The concussion protocols are based on research that primarily involves men. What about women?

Lindsay Simpson still has questions about her concussions.

Her first came when she was 16. At the time, she was playing for a club soccer team in Atlanta, as a promising high school goaltender with aspirations of a Division I scholarship and — in her biggest dreams — a professional playing career.

“I dove towards the ball and my body hit funny. I slammed the back of my head against the ground,” Simpson said. “You train very well not to do that, but mistakes happen.”

When she was injured in 2002, “concussion” was not the household word it is today. For weeks, Simpson experienced mysterious symptoms and struggled in school, leaving her and her parents wondering what was wrong. “I had this horrible, excruciating headache. I couldn’t be in the bright lights. I really wasn’t myself,” she said.

Her parents took her to doctor after doctor, trying to figure out what was wrong. She saw chiropractors, orthopedists and even an orthodontist.

Eventually they saw a neurologist who suggested it might be a concussion. “He said, ‘Have you been hit in the head lately?'” Simpson recalled.

The field of concussion research has come a long way since the early 2000s. Greater awareness among the American public — who watch college and professional football players every weekend undergo concussion evaluations — could be the reason American teenagers are reporting concussions in increasing numbers.

But many questions still abound, especially regarding the differences between men and women. Some studies have suggested that women and girls may be more susceptible to concussions and may need longer to recover.

These disparities are one of the topics researchers plan to discuss at this week’s international conference on concussions in sport. Some concussion experts hope the big meeting in Amsterdam could result in a consensus statement that could improve research on the impact of concussions on women.

Concussions took her out of the game

Outside of American football, no high school sport causes concussions at a higher rate than women’s football.

Nine months after his first concussion, Simpson was able to return to the soccer field. But for the rest of her career – from high school to her time as an NCAA Division I player, Simpson suffered concussion after concussion, some mild, some more serious.

Finally, in the last game of her second spring season at the University of Maryland, she ran out of the box to clear a ball and collided with a player from the opposing team. Simpson’s head hits the other player’s shoulder. The next thing she remembers is her teammate helping her out of the field.

The symptoms – nausea, dizziness, sensitivity to light, memory problems – were so severe that she had to drop out of class.

Afterwards, a neurologist told her that she would never play competitive football again. All these years later, she says, “it still hurts, it still stings.”

Now, at 36, Simpson still has questions about the concussions that changed the course of her life.

“The million dollar question, for me, is why? Why did I have this impact and it affected me this way – and yet you watch someone take a hit every Sunday on TV , and how are you?” she says. “That’s the question I want to answer in my life.”

Many women experience concussions, but studies have historically focused on men

Every year, millions of Americans have concussions. In a 2017 CDC survey, 2.5 million high school students — 15% of all high school students nationwide — said they had suffered a concussion in the previous year. More than 40% were girls.

Yet much of the most important research on concussions has focused on men and boys, according to new analysis published in the September issue of the British Journal of Sports Medicine.

Schools, teams and medical professionals nationwide rely on guidance from three important organizations — including the International Conference on Concussion in Sport — to help guide concussion diagnosis and protocols.

Researchers reviewed the studies cited by these organizations’ influential concussion statements. The participants, they found, were 80.1% male and only 19.9% ​​female.

“The surprising part was how masculine it was,” said Julianne Schmidt, a concussion researcher at the University of Georgia and one of the study’s authors.

Worse still, about 40% of the cited studies did not include any women or girls. “Putting a number on it made it very clear that this is a huge imbalance, and it will take a lot of work to bring it back into balance,” she said.

Schmidt is in Amsterdam for the latest International Conference on Concussion in Sport, where a panel of experts will begin drafting a consensus statement that reflects the latest concussion research to make recommendations on diagnosis and treatment.

The conference normally meets every four years. But due to pandemic delays, the latest statement is now from the 2016 meeting – a very long time ago for a rapidly evolving field in which hundreds of studies are published each year.

Because the ICCS statement is so influential, an update that reflects the research imbalance is needed, Schmidt said — even something as simple as an acknowledgment of the gender gap and a call for more research funding.

“The physician treating a sidelined NFL player uses the same statements and guidelines that a pediatrician uses to treat a 14-year-old female football player,” Schmidt said. “We can’t just assume women are miniature men.”

What the research says about women and concussions

The gender imbalance stems from the origins of concussion research – studies of high-impact sports, namely American football and ice hockey, both of which are played primarily by men.

Access to research has also been a factor: professional sports teams and top university programs have dedicated medical teams, making it easier to track and diagnose concussions in these athletes than in other populations.

The gender balance has improved over the past decade as researchers looked at more diverse groups than just top male athletes, said Dr. Christina Lin Master, a pediatrician and concussion specialist at Children’s Hospital of Philadelphia and the University of Pennsylvania.

Researchers know that women report more concussion symptoms than men after a head impact. Now, Master said, studies are needed to understand why.

“Is it because they have a more serious injury and have more symptoms, or is it gendered behavior where they report more symptoms, or are more likely to disclose, as opposed to hide, symptoms?” said Master.

The differences could also be biological, she said. There are many hypotheses: one factor could be that men have stronger neck muscles than women. Another could be hormones – even menstrual cycles. It could be that women have more delicate axons, the thin fibers that connect neurons to each other.

“There’s probably a bit of ‘both and’ and not ‘either-or’,” the Master said. And some of it may not be related to the women themselves, but rather to the medical staff around them: A study she led suggested that disparities in recovery times between male and female college athletes could explained by access to medically trained personnel.

That’s where influential groups — like the ICCS expert panel — come in, she said. An updated consensus statement could help prompt the field to answer these questions by highlighting gaps. “If they make a statement about what research is needed, I think the funding bodies pay attention to it,” she said.