By Holly Rust-March, Lead Physio Team GB Bobsleigh & Skeleton

Female athletes consistently report higher concussion rates, worse symptoms, and longer recovery times than male counterparts in the same sports. Understanding why requires looking beyond reporting behaviour and into biomechanics, brain structure, hormones and cognitive function across the menstrual cycle. This article brings together the current evidence base and outlines what it means for clinicians working with female athletes.

Women report more concussions, experience worse symptoms, and take longer to recover than men in comparable sports. But is this simply over reporting or is something more fundamental going on?

The evidence increasingly says: both. And the distinction matters clinically.

Across football, rugby, basketball, lacrosse, and beyond, female athletes consistently show higher concussion rates than male counterparts playing the same sport. A growing body of research, spanning systematic reviews, meta-analyses, prospective cohort studies, and now neuroimaging and preclinical data, has set out to explain why. The answer is not a single mechanism. It is a convergence of biomechanical, structural, hormonal, cognitive, and social factors that interact in ways we are only beginning to unpick.

The Biomechanical Case: It Starts With the Neck

Perhaps the most consistently supported explanation in the literature concerns neck strength and head-neck dynamics.

Female athletes typically have less neck muscle mass and smaller neck girth relative to head size than males. This matters because the neck acts as a dynamic shock absorber: a stronger, better-conditioned neck can attenuate and redirect the forces generated at impact, reducing the accelerations that ultimately cause neural strain. Research suggests that every additional pound of neck strength is associated with roughly a 5% reduction in concussion odds in high school athletes (Fahr et al., 2024; Lin et al., 2018; Sundaram et al., 2022). It is a modest but meaningful effect, and critically, a modifiable one.

The nature of the impact itself also differs by sex. Female athletes are more likely to sustain concussions from ball, equipment, or surface contact, whereas male athletes are more commonly injured by direct player-to-player contact (Ling et al., 2020; Sundaram et al., 2022). These different impact vectors, often less anticipated and arriving from unexpected directions, reduce the opportunity for anticipatory neck bracing, amplifying the rotational accelerations that reach the brain.

Taken together, the biomechanical picture suggests that female athletes face a lower threshold for brain injury from equivalent impact magnitudes (McGroarty et al., 2020; Fahr et al., 2024). This is not a matter of fragility. It is physics applied to anatomy.

The Structural Picture: What Happens Inside the Brain

Biomechanics explains how forces reach the brain. A growing body of preclinical and neuroimaging research is beginning to explain why those same forces cause more damage once they do.

A 2024 study using a swine model, one of the most biomechanically comparable to humans, found that female brains contain a higher proportion of small-diameter axons in white matter compared to males. This is clinically significant. Smaller axons have less structural reserve and are more susceptible to the shear forces that characterise rapid acceleration-deceleration injury. Following a concussive impact, the female brains in this study showed more widespread axonal swelling and greater loss of sodium channels, proteins essential for neuronal signalling, even when the applied force was identical across sexes. Twenty-four hours after injury, the burden of axonal pathology was measurably greater in females.

This is a biological difference in tissue-level vulnerability, not a behavioural or reporting difference. And it has direct clinical implications: the disruption of sodium channel function impairs communication between brain regions, which may help explain why women consistently report more severe acute symptoms and longer recovery trajectories across observational studies.

Neuroimaging reviews add a further layer to this picture, identifying sex-based differences in white matter organisation, connectivity patterns, and regional vulnerability to shear strain (Macleod et al., 2025; Koerte et al., 2020). Together, these structural differences may influence how mechanical forces propagate through neural tissue during impact, meaning the same event that causes a mild concussion in one person may produce greater pathological change in another.

The Hormonal Question: Plausible, and Getting More Specific

Beyond structure, sex hormones, particularly oestradiol and progesterone, have attracted significant research attention as potential modulators of concussion risk and recovery.

Proposed mechanisms that may delay recovery include hormonal influences on cerebral blood flow, neuroinflammatory responses, and brain excitability. Some studies suggest that concussion may disrupt the hypothalamic-pituitary-ovarian (HPO) axis, with reports of menstrual irregularities following head injury and associations between cycle phase and symptom severity (McGroarty et al., 2020; Lin et al., 2018; Biegon, 2021). Elevated concussion rates have been observed in the luteal phase in some prospective cohort studies, adding temporal specificity to what had previously been treated as a static hormonal explanation.

For now, the hormonal contribution remains a credible and increasingly specific hypothesis, but one that still requires prospective studies with direct hormonal measurement to establish causation (Koerte et al., 2020; Macleod et al., 2025; Musko & Demetriades, 2023).

The Cognitive Dimension: A Piece of the Puzzle That Has Been Missing

One of the most overlooked contributors to injury risk in female athletes is cognition. Most research has focused on biomechanical mechanisms; far less has considered whether fluctuations in cognitive function across the menstrual cycle might independently modulate injury risk.

