Louise Gardner, associate solicitor at Novum Law, outlines the impact of gender on brain injury and asks if there is an imbalance in the way women’s brain injuries are assessed and treated.
Gender differences in brain injuries have only been the subject of research for the last 20 years. It begs the question of why this is the case, given how long we’ve understood concussion. Does it display historic sexism in medical research? Or a lack of knowledge that men and women’s central nervous systems are different? Or is it because high-profile sporting head injuries involve men?
I have read numerous articles and research published by PINK Concussions, a non-profit organisation focusing on education and medical care for females with concussions from sport, domestic violence, accidents, and military service. Its mission is to drive change and innovation by developing gender-specific, evidence-based strategies to identify, manage, and support women with brain injuries.
Brain differences in men and women
Men and women have slight variations in their brain axons, thought to impact the likelihood and extent of injury. Traumatic brain injury causes damage to the axons; nerve cells within the brain which are vulnerable due to their fragile structure.
Male axons are often larger and have a more complex structure. Female axons are more delicate and prone to breakage of their micro tubes which are stabilised by protein. These proteins can’t unfurl fast enough to keep up with the rapid stretching during a severe injury. Damage to the micro tubes leads to degeneration and death of some of the axons. Female axons are more easily damaged, causing dysfunction rather than recovery.
During an injury, the brain moves within the skull. The sudden acceleration and deceleration forces cause the damage. Research has found that a sturdier and stronger neck stabilises the brain within the head during sudden movements protecting the brain from damage. However, an average women’s neck diameter is 30 per cent smaller than a man’s neck, which could increase the head’s potential acceleration by as much as 50 per cent, causing more significant brain damage.
Another study suggests females have a slightly faster metabolism than men, including greater blood flow to the head. If a blow to the head affects the blood supply containing glucose and oxygen, it could cause increased damage to brain structures.
Experts also think female hormones contribute to the extent of possible damage when comparing female and male injury, depending on the varying hormone levels during the menstrual cycle.
Research has shown that the differences in our physiology make it more likely to cause females injury. It has also demonstrated that symptoms, deficits and recovery can vary between the sexes.
Impact and recovery
The impact of a brain injury varies from person to person. But according to researchers, women are more likely to experience some deficits or disorders when compared to men:
- Adolescent females are more likely to be diagnosed with an endocrine disorder after a head injury and at an earlier age than men.
- Females who sustain a head injury are more likely to suffer long-term headaches, mental fatigue, mood disorders and concentration difficulties.
- Concussion symptoms can take longer to resolve for women compared to men. A study of 266 adolescents with injuries found females took 76 days to recover, while men took 50 days.
- Some female athletes with concussion, when tested, have shown to perform worse on tests of the vestibular ocular reflex. This process allows our eyes to fix on a target while the body moves.
PINK Concussions asks: what about the effects of psychosocial and societal gender roles on women’s recovery from head injury?
Could society’s historical approach of telling men to fight through pain affect the reporting of symptoms post-injury? Are women more honest about reporting TBI symptoms?
Could outdated and sexist views that women’s pain is psychological rather than physical play a part in how healthcare professionals treat them? Doctors may accept that a male brain injury patient complaining of headaches and low mood is suffering from head injury symptoms. But are women given the same consideration, or are they sometimes written off as hormonal or overly emotional?
Interestingly, studies in the US have found evidence that women are less likely to be prescribed pain killers in hospital and are prescribed sedatives instead.
So, are women’s post head injury pains being discounted? I hope they are not. But this does make me reflect on how women’s injuries are assessed, treated and what specific rehabilitation and support is available to address any gender imbalance.
Towards greater understanding of women’s TBI
Research and greater awareness of gender differences in TBI are vital. It can prevent the increased risk of severe head injuries for women in contact sports, military exercises, and other situations where brain injury may occur.
As a solicitor, an awareness of these differences could help women who are making claims for compensation get the right support and treatment.
Early intervention via the Rehabilitation Code can help address the more common symptoms experienced by women. For example, arranging early endocrine testing to identify if the injury has caused an hormonal imbalance; arranging early access to talking therapies to address mood disorders and; understanding if the inner ear organs have been damaged.
The Code could also assist injured women by providing domestic support and childcare. Often women have no choice but to continue caring for children and looking after their homes. If recommended, support can help lessen responsibilities during the acute period of recovery and potentially beyond.
