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Head Injury and Culture of Care in Female Athletes: Q & A with Dr. Donna Duffy

Updated: Jan 30, 2021

In 2018, the Women’s Rugby Coaches and Referees Association (WRCRA) partnered with Dr. Donna Duffy, Director of the Female BRAIN Project at the University of North Carolina at Greensboro. In this interview, Dr. Duffy shares her recommendations for how to reduce head injuries and create a plan for when head injuries occur, creating a “culture of care” with athletes.

What are the most important things to know and discuss with players?

As coaches, we make decisions every day that impact the health and well-being of our athletes. These decisions are made while considering many different variables, including but not limited to level of play, the length of the season, league vs. non-league competitions, weather, and injury risk. It is impossible to prevent head injuries in rugby. However, creating a culture that encourages open dialogue and sets expectations that teammates will advocate for each other’s health is a great place to start.

Make education a priority. It is critical to teach your players the difference between concussive and subconcussive head injuries. A subconcussive head impact is a bump, blow, or jolt to the head that does not cause immediate symptoms; the onset of symptoms could take 24 hours or a couple of days. This differs from concussions, which do cause immediate, observable symptoms.

The Concussion Legacy Foundation explains the difference between concussive and subconcussive head trauma: “One way to think about it is like potholes on the road. If you hit a bad pothole, you might pop a tire. The impact was so hard on your wheel that you can immediately see the damage, and you’ve got to deal with it before you can get back on the road: just like a concussion. Subconcussive hits are like the smaller potholes – they won’t pop your tire right away, but drive over repeatedly, day after day, and the damage will start to add up. Over time, you’ll see the wear and tear.”

Finally, explain to your athletes that each head injury is unique and will not mimic the symptomology and recovery patterns of others.

What do we need to know about current research on head injuries and female athletes?

  1. Research suggests that one or two “big blows” are not the likely cause of later-life neurocognitive impairment. Rather, repetitive head trauma (subconcussive trauma) throughout years of competitive play is most likely the culprit. It’s important to note that subconcussive trauma does not result in diagnosable symptoms, which may make it very difficult to pinpoint the exact moments when the head trauma was sustained.

  2. What we know about later-life neurocognitive impairment is based on male-exclusive research studies (primarily male boxers and former NFL players) and currently there is no published data on the later-life neurocognitive impairment among female athletes. This means that we do not have an understanding of how males and females differ in their later-life neurocognitive impairment as a result of repetitive head trauma.

  3. Age of first exposure to repetitive head trauma matters. Research suggests that if an athlete is exposed to repetitive head trauma before the age of 12, they have an increased risk of later life neurocognitive impairments. However, these findings are only based on male exclusive studies, which means that we do not have any data for age of first exposure outcomes for female athletes. * USWRF-WRCRA Note: There are really two camps on age of first exposure (AFE). One camp says there is no impact on aging and later life consequences, and the other camp says, there is. I believe that we don't know enough yet to say definitively one way or the other and that further studies are needed. Additionally, the metrics by which AFE are assessed were developed for male athletes and there are possible variables that could change this assessment for female athletes

  4. Clinical and recovery protocols are based on male, normative values, which means that the diagnostic and recovery plans for female athletes with a head injury are based on data that is often not applicable or appropriate for them.

What future research is needed on head injuries and female athletes?

First, female exclusive studies are necessary. Sports related head trauma in both the short and long term do not result in homogenous outcomes between the sexes. We cannot continue to apply the research findings from male exclusive studies to females during and throughout their diagnosis, recovery, and rehabilitation process(es).

Second, we need a better understanding of how the onset of menses and the menstrual cycle phases influence head injuries among female athletes at different developmental stages beginning in adolescence.

Third, at this point, there has been no effort to understand the longitudinal neurocognitive and neuropsychiatric outcomes throughout the aging process for female athletes who experienced head trauma in sports.

How can coaches help reduce head injury risk in female players?

A coach’s checklist should include the following:

  • Instruct players on proper rules and safety measures and set expectations (and accountability) that players will adhere to them.

  • Teach players the correct tackling techniques and impose strict penalties for athletes who do not implement them.

  • Lead players in exercises that strengthen their neck muscles and upper body strength.

  • Encourage players to wear a mouthguard and head gear that has been proven to mitigate head injury risk.

  • Encourage players to take breaks and not to play through energy lows. Energy lows can lead to sloppy play and technical mistakes, which can increase the risk of injury.

  • Ensure that a player’s uniform and gear fits appropriately. And continue to check for wear and tear on gear throughout the season.

What should a coach do if there is a suspected head injury in a female player?

Symptoms can vary between males and females when a head injury is sustained but the coaches response should be the same.

  1. SIT THEM OUT! First and foremost, remove the athlete from play and seek medical care immediately. As a coach of a female team, I understand that access to sideline medical care can be a challenge. There are times when an athletic trainer, school nurse, or EMT are not immediately accessible. However, as a coach you are responsible for the health and safety of your athletes, which means that there needs to be a system in place for the athlete to receive medical care. And, it is important to document the injury experience (time, location, date, observable symptoms). As a coach, I carry multiple medical report forms on my coaching clipboard and I teach my assistant coaches how to complete the form, in case I am responding to the athlete with the head injury. One of the first things that may indicate a head injury are the observable symptoms that a female athlete may display. Observable symptoms can include: confusion, dizziness, loss of balance, reduced reaction time, vomiting, sensitivity to light, and fatigue. If you observe these symptoms, these should be documented on the medical report form as well.

  2. Create a plan of care. Help the athlete to work with all stakeholders (athletic trainer, medical doctor, physician’s assistant, nurse, roommates, teammates, family members, and friends) to create a plan of care. A plan of care can consist of a day-to-day record of symptoms, the severity of symptoms, changes in symptoms, follow-up medical care, hydration notes, food intake, changes in sleep patterns, changes in mood/irritability, changes in fatigue levels, confusion, memory loss, incoherent speech, disorientation, and any other detail that may provide important insight about how the athlete is recovering from their head injury experience. It is important that each item in the plan of care has a notes section, as well as a place to note the date and time of each symptom recording.

  3. Assess whether the athlete is ready to return. If your female athlete is fortunate enough to have a continuum of care for her head injury, such as a university based athletic trainer, make sure that the athlete is completing all of their “return to….” protocols. However, if your female athlete does not have a continuum of care in place (e.g. a club player) and relies on her own primary care doctor or an urgent care doctor, both of whom may not have the slightest idea how to diagnose, treat or provide recovery plans for the athlete, it is critical that, as a coach, you take a health advocate approach for your athlete. Your league likely has rules in place regarding these types of situations so make sure that you follow all league protocols and seek other opinions when appropriate. And, make sure that the player has medical clearance before they return to practice and competition.

What do you mean by “Culture of Care”?

Create a culture of care. Athletes are sometimes hesitant to report a head injury for many different reasons, including loss of position and loss of playing time. As a coach, one of the most important things that you can do is create a culture of care, so that your athletes can be honest with you about their health and injury status. Help your athletes understand that they are also responsible for the health and safety of their teammates and should speak up when they suspect that a teammate has a head injury.

Also, provide ongoing training to your team. Invite researchers, clinicians, etc., to provide education for your players about head injuries at least once or twice per year. This will help all stakeholders stay up-to-date on the most current research and guidelines for care.

For more information regarding female athletes, head injuries, and research opportunities please contact Dr. Donna Duffy at: You can also learn more about The FEMALE Brain Project here.


All photos from Brown University Women's Rugby.

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