A UCL study by Ronca et al. (2024), published in Neuropsychologia, addressed this directly. Researchers tested 248 participants, including males, females on hormonal contraception, and naturally cycling females, on a sport-oriented cognitive battery measuring reaction times, sustained attention, inhibition, 3D spatial cognition, and crucially, spatial timing anticipation: the ability to predict when two objects moving at different speeds will collide, a process central to heading, tackling, and other time-critical sporting situations.

The within-subject findings in naturally cycling females were striking in two respects.

First, objective cognitive performance was best during menstruation, with faster reaction times, fewer errors, and less intra-individual variability, even though subjective mood and symptom burden were at their worst during the same phase. A significant proportion of women believed their symptoms were impairing their performance during menstruation. The data showed the opposite. This incongruence between perception and performance is clinically important: it suggests that the symptoms female athletes experience during menstruation do not reliably indicate that their cognitive function is impaired, and that assumptions to the contrary may be unfounded.

Second, and more concerning from an injury-risk perspective, performance on spatial timing anticipation was consistently and significantly worse during the luteal phase, regardless of test-retest learning effects. Reaction times were slower, timing errors were greater, and intra-individual variability was higher. The luteal phase is characterised by high progesterone, which has inhibitory effects on cortical excitability, potentially slowing the millisecond-accurate motor processes that underpin collision avoidance in fast-paced sport. This aligns with reports of elevated concussion and non-contact injury incidence during the luteal phase in other prospective studies.

Broader evidence on concentration across the cycle reinforces this picture. Peak cognitive performance, including better working memory, faster attention switching, and improved processing speed, tends to occur in the late follicular phase, when oestradiol is highest ahead of ovulation. The luteal and premenstrual phases are consistently associated with subjective concentration difficulties; some objective testing also demonstrates slower processing in these windows, and a 2025 longitudinal study found that sex differences in processing speed between men and women were most pronounced during menstruation specifically.

The critical clinical takeaway from this body of work is that neither cognitive performance nor injury risk tracks neatly with subjective symptom experience. Women may underperform cognitively in phases where they feel relatively well, and perform better in phases where they feel worse. This has direct implications for how clinicians, coaches, and sports scientists support female athletes across the training and competition cycle.

Reporting, Context, and the Social Layer

Any honest reading of this evidence must also grapple with reporting behaviour. Female athletes are generally more likely to disclose concussion symptoms than males (McGroarty et al., 2020; Merritt et al., 2019; Dick, 2009). This is well documented. More open reporting cultures, different social expectations around injury disclosure, and greater general health-seeking behaviour all contribute.

But, importantly, greater reporting does not fully account for the observed differences. Studies that have controlled for reporting behaviour still find higher symptom burden and longer recovery times in women (Covassin et al., 2017; Hannah et al., 2021). Women’s sports also typically involve less physical contact and lower-magnitude impacts than men’s equivalents, yet concussion rates remain elevated (Fahr et al., 2024; Dick, 2009). Higher disclosure partly explains the picture, but it does not complete it.

What the Research Does and Doesn’t Tell Us

The evidence is now strongest across multiple domains: neck strength and biomechanics as a modifiable risk factor; axonal microstructure and sodium channel vulnerability as a biological susceptibility; cognitive fluctuations across the menstrual cycle as a potential injury determinant that operates independently of symptom perception; and greater symptom burden in female athletes that persists even after controlling for reporting differences.

The hormonal literature, while increasingly specific, remains underpowered and awaits studies that directly measure hormone levels alongside injury and recovery outcomes. Many foundational studies rely on college-aged, predominantly white athletic populations, limiting generalisation (Brook et al., 2016; Macleod et al., 2025). The cognitive evidence, including Ronca et al. (2024), is proof-of-principle and needs replication in elite athletic populations with confirmed cycle tracking.

What the research tells us unambiguously is that the current evidence base was largely built on male athletes. Female-specific data across all these domains, structural, hormonal, and cognitive, remains sparse relative to the scale of female participation in sport.

What This Means in Practice

For clinicians working with female athletes, this evidence points to several practical priorities:

Area Clinical Consideration
Neck strength screening Establish sex-specific baselines using validated dynamometry; incorporate neck conditioning as a routine part of injury mitigation.
Impact mechanism awareness Recognise that ball and equipment contact is a common mechanism in female athletes; anticipatory bracing may not always be possible
Symptom-performance mismatch Do not assume that high symptom burden means impaired cognitive function, or that low symptom burden means the athlete is safe; subjective and objective measures can diverge significantly across the cycle
Cycle-phase awareness Consider that the luteal phase may represent an elevated window for both cognitive and injury risk; the late follicular phase may be associated with better cognitive reserve
Hormonal history Consider menstrual irregularity as a potential concussion sequela; enquire as part of the clinical history
Recovery expectations Avoid applying male-derived recovery timelines uncritically to female athletes; axonal pathology evidence suggests the biological basis for longer recovery is real
Research advocacy Push for female-specific data, including hormonal monitoring and cognitive assessment, in institutional and governing body research agendas

The Bigger Picture

The persistent assumption that concussion presents, progresses, and resolves in the same way regardless of sex is no longer defensible. It was never well evidenced. It simply reflected who the research was built around.