Medicolegal experts in neurological disciplines, (neurology, neuropsychology, neuropsychiatry, neuro-rehabilitation consultants, and audio vestibular experts) should be aware of gender differences and asked to advise the Court on the impact of those injuries on women’s daily activities, work and recreation.
Those impacts must be taken into account when applying the Judicial College (JC) Guidelines when assessing pain, suffering and loss of amenity (PSLA). The 15th Edition of the JC Guidelines, Chapter 3, on Brain and Head Injuries, makes clear that classification of the injury, be that severe, moderate or mild, should refer, not to the clinical categorisation of the injury, but to the effects of the injury upon the claimant.
Compensation should reflect the nature and severity of symptoms rather than any diagnostic label. With research showing the effects of TBI women can be more severe, medicolegal experts should be asked to address them, and take them into account when quantifying the value of claims.
The Court should also be advised if the claimant would benefit from additional therapies, rehabilitation, and vocational support. Any such recommendations should be costed within the Schedule of Loss.
Women’s injuries should never be investigated less thoroughly, or written off as psychological or emotional. We need to encourage women to advocate for themselves and fight for fair assessment and treatment of their injuries. If that injury is a result of someone else’s negligence, women should seek advice and support from a specialist solicitor who understands their injuries, and their impact.
‘I’m sorry for handling the steering wheel with buttered fingers’
As he continues to come to terms with the loss of his ‘ex life’ and learns to celebrate the 21st birthday of his new self, The Brain Damaged Baron reflects on the comfort blanket of support from those close to him, while struggling with the loss of vanishing friends
Let’s get straight down to business. The salient truth is that one day, the life I once knew came to an end. Yep, gone, cheerio, toodle pip.
It is an ex-life. It has ceased to be, I trotted off this mortal coil in order to push up some buttercups. Is it buttercups? I forget.
It was so very difficult, sometimes impossible, to comprehend that all I knew had gone. That sentiment only increased over the years and there have been 21 of them. Twenty-one long years. My new life has matured and is now old enough…
To vote – when it remembers to.
To drive – it can’t, partial blindness caused by the brain injury would make driving an absolute lottery. That and the complete lack of spatial awareness. After all, I can’t walk down the street without colliding with lampposts. I wouldn’t be safe in a bubble wrapped bumper car. I’m not sure the roads of the UK are ready for me just yet.
To drink alcohol – it can’t, epilepsy denied that pleasure. Due to medication, I feel half-drunk most of the time anyway. Without alcohol, I have the memory of a goldfish with Alzheimer’s disease. I hardly need the odd libation to wipe what recall I do have.
To have sex – if I can stay awake long enough. I’ll say no more. It was all I could do to prevent myself typing ‘stay up’ long enough. Ooh-er, Mrs!
And it’s now old enough to know what the hell happened to me. And is still happening right up to this very day.
That’s the nature of a bang on the bonce; confusion.
Massive disorder in my mind, incomprehension shadows me like the gloomiest raincloud preparing to unleash a deluge of perplexity. I know it’s there, it’s always there. The monkey on my back, the albatross overhead, the angry weasel with a chip on its shoulder. learnt to live with it.
That and the ability to invent nonsensical idioms. It’s a gift.
Back in the day, long before I became 21 again, it began. The curtains were closed, slammed shut. Well, to be fair, they were curtains, not so much ‘slammed’, but more ‘flopped’. They needed opening, I had to let the day begin. And commence it did, as the flaccid curtains were swept aside and the hard graft started.
While I was hurting, while I was struggling, while I was learning, there were other people around. There still are, every day. It’s just a question of tenses really.
Watching, witnessing, feeling my pain. Either on the side-lines or directly involved, family, friends, all observing the effects. Mostly it was no spectator sport, it was grim viewing, if I am honest. And still they remained, standing by with a collective arm outstretched.
Twenty-one years later and it’s still there. A comfort blanket, a safety net cushioning the unavoidable falls.
It’s a whole new world out there, and that world has a habit of biting back. Sometimes it is just a nip, although occasionally, it’s like a bite from a hungry shark. And those nibbles come thick and fast. Each bite eroded away my former self and ate away, no pun intended, at the life that had sadly departed. All the while…
Watching, witnessing, feeling my pain…
There are so many bites that they all seem to merge into one. Remembering can be exhausting beyond belief. I had never thought it possible to get so drained, so shattered simply from attempting to recall what the day is.
