. So I’m going to read some out, Michele, and then you can answer them, and we can go from there, and more people can put them in the chat as they come up. In post-concussion situations, three months, how does impulsiveness in teenage girls show up as post-concussive versus female hormones?

I’m not totally sure. I think, does that make sense?

 

Dr. Michele LaBotz –

Yeah. Well, you know, that can be hard. That can be really hard to discern, right? Because, you know, adolescents in those teenage years, there is so much change. But basically kind of what we are looking for is changes kind of in that post-concussion time period, right? And especially kind of once you’re kind of beyond that three-month window and you start to talk about kind of the, what they used to call kind of this post-concussion syndrome, excuse me, you’re really looking for comparisons to how things were before the concussion, and you’re looking for a return to baseline.

So, if they were impulsive and moody, you know, beforehand the concussion experience is not likely to make that better. But if it isn’t improving, then it is certainly worth kind of looking into. There are some, so neuropsychological tests, they’ll tell you if somebody is still having significant issues like that that interfere with their ability to function, we will oftentimes recommend interactions with the neuropsychologist who can kind of look into that a little more detail and help us to sort out, okay, what’s coming from a concussion sequela versus something else. Good question. Thank you.

Vivian Kaufman –

Yeah, thank you for that question. And then another question that came up in the Q&A was, does VOMS, or V-O-M-S, include sensitivity to light and sound?

 

Dr. Michele LaBotz –

Not so much. VOMS is… So certainly, so VOMS is those vestibular, so vestibular, kind of the ear balance, oculomotor, which are the muscles that kind of help to move and coordinate the eye. So VOMS, vestibular ocular motor symptoms. Those typically you think more in terms of kind of balance. A lot of times it can cause nausea. Now, certainly if you’re feeling off balance, right, you’re going to be much more sensitive to other things.

That sensitivity to light and noise though is slightly different and not everybody with sensitivity to light and noise are going to have VOMS symptoms. But certainly if you have VOMS symptoms, to be honest, you’re more sensitive to everything because like I said, that is a pretty miserable symptom set, especially kind of early on. Awesome.

 

Vivian Kaufman –

Well, thank you for that. That was really interesting and very helpful. If anyone else has questions, we have a few minutes. While people put in some questions, Betsy dropped some links in the chat, including to our website and our newsletter signup.

Also in our concussion resources we have some TrueSport articles that we worked on with Michele that are linked there, and then also some other resources linked. So definitely take a look at those. And then we have another question. We had a question from Jenny in the chat, and she said, “We are working on concussion process for our school district to address expectations for both return to play and return to sport, or return to play and return to learn so that athletes, teachers, coaches, and parents will all have the same information. What suggestions do you have for us in the process?

 

Dr. Michele LaBotz –

Sure. So, I think so a couple things. So, there are a number of good resources that are out there. So for instance the Maine State Department of, so I live in Maine, and our Department of Education has put forward a excellent very practically oriented with a lot of guidance in it for educators regarding that kind of return to learn process in particular. I think the one thing that I hear about the most is that families and athletes perceive that once they get that clearance letter or that clearance call from the doctor that they’re good to go, that they assume that, okay, I can play in tomorrow’s game.

You know, I can start kind of doing full homework without kind of recognizing that it’s a process. That return to learn educators handout that is in the resource document is another very helpful piece of information. And certainly if you want to kind of reach out to TrueSport, I can send you a link or a PDF of what we’ve developed here in Maine. We’ve gotten fabulous feedback from educators and families and athletic trainers in terms of the type of guidance that is provided there. But I am so glad you’re doing the work because it’s really important and there is a lot of misperception out there.

 

Vivian Kaufman –

Thanks, Jenny, for that question. Thank you, Michele, for that response. We have another one in the Q&A. Is there a middle ground where we should be aware and act accordingly, but how to not be overstressed? So, does that make sense? Knowledge- –

 

Dr. Michele LaBotz –

So. Go ahead.

 

Vivian Kaufman –

Yeah. No, I’ll just read the whole thing, sorry. Knowledge is power. We all know that very well the same goes. Little information. Is there a middle ground where we should be aware and act accordingly but not be like overly stressed by concussions and response?