Female athletes are not men with different hormone levels. They present with different injury mechanics, different tissue-level vulnerability, cyclically fluctuating cognitive profiles that do not track with symptom perception, and, the evidence suggests, a genuinely different risk profile at every level from axon to sideline decision-making. Understanding all of that is not a niche concern for women’s sport specialists. It is a basic requirement of good concussion care.

The field is moving in the right direction. But the pace needs to match the scale of female participation in sport at every level, from grassroots to elite.

References

Biegon, A. (2021). Considering biological sex in traumatic brain injury. Frontiers in Neurology, 12. https://doi.org/10.3389/fneur.2021.576366

Blyth, R., Alcock, M., & Tumilty, S. (2021). Why are female soccer players experiencing a concussion more often than their male counterparts? A scoping review. Physical Therapy in Sport, 52, 54–68. https://doi.org/10.1016/j.ptsp.2021.08.001

Brook, E., Luo, X., Curry, E., & Matzkin, E. (2016). A heads up on concussions: are there sex-related differences? The Physician and Sportsmedicine, 44, 20–28. https://doi.org/10.1080/00913847.2016.1142834

Cheng, J., Ammerman, B., Santiago, K., Jivanelli, B., Lin, E., Casey, E., & Ling, D. (2019). Sex-based differences in the incidence of sports-related concussion: Systematic review and meta-analysis. Sports Health: A Multidisciplinary Approach, 11, 486–491. https://doi.org/10.1177/1941738119877186

Covassin, T., Savage, J., Bretzin, A., & Fox, M. (2017). Sex differences in sport-related concussion long-term outcomes. International Journal of Psychophysiology, 132, 9–13. https://doi.org/10.1016/j.ijpsycho.2017.09.010

Dick, R. (2009). Is there a gender difference in concussion incidence and outcomes? British Journal of Sports Medicine, 43, i46–i50. https://doi.org/10.1136/bjsm.2009.058172

Fahr, J., Kraff, O., Deuschl, C., & Dodel, R. (2024). Concussion in female athletes of contact sports: A scoping review. Orthopaedic Journal of Sports Medicine, 12. https://doi.org/10.1177/23259671241276447

Hannah, T., Li, A., Spiera, Z., Kuohn, L., Dai, J., McAuley, F., Ali, M., Durbin, J., Dreher, N., Marayati, N., Gometz, A., Lovell, M., & Choudhri, T. (2021). Sex-related differences in the incidence, severity, and recovery of concussion in adolescent student-athletes between 2009 and 2019. The American Journal of Sports Medicine, 49, 1929–1937. https://doi.org/10.1177/03635465211008596

Koerte, I., Schultz, V., Sydnor, V., Howell, D., Guenette, J., Dennis, E., Kochsiek, J., Kaufmann, D., Sollmann, N., Mondello, S., Shenton, M., & Lin, A. (2020). Sex-related differences in the effects of sports-related concussion: A review. Journal of Neuroimaging, 30, 387–409. https://doi.org/10.1111/jon.12726

Lin, C., Casey, E., Herman, D., Katz, N., & Tenforde, A. (2018). Sex differences in common sports injuries. PM&R, 10. https://doi.org/10.1016/j.pmrj.2018.03.008

Ling, D., Cheng, J., Santiago, K., Ammerman, B., Jivanelli, B., Hannafin, J., & Casey, E. (2020). Women are at higher risk for concussions due to ball or equipment contact in soccer and lacrosse. Clinical Orthopaedics & Related Research. https://doi.org/10.1097/corr.0000000000000995

Macleod, H., Smith, C., & Laycock, R. (2025). Using neuroimaging to identify sex differences in adults with sports-related concussion: A systematic review. Brain Imaging and Behavior, 19, 594–608. https://doi.org/10.1007/s11682-025-00970-6

Malcolm, D. (2023). Some problems of research exploring sex differences in sport-related concussions: A narrative review. Research in Sports Medicine, 32, 810–819. https://doi.org/10.1080/15438627.2023.2271604

McGroarty, N., Brown, S., & Mulcahey, M. (2020). Sport-related concussion in female athletes: A systematic review. Orthopaedic Journal of Sports Medicine, 8. https://doi.org/10.1177/2325967120932306

Merritt, V., Padgett, C., & Jak, A. (2019). A systematic review of sex differences in concussion outcome: What do we know? The Clinical Neuropsychologist, 33, 1016–1043. https://doi.org/10.1080/13854046.2018.1508616

Musko, P., & Demetriades, A. (2023). Are sex differences in collegiate and high school sports-related concussion reflected in the guidelines? A scoping review. Brain Sciences, 13. https://doi.org/10.3390/brainsci13091310

Ronca, F., Blodgett, J.M., Bruinvels, G., Lowery, M., Raviraj, M., Sandhar, G., Symeonides, N., Jones, C., Loosemore, M., & Burgess, P.W. (2024). Attentional, anticipatory and spatial cognition fluctuate throughout the menstrual cycle: Potential implications for female sport. Neuropsychologia. https://doi.org/10.1016/j.neuropsychologia.2024.108909

Sundaram, V., Ramachandran, A., Singh, U., & Pearce, A. (2022). Sex-based differences in concussion incidence and its underlying injury mechanism in team bat/stick sports: A systematic review and meta-analysis. International Journal of Sports Science & Coaching, 18, 1735–1753. https://doi.org/10.1177/17479541221131650

Westhead, R., Sigala, N., Westhead, C., & Westhead, R. (2025). Sport concussion in female athletes: A systematic review. https://doi.org/10.1101/2025.09.29.25336877

Last week was Brain Health Awareness Week, a timely reminder of how rapidly our understanding of the brain continues to evolve. It also provided the perfect opportunity to revisit some of the most important research developments shaping clinical practice. Looking back at 2025 several key themes stood out not only for their scientific progress, but for their real potential to bridge the gap between research and everyday patient care.

