Every year, around 3000 Australians are hospitalised from a sports-related concussion – and most won’t even know it.

But while the rules surrounding concussion management are informed by science, there is a huge gap in knowledge regarding its causes – especially among women.

Where do the rules come from?

Despite many claims that concussion management rules are arbitrary, they are actually dictated by an international consensus statement.

Every four years, a group of experts -called the Concussion in Sport Group – meets to update the consensus statement with new research. This is later translated back to clubs to implement.

“[The group is] from all over the world. They’re usually doctors, psychologists or physios who’ve been studying this area for a long period of time,” says Shreya McLeod of the University of Newcastle.

The group were due to meet in 2020, but the conference is postponed until 2022 because of the pandemic.

We know a lot of the aftermath, but not as much about the cause

When it comes to concussions research, four years is a long time. New technologies are continuously bringing in new information. Sometimes, this is why new club rules are added even though the consensus hasn’t been updated.

“The space is changing rapidly. So, five years ago, people were advised complete physical and cognitive rest after concussions. It was quite often that people were prescribed a week’s rest cognitive and physical rest,” McLeod says.

“However, we now know that 24 to 48 hours is all we need to rest for true cognitive rest. In fact, [some] submaximal aerobic exercise is important in recovery. I guess part of it is the changing research space”.

And recovery research isn’t the only type of research conducted. Knowing why and how injuries are sustained is as, if not more, important than clinical rehabilitation. Again, this is necessary to inform how training and play can be made safer to prevent injuries in the first place.

Read more: Cosmos Q&A: Concussion

But here is the catch – there isn’t much data about how injuries are sustained because most of the data comes from after a concussion occurs. Data from before play is necessary to identify fine biological changes. After all, not every concussion is even recognised.

“The gold standard is to look at preseason and postseason imaging data sets, particularly with very advanced techniques like diffusion tensor imaging,” says Alan Pearce of La Trobe University.

“Using these techniques In the United States, they’ve shown that, without any [diagnosed] concussions, there are [still] changes in white matter, which is a little bit scary.”

Right now, the knowledge basis is skewed towards concussion after it has happened, so the minute factors that induce a concussion are still unclear.

Beyond this, concussion is highly individual. Proper management techniques cannot be employed until we understand all players – and that includes women.

Women and concussion

Another gap in concussion research is how it affects different people. This is because most research has focused on professional male athletes.

In science, the average person is traditionally a Caucasian male because that is who previous studies have focused on.

So, what about women? Are they affected differently?

“I am very interested in this space because, as a physio, I have enjoyed working with female athletes,” explains McLeod. “They are mentally and physiologically different from men.”

“We know that there is definitely a hormonal component with other musculoskeletal injuries, such as knee injuries.

“For example, we see a lot of ACL [injuries] that happen around a certain phase of the menstrual cycle, so it’s intuitive [to] think concussion would also follow in a similar pathway.

“But, of course, that needs further investigation”.

This translates to, potentially, more severe or long-lasting concussions in women because of hormonal or biological differences.

Read more: A safer and faster concussion diagnosis

“With the very limited evidence, women seem to have higher, more severe symptoms and take longer to recover than men – with the caveat that I don’t think that men are honest enough,” says Pearce.

“But it’s a really good question because we don’t know [whether women are more susceptible] at this stage. All we know is the aftermath of the concussion.”

This bias means women were excluded from studies but still subjected to the same types of concussion management men used.

“I think from our end, there is a gap between the consensus and the amount of research and data coming in,” explains McLeod.

“It’s only just now that we’re all doing a lot more work in this space.”

Bias even leaks into diagnostics because covert signs of concussion in men are used as a standard for all athletes.

“We actually don’t have any of that [type of] data for women at all,” says McLeod.

“We have nothing for the female space. Everything we’ve been looking at has been carried over from the male space to the female space – a one shoe fits the more kind of thing.”

If women are so severely affected, then why play at all?

This is the wrong question, McLeod says. Women may be impacted in ways men aren’t because the management practices are geared towards men. What’s needed, she says, is more information about women and concussions to build better frameworks.

“I think part of it is education, and part of it is working on a structure for females,” says McLeod.

“We don’t actually know whether women tackle differently. We don’t actually know whether breast tissue is involved in the way we tackle.”

This all gets back to the question of how concussions are sustained and what factors contribute to them.

Instead, the solutions require team concussion management to reflect women-specific data, especially when it comes to techniques to safeguard the brain.

“The thing to do is figure out whether we can make the games safer,” says McLeod.

“[We could do this by] looking at tackle characteristics. Is there a big difference between males and females and the way we tackle?”

Not only this, but young girls are less likely than boys to have played other forms of amateur or casual sports where tackling and fall techniques are taught.

“These girls who started playing collision sports come from a non-collision sport background. They’ve never had that opportunity [to learn how to tackle].

“We need to start them learning to tackle and roll.”

Ultimately, when it comes to managing concussions in athletes, we can’t forget about our girls.

Image credit: Shutterstock

This article was originally published on cosmosmagazine.com and was written by Deborah Devis.