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Factors Associated with Symptom Reporting in U.S. Service Academy Cadets and NCAA Student Athletes without Concussion: Findings from the CARE Consortium

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Abstract

Background

Symptom resolution is a key marker in determining fitness for return to activity following concussion, but in some cases, distinguishing persistent symptoms due to concussion versus symptoms related to other factors can be challenging.

Objective

To determine base rates of postconcussional syndrome (PCS) diagnostic categorization in healthy cadets and student athletes with no recent concussion.

Methods

13,009 cadets and 21,006 student athletes completed baseline preseason testing. After inclusion/exclusion criteria were applied, the final sample included 12,039 cadets [9123 men (75.8%); 2916 women (24.2%)] and 18,548 student athletes [10,192 men (54.9%); 8356 women (45.1%)]. Participants completed the Sport Concussion Assessment Tool–3rd Edition (SCAT3) symptom evaluation as part of baseline preseason testing. The PCS diagnostic categorization was classified by the International Classification of Diseases, 10th Revision (ICD-10) symptom criteria for PCS.

Results

In the absence of recent concussion, subgroups of cadets (17.8% of men; 27.6% of women) and student athletes (11.4% of men; 20.0% of women) reported a cluster of symptoms that would meet the ICD-10 symptom criteria for PCS. Participants with insufficient sleep and/or preexisting conditions (e.g., mental health problems), freshmen cadets, and cadets at the U.S. Coast Guard Academy and at the U.S. Air Force Academy (freshmen were tested during basic cadet training) were more likely to report a cluster of symptoms that would meet the ICD-10 symptom criteria for PCS.

Conclusion

The ICD-10 symptom criteria for PCS can be mimicked by preexisting conditions, insufficient sleep, and/or stress. Findings support person-specific assessment and management of symptoms following concussion.

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Acknowledgements

Contributing care consortium investigators include: April Marie (Reed) Hoy, MS, ATC (Azusa Pacific University); Joseph B. Hazzard Jr, EdD, ATC (Bloomsburg University); Louise A. Kelly, PhD (California Lutheran University); Justus D. Ortega, PhD (Humboldt State University); Nicholas Port, PhD (Indiana University); Margot Putukian MD (Princeton University); T. Dianne Langford, PhD (Temple University); Christopher C. Giza, MD and Joshua T. Goldman, MD, MBA (University of California, Los Angeles); Holly J. Benjamin MD (University of Chicago); Julianne D. Schmidt, PhD, ATC (University of Georgia); James T. Eckner, MD, MS (University of Michigan); Jason P. Mihalik, PhD, CAT(C), ATC (University of North Carolina at Chapel Hill); Jessica Dysart Miles, PhD, ATC (University of North Georgia); Scott Anderson, ATC (University of Oklahoma); Christina L. Master, MD (University of Pennsylvania); Anthony P. Kontos, PhD (University of Pittsburgh Medical Center); Sara P.O. Chrisman, MD, MPH (University of Washington); Alison Brooks, MD, MPH (University of Wisconsin-Madison); Stefan Duma, PhD and Steve Rowson, PhD (Virginia Tech); Christopher M. Miles, MD (Wake Forest University); Laura Lintner DO (Winston-Salem University).

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Correspondence to Jaclyn B. Caccese.

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Funding

This publication was made possible, in part, with support from the Grand Alliance CARE Consortium, funded by the NCAA and the DoD. The USAMRAA, Fort Detrick, MD, USA, is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Psychological Health and Traumatic Brain Injury Program under Award No. W81XWH-14-2-0151. Opinions, interpretations, conclusions and recommendations are those of the authors and are not necessarily endorsed by the DoD (DHP funds).

Conflict of interest

Grant Iverson, Ph.D. serves as a scientific advisor for BioDirection, Inc., Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs (including athletes). He has received research funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He has received research funding as a principal investigator from the National Football League, and salary support as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. He acknowledges unrestricted philanthropic support from ImPACT Applications, Inc., the Heinz Family Foundation, the Mooney-Reed Charitable Foundation, and the Spaulding Research Institute. None of the other authors have any conflicts of interest to declare.

Ethics approval

The local Institutional Review Board at each of the performance sites and the US Army Medical Research and Materiel Command Human Research Protection Office (HRPO) reviewed and approved all study procedures. This study was performed in accordance with the standards of ethics outlined in the Declaration of Helsinki.

Consent to participate

Participants provided written informed consent prior to participation.

Consent for publication

Not applicable.

Availability of data

The CARE Consortium datasets generated and analyzed during the current study are available in the FITBIR repository (https://fitbir.nih.gov/).

Code availability

Not applicable.

Author contributions

JBC was involved in the conception and design of the study, the analysis and interpretation of data, drafting the article, and final approval of the version to be submitted. GLI and TAB were involved in the conception and design of the study, the interpretation of data, revising the article for important intellectual content, and final approval of the version to be submitted. KJH was involved in the conception and design of the study, the analysis of data, revising the article for important intellectual content, and final approval of the version to be submitted. All of the remaining authors were involved in the conception and design of the study, revising the article for important intellectual content, and final approval of the version to be submitted.

Additional information

This article is part of a Collection on The NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium.

The members of CARE Consortium Investigators are listed in the Acknowledgements section.

Supplementary Information

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Caccese, J.B., Iverson, G.L., Hunzinger, K.J. et al. Factors Associated with Symptom Reporting in U.S. Service Academy Cadets and NCAA Student Athletes without Concussion: Findings from the CARE Consortium. Sports Med 51, 1087–1105 (2021). https://doi.org/10.1007/s40279-020-01415-4

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