Here are the five topics we think are set to influence brain health and rehabilitation practice in 2026 and beyond!

1. Bimanual Upper Limb Rehabilitation for Stroke

Stroke upper limb recovery research is finally moving beyond basic reach-and-grasp movements to address the complexity of real-world activities. Historically, much of the research has been overly simplified, with improvements demonstrated in functional outcome measures, particularly in higher-functioning stroke survivors, but with limited translation into meaningful real-world activity.

New approaches are now beginning to address this gap. Recent data shows that bimanual performance (using both hands together) improves most significantly within the first six months post-stroke. Importantly, admission grasp function and stroke severity have been identified as the strongest predictors of how well a patient will manage two-handed tasks at one year.

The introduction of clinical decision trees offers a more structured and realistic way for therapists to set goals, helping to better align rehabilitation outcomes with the demands of daily life.

Key paper:
Van Gils, A., Zou, Y., Meyer, S., Michielsen, M., Lafosse, C., Beyens, H., Schillebeeckx, F., Kos, D., & Verheyden, G. (2025). Tracking bimanual recovery after stroke: Grasp function and stroke severity predict 1-year performance. Clinical Rehabilitation.

2. Non-Invasive Brain Stimulation (NIBS): Precision and Synergy

After decades of development within research settings, non-invasive brain stimulation (NIBS) is now moving closer to mainstream clinical application, driven by advances in precision targeting and combined treatment approaches.

In Alzheimer’s care, meta-analyses demonstrate that repetitive Transcranial Magnetic Stimulation (rTMS) targeting the dorsolateral prefrontal cortex (DLPFC), alongside transcranial Direct Current Stimulation (tDCS) targeting temporal regions, can significantly improve memory symptoms.

In depression treatment, 2025 saw a notable breakthrough in combination therapy. Using tDCS to “precondition” neuronal activity prior to rTMS has produced response rates of up to 85% within two weeks in treatment-resistant cases.

As understanding of functional brain networks continues to improve, increasingly precise and synergistic applications of these techniques are expected to drive further clinical impact.

Key paper:
Rektorová, I., Pupíková, M., Fleury, L., Brabenec, L., & Hummel, F. C. (2025). Non-invasive brain stimulation: current and future applications in neurology. Nature Reviews Neurology, 21(12), 669–686.

3. A Shift in Managing Migraine

The International Headache Society (IHS) has called for a fundamental shift in migraine management; from treating individual attacks to preventing disease progression.

With the emergence of highly effective anti-CGRP therapies, there is now a strong emphasis on early intervention. Treating migraine proactively, before it becomes chronic or high-frequency, offers the potential to reduce both individual burden and wider societal impact, while preserving long-term brain health.

This shift aligns closely with ongoing efforts to improve clinical education and standards across both pharmacological and non-pharmacological management of migraine, supporting a more preventative and holistic approach to care.

Key paper:
Pozo-Rosich, P., et al. (2025). Early treatment in migraine – A call to shift prevention from attacks to disease progression: A position statement from the International Headache Society. Cephalalgia.

4. Exercise for Cognition: The Power of the “Weekend Warrior” and Beyond

With up to 50% of dementia cases now considered preventable, exercise has become a central pillar of brain health and longevity.

New longitudinal research has validated the “weekend warrior” model, showing that individuals who complete their physical activity in one or two sessions per week achieve a 25% reduction in mild dementia risk, outperforming the 11% reduction seen in those who exercise more frequently. This suggests that total volume of activity may be more important than frequency, particularly for individuals with time constraints.

Further strengthening this evidence base, a large umbrella review and meta-meta-analysis published in 2025 confirms that exercise delivers measurable improvements in cognition, memory, and executive function, reinforcing its role as a key intervention in both prevention and treatment.

Key papers:
O’Donovan, G., et al. (2024). Associations of the ‘weekend warrior’ physical activity pattern with mild dementia. British Journal of Sports Medicine.
(2025). Effectiveness of exercise for improving cognition, memory and executive function: a systematic umbrella review and meta-meta-analysis. British Journal of Sports Medicine.

5. Proactive Brain Health Screening for Serious Falls

Proactive brain health surveillance is gaining traction as a practical way to identify risk early and intervene before significant decline occurs.

Simple, measurable markers such as gait speed, grip strength, and mental health indicators are proving to be powerful predictors of outcomes. Research shows that combining gait speed and grip strength can effectively identify individuals at higher risk of serious falls, while monitoring depression and anxiety is increasingly recognised as essential to comprehensive assessment.

