Click play for an audio readthrough of this article
With women at double the risk of concussion, and sub-concussions referred to as the silent killer, we need action – now.
Quick explainer: a concussion can result from a hefty blow to the head or body. Basically, a blow of sufficient force (whether direct or indirect) rattles the brain and damages brain cells. Concussions may be symptomless, or they can present as fogginess, glassy-eyes, dizziness, sickness, memory loss, balance issues, headaches and migraines.
Short-term, concussions are concerning. Long term they can be devastating.
Perhaps obvious, concussions are most common in contact sports, and that certainly includes netball. Our sport involves stop-starts, direction-changes, bumps, knocks and collisions – all on an unforgiving surface.
Unlike many other sports, and society as a whole, netball has begun to confront the issue of concussions, which is so important given what you’re about to read.
The alarm
Research into concussions has been ongoing for decades but we continue to learn more and more about the impact – short-term and long – of brain trauma in general, and specifically in women.
We now think that women are twice as likely to suffer concussion than men. Our symptoms are more severe and our recovery time is longer.
The reason for alarm is that concussions and sub-concussions (more in a minute), leave definite marks on the brain. Enough bumps, knocks and blows over a long enough timeline and evidence points at significant neurodegenerative decline.
To repeat, it’s not just impact to the head that damages the brain. Impact to the body – think a big body block or a shoulder barge – can also generate enough force to rattle the brain. Hence the ‘silent killer’ moniker.
Concussions can be subtle and quiet too.
In many ways we’re at the tip of an iceberg here. We’re beginning to understand the long-term impacts of head injuries and brain trauma in sport, thanks to long-term studies and historic athlete data. But the male / female component is problematic because 80% of existing concussion research is / was conducted on males.
This leaves academics with a catch-up-job to learn more about women and, to be fair, efforts are underway. In fact, a multi-year study of women’s elite rugby recently moved the conversation on …
And yes, the problem is at least as big as we thought.
Sub-concussions
A full-on concussion is usually (not always) pretty obvious. If a heavy head knock or fall on court results in a player feeling dizzy, discombobulated, sick, glassy-eyed, vision-impaired or even unconscious then you probably have a concussion.
The current guidelines for recognising concussion and safely returning players to court were released in 2023. The guidance strap-line ‘If in doubt, sit them out’ builds on guidelines already introduced in Scotland that make clear no-one should return to sport within 24 hours of a suspected concussion.
But it’s not just obvious blows to the head we need to worry about. We said that academia is still catching up in this field, and insights around sub-concussions are emerging as another cause for alarm.
As the name suggests, a sub-concussion is a blow to the head or body where the impact or damage isn’t so severe that it meets the threshold of a full-on concussion. In fact, in a sub-concussion the brain experiences about 25% of the force of a full-on concussion.
But the lesser-sounding name doesn’t tell the full story. The human brain is made of both white and grey matter and these are different densities. These two regions of the brain like to move as one unit, but a blast from external forces – think head knocks or body blows – can knock them out of sync. When they do, women’s long and thin brain cells may rotate, twist and contort and, in response, become inflamed.
If such bumps are rare there’s little to worry about as the brain can recover and the inflammation will die down. But when your sport involves regular head knocks, body contact, and falls to the floor, the brain may not be given the time it needs to recover and this is when damage can accumulate.
Should brain cell inflammation become chronic, the brain will start to produce certain proteins, and these are the same proteins found in the brains of people with significant neurodegenerative diseases.
CTE
The life of a netball player, at a certain level of competition anyway, may involve the odd concussion. It will certainly involve bumps, knocks and falls aplenty.
Concussions and sub-concussions can and do leave marks on the brain. Enough bumps, trauma and microtrauma and bad proteins can build up in patches of the brain.
If this happens we’re into serious risk territory.
The condition known as Chronic Traumatic Encephalopathy (CTE) is one possible result of regular brain trauma (or microtrauma) over time. It’s incredibly serious and there’s no cure.
CTE can cause emotional, memory and cognitive problems, significant mental health issues and, soberingly, early onset neurodegenerative diseases such as Alzheimer’s and dementia.
Again, we’re learning more and more about the long-term impact of head / brain injuries in sport over time, and we don’t have to look much further than England’s 1966 World Cup heroes, a number of whom have fallen to dementia. In fact, recent news reports that footballers are five times more likely to develop dementia than the general population.
What’s the why?
As said, the investigation into women and concussion still has a long way to go but there are prominent theories as to why women suffer worse than men.