Another aspect of my life that my previous self had taken for granted. There was never any reason not to. I was a 25-year-old man and it didn’t seem a lot to ask to remember where I kept my keys. It was never a conundrum.
However, after the injury, I could then forget where I kept my pants and socks, let alone my keys. Not when I was wearing them, obviously; my pants and socks that is, not my keys.
And with the exertion of something as basic to a human being as ‘thought’ came the inevitable headaches. The first to strike shook me to my very core. It smarted, just a tad. They continue to this day, bless ‘em.
Almost a year after the old brain took its battering and continued to fight the good fight, epilepsy was thrust into my life. The unwanted gate crasher causing havoc with every appearance. A lightning bolt from the deepest blue. Body spasms, unconsciousness, confusion, memory lapses, post seizure headaches that make the usual head pains seem like old friends. Well, it keeps me on my toes. And still…
Watching, witnessing, still feeling my pain. The outstretched arm remained, absorbing the anger and feeling my frustration.
Fatigue and apathy soon entered the fray. More undesirable visitors cluttering an already overloaded brain. They pushed aside my old friends ‘eagerness’ and ‘concentration’ as ‘alertness’ looked on with all the subtlety of a slightly annoyed bricklayer wielding a sledgehammer. Oh, he had anger issues too.
The passage of time was a cruel mistress. Particularly when my addled brain was struggling to establish some form of normality… whatever that may be.
My life in its entirety had altered beyond recognition. Epilepsy could now strike without warning at any given moment, throwing the day into chaos. Fatigue that plagued almost every aspect of my life began to throw up barricades.
It was hard to live with what I had become. To live in the present and not rely on the past.
And still they watched, witnessed, felt my pain. And for some, it was too much, too difficult, too much like hard work.
Relationships ended and friendships broke down. Ultimately, people vanished. They had their reasons, I was never told what they were, but I’m sure they had them. Occasionally I had the courtesy of an invented tissue of lies that possibly salved their own conscience, but only served to batter my own into submission.
Relationships with everyone in my life, friends, new acquaintances, and even the odd member of my family, seem to be based on the flip of a coin.
Should a ‘Head’ land on terra firma and whatever my brain throws into the mix, they’ll hang around. Should a ‘Tail’ drop gracefully to the ground and they’ll turn that tail and run for the hills. And that’s how it’s been since the day I landed on my cranium with one hell of a thud. But wait a moment here…
I like to think I’m not a stupid man, I pride myself on it in fact. I’m 46-years-old now, time is marching on relentlessly like a runaway train with only one destination.
I’m married to my best friend, a couple of children have their place in my life and I’m still learning more about my own limitations and abilities. Only one thing has remained constant throughout the journey that became my second shot at this rollercoaster we call ‘Life’. That damn scar on my brain still throws its weight around whenever it fancies a bit of a giggle. And thus…
I still forget things with frightening regularity.
I can’t control my emotions like I should.
Background noise irritates me to the point of exasperation.
I still invent idioms like a ferocious aardvark with a knuckleduster.
I may have a seizure with varying degrees of severity at any given moment.
Fatigue is a pest that simply won’t leave me be. And sleep is my panacea.
I can’t socialise like I once could.
I can’t drink, I can’t drive.
I am no longer the ‘me’ I once was. And do you know what? I no longer care. I wouldn’t change one God damned thing.
I throw out these statements with gay abandon, almost on a whim. The fact remains that while I was coming to terms with the throwaway facts, those people close to me WERE watching, they WERE witnessing and they WERE feeling my pain.
For instance, let’s start at the very beginning. I was in a coma in hospital. Essentially, I was asleep, just for a smidgeon longer than usual. I always was a lazy sod. While I slept, my family and friends sat at my hospital bedside wondering whether I would live or die. I had it easy, I really did. I still do.
The first epileptic seizure and every single one since sees my good self disappear into another world for however long, while whoever is there can only watch, wait, and worry. Again, I repeat, I have it easy.
I have a wife I adore. The lady who came along and turned out to be the missing piece in my jigsaw. Who knew? The rock to my roll, the milk on my cornflakes. Much like my friends and family who were there long before that missing piece arrived, she tolerates the moods and the headaches. She lives with the forgetfulness, the now thankfully muted anger, the annoyances, etc. They’re all part of just another day.