A useful way to conceptualise this approach is to think of brain health like a high-performance vehicle. Rather than waiting for a major failure, proactive screening acts as a dashboard of warning lights, allowing early adjustments and maintenance to support long-term performance and resilience.

Digital platforms such as ScreenIT support this multimodal approach, enabling longitudinal health profiling and earlier identification of risk patterns and one of the key reasons why we have developed it.

Key paper:
Raru, T. B., et al. (2025). Contribution of gait speed, grip strength, and depression on the risk of serious falls among older adults. Archives of Gerontology and Geriatrics Plus.

Several other important research areas narrowly missed this list. As the field continues to evolve, ongoing discussion and collaboration remain essential to translating these developments into meaningful improvements in clinical practice.

By Associate Professor James McLoughlin

Chief Academic Officer, Your Brain Health

At Your Brain Health, staying ahead of the evidence is core to our mission. It is essential that we incorporate this knowledge into our educational courses and resources, and use it to evolve and improve ScreenIT.

There was a plethora of concussion research in 2025. Here are our nominations for the five biggest themes in concussion research in 2025 based on our own biases and interests!

1. Mental Health & Fear Avoidance

Mental health is finally (and rightly) recognised as a central component of concussion recovery and persisting symptoms. Two major studies this year emphasise that catastrophising thoughts, fear-avoidance behaviours, and perceptions about symptoms strongly influence long-term outcomes—sometimes more than the injury itself.

Key insights:

  • Mental health concerns are common but often overlooked in concussion care.
  • People may avoid seeking help due to fear or misunderstanding of their symptoms.
  • Education and early support remain essential.
  • Including mental health in routine brain health surveillance helps normalise monitoring and encourages early intervention.

Key papers:

Hecker, L., King, S., Wijenberg, M., Geusgens, C., Stapert, S., Verbunt, J., & Van Heugten, C. (2025). Catastrophizing thoughts and fear-avoidance behavior are related to persistent post-concussion symptoms after mild traumatic brain injury. Neurotrauma Reports, 6(1), 148–157.

Otamendi, T., Sanghera, S. K., Mortenson, W. B., Li, L. C., & Silverberg, N. D. (2025). Patient perceptions of persistent symptoms after mild traumatic brain injury and their influence on mental health treatment-seeking: A grounded theory study. Disability and Rehabilitation, 1–9.

2. Functional Neurological Disorder & Functional Overlay After Concussion

FND has historically fallen between neurology and psychiatry, but 2025 marks a shift. There is a stronger recognition of functional overlay following concussion: best-practice now promotes positive “rule-in” diagnostics and targeted rehabilitation, providing new clarity for clinicians.

Key insights:

  • Functional overlay after concussion is common, including functional cognitive symptoms.
  • FND and Persisting Symptoms Post Concussion share both risk factors and clinical presentations, which clinicians should be aware of. I recently met Dr Ioannis Mavroudis in Leeds UK, who has a wealth of knowledge and experience in both concussions, TBI and FND. Ioannis was lead author in an excellent discussion that I recommend everyone read!
  • Understanding these mechanisms can prevent misdiagnosis and ineffective management.
  • Oculomotor data—such as saccades, anti-saccades and smooth pursuit—already collected across the YBH network may prove particularly informative.
  • Longitudinal brain-health surveillance can help distinguish functional recovery patterns.

Key insights:

Mavroudis, I., Petridis, F., Karantali, E., Ciobica, A., Papagiannopoulos, S., & Kazis, D. (2025). Post-concussion syndrome and Functional Neurological Disorder: Diagnostic interfaces, risk mechanisms, and the Functional Overlay Model. Brain Sciences, 15(7), 755. 

Sangare, A., de Liège, A., Gaymard, B., Rivaud-Péchoux, S., Bonnet, C., Růžička, E., May, J., Serranová, T., Mesrati, F., Roze, E., Vidailhet, M., Louapre, C., Naccache, L., & Garcin, B. (2025). Ocular motor abnormalities in functional neurological disorder: A video-oculography study. Movement Disorders Clinical Practice. https://doi.org/10.1002/mdc3.70394

3. Football Headers: Technique, Demands & The Future of Prevention

One of the defining questions in sport science today is: How can we reduce head-impact exposure in football without changing the game itself?

In 2025, several landmark papers have begun to answer this

Key insights:

  • Townsend et al. produced the first high-resolution dataset of heading demands for elite men and women, establishing an important foundation for accurate load monitoring. Impressive work!
  • Peek and colleagues at FIFA argue that prevention will be most effective when focused not only on neck strength, but also whole-body technique and tactical decision-making. This is a shift that places coaches at the centre of injury-prevention strategy. A smart approach, so keep coaches involved as we progress this knowledge together!
  • Multimodal cervical training in women shows promising early results. A you may have already gathered, we (at YBH) think the neck is a crucial part of concussion rehabilitation in many cases!
  • At YBH, these findings reinforce our view that performance data, biomechanics, and applied coaching must sit alongside medical care in concussion-prevention frameworks.