 

Dr. Michele LaBotz –

Yeah. I think that is a fabulous point because there has just been, there’s been a lot of histrionics about this and I have been in this field long enough that I’ve kind of seen the pendulum swing where we, you know, initially, man, you know, you didn’t really care much about concussions, right?

You got your bell rung, you went back in for the next play. And then we got really, really concerned about it. And we put these kids in the quiet room for a week and we kept them out of school until they felt all better. And we made them stop participating in sports if they had their third concussion. And now I feel like the pendulum is kind of coming kind of back to a middle ground where, again, we are letting kids start living their life while they’re still having some of their concussion symptoms and finding that that’s actually an essential part of recovery.

We are not pulling them out of a sport. Kind of it’s not, you know, a three strikes, you’re out type of situation like it was commonly perceived earlier, right? There’s this individualized decision-making. And I think that’s kind of where kind of that middle ground lies in terms of kind of figuring out what is the best approach for each patient. Figuring out where are those things that you can provide, you know, whether you’re a parent, whether you’re an educator, whether you’re, you know, mental health professional, whatever, athletic trainer that you can kind of help that particular athlete.

Because hopefully as I’ve tried to convey in here, it is not one-stop shopping, right? Each concussion is truly unique. And I’m glad that it feels to me like there is a voice of reason coming out in terms of our concern and our approach to concussions. Great question.

 

Vivian Kaufman –

Awesome and I think we have one more or maybe one or two more questions, but from Brenda in the chat. “Given that the impact test tends to be heavily relied upon with the generalized symptoms you have provided where we see both boys and girls tending to present with, is there a test?

Is that test still efficient for female athletes or are there other screening and progress tracking tools available?”

 

Dr. Michele LaBotz –

Yeah. You know, the impact test there’s a lot of variability in terms of how frequently it’s used and the effectiveness of its use, right? There are these population kind of normal values, you know, for males and for females that we can use. But really there is so much variability that, you know, getting a good valid individual baseline is important but can be a challenge because oftentimes, you know, kids know the game and they know that you’re looking for these improvements. So sometimes that baseline isn’t a completely accurate view of their skillset.

So, I’d say that I will use the impact test as one piece of information in terms of making a return to play decision. So especially if I’m not certain if somebody is kind of accurately reporting kind of resolution of symptoms that they tell me they’re good but I’m not convinced I’ll oftentimes kind of look at that impact report. But sometimes you have an impact report where there are some changes from kind of either a baseline from population norms where everything else is back to normal, you know, they’re back to their baseline level of school. To my thinking and my decision-making, that kind of real life information is much more important to me in decision-making than the information from a single kind of impact test or COG sport or some of the other kind of computerized neuropsych programs or neuropsych assessments rather, sorry.

 

Vivian Kaufman –

Awesome. I think we have one time for one more question that came in the Q&A. – Sure. And the question is, has there been any changes in the frequency of repeat concussions with the new protocols?

 

Dr. Michele LaBotz –

That is a great question. And I have to tell you, I don’t know the answer to that and I don’t know if there is an answer to that because the way kind of these new protocols have been rolled out, right, they haven’t been universal. And even kind of up in our community where we try to do a lot of education, there are still a lot of educators. There are still a lot of clinicians and coaches who are kind of basing their treatment on kind of the older kind of paradigm, the more restrictive paradigm.

So, I don’t know the answer to that question. I don’t know if there’s kind of high quality data that we can hang our hat on, but I love the question and I’m going to look into it.

 

Vivian Kaufman –

Awesome. Thank you, Michele, for that. And thank you, everyone, for joining today. I think that is the end of the time we have. But if you want, if you have any other questions feel free to put them in the feedback form and leave your email and we can get back to you. As well as if you have any suggestions for future webinars that you’re interested in with that you would like us to host, please put that in there.

We are always looking for suggestions and yeah, thank you so much. Keep in touch with TrueSport. Yeah, have a great rest of your evening, everyone. Thank you.

 

Dr. Michele LaBotz –

Thank you.