Twenty years of watching and worry. Good grief, I’m so sorry for putting you all through this journey, none of you asked to be passengers, you really didn’t. You still don’t, you never so much as complain. I certainly didn’t want to be the driver and I’m sorry for handling the steering wheel with buttered fingers…
Sleep problems ‘can be worse with mild TBI’
Sleep disorders are more prevalent among people with mild traumatic brain injuries (TBI) in comparison to those with more a severe diagnosis, new research has revealed.
In the study, the links between TBI and sleep problems were strengthened further, with people with TBI shown to be up to 50 per cent more likely to develop insomnia, sleep apnea and other sleep disorders than people who have not been injured.
And in a significant outcome, the association with sleep disorders was stronger amongst those with mild TBI than in the case of serious injury.
The research also showed that the risk for sleep disorders increased for up to 14 years after a brain injury – showing the need for the impact of TBI to be assessed in the long-term, said the research team from the University of California.
“Clinicians should ask TBI patients about their sleep and they should follow that up,” says study investigator Yue Leng, assistant professor in the university’s Department of Psychiatry and Behavioral Sciences.
Data was analysed from 98,709 Veterans Health Administration patients diagnosed with TBI, alongside an age-matched group of the same number of veterans who had not received such a diagnosis. The mean age of the participants was 49 years at baseline, and 11.7 per cent were women. Of the TBI cases, 49.6 per cent were mild.
Researchers assessed a number of sleep disorders, including insomnia, hypersomnia disorders, narcolepsy, sleep-related breathing disorders, and sleep-related movement disorders.
During a follow-up period that averaged five years but ranged as high as 14 years, 23.4 per cent of veterans with TBI and 15.8 per cent of those without TBI developed a sleep disorder.
After adjusting for age, sex, race, education and income, those who had suffered a TBI were 50 per cent more likely to develop any sleep disorder compared to those who had not had a TBI.
The association with sleep disorders was also found to be stronger for mild TBI than for moderate to severe TBI which, say the research time, might be due to differences in the brain injury mechanism.
While the study was conducted with veterans, the research team expected to find an increase in probability of sleep problems in those with PTSD.
“But actually we found the association was pretty similar in those with, and without, PTSD, so that was contrary to our hypothesis,” says Leng.
The researchers could not examine the trajectory of sleep problems, so it could not be concluded whether sleep problems worsen or get better over time, she adds.
Women ‘more likely to have long-term issues after concussion’
Women may be at increased risk of long-term physical and mental issues after a concussion, a new study has revealed.
In analysis of 2,000 people who sustained a head injury, women were found to be more likely than men to still have some symptoms a year later.
These included memory and concentration problems, alongside headaches, dizziness or fatigue.
Women between the ages of 35 and 49 typically had worse symptoms than both younger and older women, the research found.
The study revealed that in other traumatic injuries, men and women’s recovery times were similar – the main area of disparity was in brain injuries.
While this research cannot answer the question as to why this happens, says lead researcher Professor Harvey Levin, from Baylor College of Medicine in Houston – it is possible, he says, that chronic inflammation in the brain tissue or hormonal influences play a role.
The brain has receptors for oestrogen, and previous research has indicated that women who sustain concussion at certain times in the menstrual cycle tend to have a slower recovery.
It also builds on previous research which has also pointed to sex differences in concussion recovery.
Writing an accompanying piece to the study, which was published in JAMA Network Open, Martina Anto-Ocrah, an assistant professor of emergency medicine and neurology at the University of Rochester Medical Center, says it strengthens the case that women’s slower recovery is related to concussion.
“We expect most patients to recover within weeks,” Anto-Ocrah says, adding that about 90 per cent have largely recovered within three months.
But in the study, women did have higher rates of depression and anxiety diagnoses before the concussion, compared to men. And those are risk factors for prolonged concussion symptoms, Anto-Ocrah adds.
However, the researchers accounted for depression and anxiety, and those diagnoses did not seem to explain women’s more persistent symptoms.
Some women, Anto-Ocrah says, encounter scepticism when they tell their doctor they are still having concussion symptoms many months after the injury.
“This is additional proof that it’s not all in your head,” she adds.
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