Key papers:

Peek, K., Georgieva, J., Wilson, B., Massey, A., & Serner, A. (2025). Re-thinking head injury prevention in football: The role of tactics and technique. Journal of Science and Medicine in Sport. https://doi.org/10.1016/j.jsams.2025.07.009

Thompson, B. J., & Lattimer, L. J. (2025). A pilot study on the effects of multimodal cervical exercise training on clinical concussion risk factors in female athletes. Physical Therapy in Sport, 72, 39–45.

Townsend, D. C., Jones, C., Patel, S., Green, M., Riley, P., Brownlow, M., Gillett, M., & Belli, A. (2025). Heading to guidance: Understanding in-training heading demands for elite men’s and women’s football. British Journal of Sports Medicine. bjsports-2024-109525.

4. Sport-Specific Considerations: From Circus to Cricket

Best-practice guidelines are essential—but athletes rarely fit into one generic model. This year, we’ve seen excellent work applying concussion evidence to very specific performance environments.

Highlights:

  • Circus artists face complex inverted positions, spinning, aerial rotations and extreme physical demands. I had the pleasure of meeting David Munro this year, an experienced concussion physiotherapist from Melbourne. David and colleagues have produced a much-needed extension of the CISG guidelines tailored to circus performance—something I deeply appreciate after meeting with the Cirque du Soleil medical team ealier this year.
  • Cricket, currently in the spotlight with the Ashes, requires nuanced return-to-play (RTP) considerations: batting reaction timing, fast-bowling workloads, fielding exposure, travel fatigue, and more. Golding et al. provide an excellent framework for cricket-specific concussion care.

Key papers:

Munro, D., Greenspan, S., Nicholas, J., & Stuckey, M. I. (2025). Circus-specific extension of the 6th international consensus statement on concussion in sport. BMJ Open Sport & Exercise Medicine, 11(2), e002524.

Golding, L., Orchard, J. W., & Swan, M. (2025). Concussion in cricket: Risk, mechanism, identification and return to play. In Cricket Sports Medicine (pp. 333–339). Springer Nature Singapore.

5. Concussion in Older Adults: A Critical Knowledge Gap

While most assume concussion is primarily a youth-sport issue, the truth is stark: most concussions occur due to falls in older adults. Yet research in this population is decades behind.

Key insights:

  • Concussion symptoms in older adults often overlap with dementia, depression, delirium or medication effects.
  • Little is known about their recovery trajectories.
  • Falls risk itself is rising with ageing populations.
  • Without structured monitoring, concussion may remain undetected—or misattributed—for months.
  • Many of our cognitive, balance and vestibular outcome measures used in concussion care, overlap with measures that relate to falls risk. ScreenIT will hold some valuable data soon that will give interesting insights!

Key papers:

Joghataie, G., Hundal, S., Mushtaque, A., Tator, C. H., & Tartaglia, M. C. (2025). Critical gap in practice—Lack of attention to falls and possible fall-related post-concussion symptoms in older adults and individuals with neurodegenerative disease. GeroScience, 47(1), 1269–1276.

Okrah, A. K., Tharrington, S., Shin, I., Wagoner, A., Woodsmall, K. S., & Jehu, D. A. (2025). Risk factors for fall-related mild traumatic brain injuries among older adults: A systematic review highlighting research gaps. International Journal of Environmental Research and Public Health, 22(2). https://doi.org/10.3390/ijerph22020255

We think these research papers in 2025 were worth sharing. But plenty of great research was not included. We are happy for anyone in our growing Your Brain Health community to share other research in 2025 that we missed.

Also, keep an eye out for our Top 5 Topics Brain Health Research next!

By Associate Professor James McLoughlin 

Over the past decade, vestibular education has strongly emphasized the role of the Head Impulse Test (HIT) and its video-based cousin (vHIT), particularly in acute settings. This focus stems from their pivotal role in the Head Impulse, Nystagmus, Test of Skew (HINTS) protocol, which—when applied accurately and in the right context—can help differentiate central causes (e.g., stroke) from peripheral vestibulopathies (e.g., vestibular neuritis). Rightly so: it’s a powerful, bedside decision tool in emergency neurology. 

However, I have noticed over the past 5 years, this stroke-centric application of HIT/vHIT taught in many vestibular courses has disproportionately shaped the broader clinical conversation—especially in rehabilitation and sports medicine. Too often, clinicians are left with the impression that a normal vHIT rules out significant dysfunction. In reality, this is where functional vestibular assessment should begin. 

The Limits of HIT/vHIT 

HIT and vHIT primarily assess high-frequency, high-acceleration components of the vestibulo-ocular reflex (VOR). They’re excellent at detecting large, acute deficits in semicircular canal output. But these tools do not capture: 

  • Low- and mid-frequency impairments 
  • Central integration deficits 
  • Dynamic visual acuity 
  • Symptom provocation during movement 

In cases like concussion, cerebellar ataxia, migraine-associated dizziness, or motion sensitivity, the vHIT may be entirely normal while patients still report disabling dizziness, fogginess, or blurred vision during head movement. 