We think that women’s weaker necks and lighter heads create more acceleration force when we fall or collide. Essentially, the whiplash effect is more intense, and women have less ability to prevent or blunt the impact of a knock to the ground or another player’s shoulder.
It’s also very possible that menstrual cycle hormones play a role in making things worse. Limited research suggests that women suffer poorer concussion outcomes specifically in the second half of their cycle; when progesterone levels are high. Progesterone is actually protective in our brain, but it’s thought the sudden withdrawal of progesterone as a result of concussion leaves the brain more susceptible to the effects of a concussion, or less able to recover as effectively.
Interestingly, women’s and men’s differing brain structures may be another variable in the mix. The human brain’s 100 billion neurons – the connectors that allow us to think, move, talk, sing, sleep and boil eggs – are slightly different in shape, women to men. Women’s are longer and thinner and, as such, are extra vulnerable to the powerful rotational forces – think of it as a crunching, twisting motion – caused by a bodycheck or head-knock.
These theories are developing, but it’s almost certain that women’s heightened risk of concussion is a combination of these and other risk factors.
Problems unsolved
Sport has been slow to confront the issue of concussions in general. As recently as 2021, a group of UK MPs reported their grave concerns about concussions, citing sport’s ‘negligible’ effort to track and monitor brain injuries. The MPs even stated that athletes were unwittingly putting their future health on the line.
With concussion research 80% built on men, the most recent guidelines from the Concussion in Sport Group did not single women out as a population. The Group made specific recommendations for some ‘special’ populations – including younger people and elite athletes – but not women.
What does this all mean? It means there are no sex-specific guidelines on dealing with concussions. It means organisations – from schools to the military to sport bodies – know very little and, as such, have no specific protocols for the half of the population that carries double the risk.
And because there’s little leadership on the issue, clubs, teams, schools and so on are failing to solve a problem … because they barely know they have one.
Solutions
Solutions to the concussion conundrum are a mix of the long-term and the short. Long-term, academia has to catch up and we need clarity at the decision-making level so better messages can filter through all levels of sport, education and society.
We need to educate a majority on how to recognise concussion, and what to do during and after a player has been concussed. This should be a non-negotiable part in training coaches, officials and even players themselves. Just as we learn how to administer first aid – and refresh it every couple of years to keep our qualification up to date – regular education about concussion should be an essential part of being involved in sport.
That’s the long term. Until then, sports like netball – and all of us – can continue to take the initiative and arrest a significant problem in our sport and beyond. We can share this article and spread the word with peers and clubs. This itself would be a brilliant start.
Then there’s physical training. Dr Elisabeth Williams from Swansea University, an expert in the topic, suggests it’s highly important that women deliberately develop neck strength as part of any training regime. It’s also paramount we teach girls how to fall safely.
We also need to burst the myth about skull-caps and helmets in sport protecting the brain. They don’t. They protect against wounds and skull injuries but offer no, repeat no, protection against brain trauma.
Protective headwear
While old helmets and skullcaps aren’t effective against brain injury, some manufacturers have stepped up to develop specialist headwear specifically to mitigate the risk of concussion in sport. One such manufacturer is Rezon.
The company’s starting point says it all: In sport why do we protect our shins and not our brain?
Rezon’s headband is engineered entirely to protect the brain and reduce trauma by absorbing some of the forces which act on the brain during sport. It can reduce rotational forces acting on the brain by up to 60%, and is the only kitemarked PPE (personal protection equipment) for the brain in sport. The lack of other regulated and scientifically backed products to protect the brain health of athletes reflects a dire need for more innovation and investment in this area.
A leading expert on the issue of female concussion in sport – Dr Emer MacSweeney – suggests that everyone who participates in sports which involve contact or the risk of falls should wear brain protection to reduce the risk of developing CTE.
Next steps
This article has gone long, but head and brain trauma in sport is such an important area of study that we all need to know this.
The legacy impact of brain trauma on athletes in general is major, and it could be even more pronounced for female athletes. If we don’t change the tide, we’ll be asking why we didn’t take action 10, 25, 50 years ago.
We must start now. If you want to learn more, we suggest the following media as good places to start, and let’s all of us start promoting awareness, training and protective headwear in our clubs, social circles and communities.
Further research
As a reminder, the content of the course belongs to The Well HQ. You have permission to access and use the content yourself or, if you are an organisation, for the number of users selected, but are not otherwise permitted to share such content with others, all in accordance with our Course Terms and Conditions.