Factors Associated With Return to Activity After Concussion Among Female Service Academy Members: Findings From the NCAA-DoD CARE Consortium

Introduction: Service academy members are at high risk for concussions as a result of participation in both sports and military-specific training activities. Approximately 17% of active duty service members are female, and they face unique challenges in achieving timely recovery from concussions. Understanding the unique characteristics affecting return to unrestricted activity (RTA) among female service academy members is imperative for the ever-growing proportion of females across the U.S. military. The goal of this analysis was to determine how specific injury and individual characteristics of concussion affect 2 RTA protocol events in female service academy members: time to protocol initiation and time to protocol completion.

Materials and methods: All data were collected as part of the National Collegiate Athletic Association (NCAA) and the DoD Concussion Assessment, Research and Education Consortium. We examined data from female U.S. military service academy members at the 4 U.S. Service Academy sites who sustained a concussion between Fall 2014 and Spring 2020 (N = 752). Return to unrestricted activity protocol initiation time was defined as the time from injury to when cadets were cleared to begin gradual RTA, while RTA protocol completion time was defined as the time from injury to when cadets were cleared to RTA. Multivariable Cox regression analyses were used to determine the effect of 4 characteristics on RTA event times: (1) service academy members' NCAA status (e.g., student athlete), (2) prior history of concussion, (3) reporting time of concussion, and (4) sport-related concussion (SRC) or non-SRC. Because of missing data, 520 cadets were included in the model of RTA protocol initiation and 556 were included in the model of RTA protocol completion. Chi-squared analyses assessed interactions between reporting time, NCAA status, and SRC or non-SRC.

Results: Service academy members who were NCAA athletes (hazard ratio [95% CI](HR [95% CI]): 1.58 [1.32, 1.90]), immediately reported their injury (HR [95% CI]: 1.40 [1.18, 1.67]), or had an SRC (HR [95% CI]: 1.29 [1.08, 1.54]) were significantly more likely to have initiated or completed the RTA protocol on any given day post-concussion compared to those who were not NCAA athletes, delayed reporting their injury, or had a non-SRC, respectively. We observed that among those with SRCs, a greater proportion of NCAA service academy members immediately reported their injury (53.9%) compared to non-NCAA (37.3%, P < .001); there was no difference in the proportion of NCAA and non-NCAA service academy members with non-SRCs who immediately reported their injury (P = .18).

Conclusions: A greater proportion of female service academy members who sustained SRCs and were NCAA athletes reported their injuries immediately, which was associated with a greater likelihood of RTA protocol initiation and completion on any given day after injury. This may be attributable to easy and timely access to medical personnel (e.g., athletic trainers) or the presence of individuals trained in identifying concussion (e.g., coaches). Future initiatives among female service academy members should include improved access to medical care across a variety of injury settings and education on the importance of early reporting after concussion.