Functional Gaze Stability = Everyday Brain Performance 

Patients don’t live in a vHIT lab. They live in dynamic environments—navigating busy streets, scanning playing fields, or walking through supermarkets. These real-world tasks require gaze stability across a variety of head speeds, directions, and cognitive loads. 

We must assess gaze stability across a range of speeds and tasks to: 

  • Identify direction and speed specific subtle deficits 
  • Track rehab progress 
  • Assessing cervical-vestibular coordination and compensatory strategies 
  • Tailor VOR retraining 
  • Guide return-to-play and return-to-learn decisions 

Even simple tools like Dynamic Visual Acuity (DVA) and the VOMS battery can reveal critical deficits missed by vHIT. 

Concussion and Cerebellar Cases 

In concussion, vestibular symptoms often reflect central processing issues, not peripheral loss. Patients may pass vHIT yet experience visual blurring, dizziness, or cognitive fatigue. 

Cerebellar disorders affect the coordination of eye-head movement and often require dynamic, functionally relevant testing to identify deficits. 

Recalibrating Our Focus 

vHIT is a starting point. To support recovery, clinicians could incorporate: 

  • Smooth pursuit and VOR cancellation 
  • DVA at varied speeds 
  • Head precision and proprioceptive control (e.g., HeadX Kross) 
  • Functional movement with gaze tasks 

Final Thought 

If symptoms persist, dig deeper than just HIT and vHIT. Gaze stability is not binary. Like all brain functions, it must be assessed across varied speeds, loads, and contexts to understand and treat it most effectively. 

 

By Associate Professor James McLoughlin, Chief Academic Officer at Your Brain Health

Step 1: Confirming the Concussion

Think of this as saying, “Yep, you’ve had a knock.” It’s an important first step — but it’s only the beginning.

Imagine a car that’s been in a minor crash. The first thing you do is check for visible damage. Confirming a concussion is similar. The brain — along with the neck and brainstem — has taken a hit, and there’s been a temporary change in function.

In the immediate aftermath, the top priority is determining whether emergency medical care is needed. We look for red flags that require an immediate medical response. Following this we monitor physical, cognitive, and emotional symptoms over the next few days. This process should be overseen by a responsible adult — not your mates while out at the pub.

To help guide decision making in this acute phase, the Concussion Recognition Tool 6 (CRT6) is the go-to resource. It’s simple, safe, and designed for use by coaches, trainers, parents, and anyone involved in player care. It helps recognise red flags and core symptoms and provides helpful advice for what to do next.

Yes, emerging technologies like blood biomarkers, saliva tests, and wearable sensors are exciting — but they need to add value. That means improving decisions and guiding actions. These tools must be co-designed with those on the front lines: players, physios, coaches, and carers. Plenty of apps and other portable measures of specific brain functions are now hitting the market. However, if it doesn’t support and enhance decision-making, it’s not helping.

Step 2: Profiling Brain Health

This is where concussion care gets truly clever.

Knowing someone has had a concussion is one thing. But understanding how it’s affecting them is another. Is balance off? Vision blurry? Thinking slow? Mood unstable? Sleep disrupted? A bit of everything?

Now we’re popping the hood to see what’s really going on.

Multimodal brain profiling goes beyond diagnosis. It assesses the systems most often disrupted by concussion, including:

  • Symptoms (e.g. headache, dizziness, nausea)
  • Mental health
  • Sleep quality
  • Vestibular system function
  • Cervical spine function
  • Oculomotor function
  • Balance and coordination
  • Cognitive performance
  • Autonomic nervous system regulation

To get the most accurate picture, we also integrate:

  • Individual brain health history
  • Previous baseline brain health screening data

Without evaluating all of these domains, you risk missing key information. But by using comprehensive brain health profiling, we can track recovery, guide referrals to the right professionals, and tailor rehabilitation to the individual’s needs.

Excitingly, repeatable baseline screens now allow us to track these domains over time. This opens the door to a more preventative and personalised approach to brain health — targeting modifiable risk factors long before issues become chronic. Multimodal brain health profiling, built into platforms like ScreenIT, enables clinicians to deliver this personalised approach at scale. And with nearly half of all dementia cases considered preventable, this kind of proactive strategy is a genuine game-changer.

Why It Matters

When we know which systems are affected, we can deliver targeted support — whether it’s neck physiotherapy, balance training, vision rehab, heart rate-guided aerobic exercise, or structured rest strategies.

We’re not just managing the concussion — we’re tuning the whole system. That includes identifying pre-existing conditions (e.g. migraine, anxiety, ADHD) that might influence how we approach rehabilitation and recovery.

This leads to:

  • Faster, safer return to activity
  • Reduced risk of prolonged symptoms
  • Better outcomes across the board

So, the next time you hear about a “new tool” to diagnose concussion, ask: Does it help improve care? Does it inform recovery planning?

Diagnosis is step one. But multimodal brain health profiling continues to evolve — and it’s here to stay!

We were delighted that Simon Shepard was joined by Associate Professor James McLoughlin alongside Liz Jemson-Ledger as the latest guests in the final of our 2024 concussion webinar series.

