Concussions are categorized as mild traumatic brain injuries, and manifestations of the diagnosis are divided into physical, emotional, cognitive, and observed symptoms. The spectrum of symptoms is wide, ranging from difficulty concentrating and thinking clearly to headaches and dizziness.11 Compared with male athletes who sustain a concussion, female athletes report more of these concussive symptoms and have worse visual memory scores.12
Efforts to change sports at the player level have been resisted. Helmets have been proposed for field hockey and lacrosse but have not passed stringent concussion testing. In soccer, which has a high rate of concussion, a reform to eliminate heading the ball has been considered. Resistance to these suggestions stems from the thought that changes could alter the traditions of the games. Some individuals have indicated that helmets may give players a false sense of security and thereby cause them to play more aggressively.
Orthopedic surgeons must be aware of concussion symptoms. Multiple concussions may have a cumulative effect on functional ability and emotional well-being and may lead to chronic traumatic encephalopathy.13 Concern about the long-term effects of concussion has led to the implementation of universal “return to play” laws. These laws vary by state but have 3 steps in common: Educate coaches, players, and athletes; remove athletes from play; and obtain health care professionals’ permission to return to play.14 These guidelines set up an action plan for treating an athlete who has sustained a concussion.
Encouraging results of educating coaches have been noted. Coaches who were given Centers for Disease Control and Prevention–sponsored material on preventing, recognizing, and responding to concussions were able to effectively address concussions; 6 months later, 63% were better able to appreciate the severity of concussions.15 Continued education of athletic communities should help bring this injury to the attention of those treating female athletes.
3. Exercise safety in pregnancy
Women in sports can continue their athletic regimens during pregnancy. It is important to address challenges to the pregnant woman and to the fetus when assessing the risks of exercise.
The physiologic changes that occur during pregnancy may affect how a pregnant athlete responds to stress. Plasma volume, red blood cell volume, and cardiac function and output all increase during normal pregnancy.3,16 Abnormal heart rate during pregnancy can adversely affect the fetus. During and after exercise, fetal bradycardia can occur. Therefore, recommendations should include not exceeding pre-pregnancy activity levels.3 Careful monitoring of exercise intensity is recommended by the American College of Obstetrics and Gynecology; the guideline is to maintain less than 70% of maximal heart rate.17,18
The negative effects of exercise on the pregnant athlete are limited, but it is important to educate patients and to consider preventive strategies. One physiologic change that occurs during pregnancy is ligamentous laxity, which is caused by the hormone relaxin.16 Ligamentous laxity has the potential to put pregnant athletes at risk for soft-tissue and bony injury during impact sports. However, the positive effects of exercise during pregnancy include improved appetite, sleep, and emotional health.19 Aerobic exercise during pregnancy may reverse insulin resistance as demonstrated in animal studies; though this outcome has not been demonstrated in human studies,20 women should be reassured that moderate exercise has overall beneficial effects.
Some research suggests that exercise may expose the fetus to hyperthermia, blood sugar changes, physical injury, and premature labor.16 Typically, fetal heat is dissipated from the mother. After intense exercise, maternal body temperature rises and leads to some degree of fetal hyperthermia.16 Animal model studies have suggested that hyperthermia may result in a slightly higher rate of congenital abnormalities. Pregnant women should keep their exercise routines to less than 60 minutes, should exercise in a thermally regulated environment, and should keep themselves hydrated to avoid fetal hyperthermia.18
Reduced blood flow, accompanied by a deficit of oxygen to the uterus and the developing fetus, is another concern for pregnant athletes. During exercise, when more blood is flowing to the muscles, less is flowing to the uterus.16 Furthermore, during the third trimester, women should avoid supine exercise, as venous outflow is poor with the body in that position.21
Elite athletes who continue training during pregnancy should be carefully counseled about adjusting their training regimens. Because of increased cardiac output and blood volume, the heart rate will be lower than usual, demanding an adjustment in interpretation. Blood cell counts do not increase as much as plasma volume does—often leading to relative anemia. For elite athletes, this means iron supplementation is crucial.22 Thermal regulation may be more difficult, as training regimens may demand prolonged exercise. Physicians should recommend adequate hydration for these athletes.18