Watch back as we discussed:


* How patients with persistent concussion symptoms often present

* What interventions can have a positive impact on outcomes, including real life case studies

* The importance of early intervention in preventing persistent symptoms

We explored all of this, and much more besides, in what was an interesting and lively update on the current research in concussion care, followed by a live Q&A.

Webinar: Management of Persistent Concussion Symptoms

You’re at the top of your game, both mentally and physically, tackling life head-on. Then, bam! You suffer a concussion, and suddenly, everything feels off.

Headaches, dizziness, memory loss – the usual suspects.

But what about those silent saboteurs lurking at the bottom of the SCAT score sheet?

Anxiety, irritability, sadness – the uninvited guests crashing the post-concussion party.

 

The link between concussions and mental health struggles isn’t a mere coincidence; it’s a well-established fact. Studies reveal that over 65% of concussion survivors battle with depression and anxiety post-injury. And if you’re among the unlucky 20-30% stuck with lingering symptoms for more than two weeks, those odds skyrocket to a staggering 76%.

Now, let’s put things into perspective. The World Health Organization defines mental health as ‘a state of mental well-being, that enables individuals to cope with difficulties in life, understanding their abilities, and working towards the betterment of themselves as well as for the community.’  But what happens when a concussion disrupts this delicate balance?

In adolescents, a history of concussion in the past year increases the risk of suicidal thoughts and actions. Considering that suicide ranks as the second leading cause of death among U.S. teens, and an estimated mind-boggling 33 million children worldwide suffer concussions yearly, the gravity of mental health post-concussion becomes painfully clear.

Mental health matters. And post-concussion, it really matters.

 

So, what’s going on inside our heads after a knock to the noggin? Let’s explore four potential culprits:

First up, the physical aftermath of a concussion have been proposed to affect the neural mechanisms of mood regulation circuits. When your brain’s emotional control centre takes a hit, it’s no wonder your mental health takes a nosedive.

Secondly, concussions aren’t just about physical pain; they’re a psychological rollercoaster. Factors like social isolation, fear of re-injury, and decreased participation, compounded by concerns over selection or contracts, as well as the dread of letting teammates down, can create a downward spiral into mental health challenges. This combination can morph into a vortex of despair, leading to significant mental health consequences.

Thirdly, your family and personal mental health history might increase your susceptibility to poor mental health post-concussion. It’s like having a genetic predisposition to a double whammy of emotional turmoil.

And let’s not forget the sleep-depression connection. With persistent concussions throwing your sleep regulation out of whack, it’s no surprise that executive function, working memory and processing speed take a hit, dragging your mental health down with them.

 

Now, here’s the kicker: despite the glaring mental health implications, a whopping 50% of concussions reportedly go undiagnosed. With no definitive test in sight, concussion remains a clinical diagnosis. So, when a patient waltzes into your office with nothing but mental health symptoms, are you equipped to connect the dots?

Tools like GAD-7, PHQ-9, and the Pittsburgh Sleep Quality Index might just hold the key to unlocking the silent suffering of concussion survivors.

Because mental health matters, today and every day.

We were delighted that Millie Bishop was joined by Nicola Hunt alongside Head of Medical and Research at Neuroflex, Dr David Stevens as the latest guests in our 2024 concussion webinar series.

Watch back as we discussed:

* The development and research behind Vestibular-Ocular motor technology

* How the technology works

* How NeuroFlex can be used in practise to improve clinical care and patient outcomes.

We explored all of this, and much more besides, in what was an interesting and lively update on the current research in concussion care, followed by a live Q&A.

Neuroflex: Utilising Technology to Support Vestibular-Oculor Assessments

We were delighted that James McLoughlin was joined by Co-Chair of the Concussion in Sport Group, Professor Jon Patricios as the latest guest in our 2024 concussion webinar series.

Watch this on demand video as we discussed:

* Why there has been advancement in Vestibular Oculor Motor Assessments in concussion care

* Why the CISG decided to vote on the VOMS being included in SCAT-6

* The importance of gaining objective baseline screening data on the Vestibular-Oculor motor system.

* What the future of concussion care might look like.

We explored all of this, and much more besides, in what was an interesting and lively update on the current research in concussion care, followed by a live Q&A.

Advancements in Vestibular-Ocular Assessments in Concussion Management

We were delighted that Professor James McLoughlin was joined by Nicola Hunt as the first guest in our 2024 concussion webinar series.

Watch this on demand video as we discussed:

* How a multimodal approach to baseline screening can facilitate better care.

* How multisystemic assessment of concussion results in better practice.

* How early targeted rehabilitation is likely to lead to better outcomes.

We explored all of this, and much more besides, in what was an interesting and lively update on the current research in concussion care, followed by a live Q&A.

A Proactive Approach to Concussion Management & Rehabilitation

And don’t forget that that James McLoughlin will be joined by Co-Chair of the Concussion in Sport Group, Professor Jon Patricios as the next guest in our 2024 concussion webinar series on March 27th at 8pm (GMT) to discuss:

Advancements in Vestibular-Oculor Assessments in Concussion Management

Register here now!

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