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Initial Mild Traumatic Brain Injury Characteristics and Recovery Patterns Among Females Across the United States Military Service Academies: A Report from the NCAA-DoD CARE Consortium

  • S.I. : Concussions II
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Mild traumatic brain injury (mTBI) has been described in the United States (US) military service academy cadet population, but female-specific characteristics and recovery outcomes are poorly characterized despite sex being a confounder. Our objective was to describe female cadets’ initial characteristics, assessment performance, and return-to-activity outcomes post-mTBI. Female cadets (n = 472) from the four US military service academies who experienced a mTBI completed standardized mTBI assessments from pre-injury to acute initial injury and unrestricted return-to-duty (uRTD). Initial injury presentation characteristics (e.g., delayed symptoms, retrograde amnesia) and return-to-activity outcomes [i.e., return-to-learn, initiate return-to-duty protocol (iRTD), uRTD] were documented. Descriptive statistics summarized female cadets’ injury characteristics, return-to-activity outcomes, and post-mTBI assessment performance change categorization (worsened, unchanged, improved) relative to pre-injury baseline using established change score confidence rank criteria for each assessment score. The median (interquartile range) days to return-to-learn (n = 157) was 7.0 (3.0–14.0), to iRTD (n = 412) was 14.7 (8.6–25.8), and to uRTD (n = 431) was 26.0 (17.7–41.8). The majority experienced worse SCAT total symptom severity (77.8%) and ImPACT reaction time (97.0%) acutely < 24-h versus baseline, but unchanged BESS total errors (75.2%), SAC total score (72%), BSI-18 total score (69.6%), and ImPACT verbal memory (62.3%), visual memory (58.4%), and visual motor speed (52.5%). We observed similar return-to-activity times in the present female cadet cohort relative to the existing female-specific literature. Confidence ranks categorizing post-mTBI performance were heterogenous and indicate multimodal assessments are necessary. Our findings provide clinically relevant insights to female cadets experiencing mTBI across the US service academies for stakeholders providing healthcare.

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Data Availability

The CARE Consortium datasets generated and analyzed during the current study are available in the FITBIR repository (

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The authors would also like to thank Jody Harland, Janetta Matesan, Michael Menser (Indiana University School of Medicine); Ashley Rettmann, Nicole L’Heureux, (University of Michigan); Melissa McEachern (Medical College of Wisconsin); Michael Jarrett, Vibeke Brinck, and Bianca Byrne, (Quesgen); Melissa Baker, Christy Collins, Will Felix, Bethany Morath (Datalys Center for Sports Injury Research and Prevention); and the research and medical staff at each of the CARE participation sites, and the authors are grateful for the participation of the student-athletes without whom this research would not be possible.

The authors would also like to thank the CARE Working Group consisting of the following individuals for their help and support: Scott Anderson, ATC (no affiliation; retired); Kristy Arbogast, PhD and Tricia Roby, PhD, ATC (Children’s Hospital of Philadelphia); Jay Clugston, MD (University of Florida); Stacey Harcum, DrPH, Jalyn Jannace, PhD, MPH, and Franseca Scott (Uniformed Services University); Dianne Langford, PhD and Jane McDevitt, PhD, ATC (Temple University); Susan Perkins, PhD (Indiana University), Jessica Wallace (University of Alabama).


This study was made possible, in part, with support from the Grand Alliance Concussion Assessment, Research, and Education Consortium, funded by the National Collegiate Athletic Association and the Department of Defense. The US Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702-5014, 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 Department of Defense (Defense Health Program funds).

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Authors and Affiliations



LBL conceived this specific plan for this report, carried out the statistical analyses, and drafted the manuscript; EE, AJB, and JC participated in the statistical analysis; PFP, MAM, TWM, and SPB participated in the study design and coordination, and conceived the original overarching study. All authors have read, provided feedback, and approved the final version of the manuscript.

Corresponding author

Correspondence to Landon B. Lempke.

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Conflict of interest

All disclosures below are not directly related to the current project, but are reported for full transparency to readers. Dr. Landon Lempke has current or prior funding unrelated to the current project from the National Athletic Trainers’ Association (NATA), American College of Sports Medicine (ACSM), Eastern Athletic Trainers’ Association, VALD, internally from university affiliations, and has received various speaker honorarium and travel reimbursement for talks given. Dr. Thomas Buckley reports current or prior funding from NIH, Henry F. Jackson Foundation for the Advancement of Military Medicine, and State Space, Inc. Dr. James Eckner reports current or prior funding from NIH, NSF, and internal university funding. Dr. Eckner also reports being a co-author (stipend received) for a book chapter in “Concussion Management for Wheelchair Athletes,” on the editorial board (unpaid) for the journal Physical Medicine and Rehabilitation, and a co-inventor on US Patent #8657295, and a Data and Safety Monitoring Board member for an unrelated NIH project. Dr. Margot Putukian reports the following committee and position roles: CMO for MLS, Senior Advisor NFL HN&S Committee, FA Research Task Force, CISG Expert Group, NOCSAE SAC, and receives royalties from Netters Sports Medicine Textbook and UpToDate chapter. Dr. Michael McCrea has received research funding from the NIH, CDC, DoD, NCAA, NFL, and Abbott Laboratories. Dr. Thomas McAllister reports current or prior grant support from NIH, DoD, and NCAA, as well as textbook royalties from the “Textbook of Traumatic Brain Injury” from the American Psychiatric Association Publishing, Inc., and is an unpaid member for the concussion Scientific Advisory Committee for the Australian-Rules Football Conference. Dr. Steven Broglio has current or past research funding from the NIH, CDC, DoD, NCAA, NATA, NFL/Under Armour/GE; Simbex; and ElmindA. Dr. Broglio has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medico-legal litigation, and received speaker honorarium and travel reimbursements for talks given. Dr. Broglio is also a co-author of “Biomechanics of Injury (3rd edition)” and has a patent pending on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” (U.S. Application No. 17/164490). Lastly, Dr. Broglio is on the editorial boards (all unpaid) for Journal of Athletic Training (2015 to present), Concussion (2014 to present), Athletic Training and Sports Health Care (2008 to present), and British Journal of Sports Medicine (2008 to 2019).

Ethical Approval

The study was performed in accordance with the standards of ethics outlined in the Declaration of Helsinki. All study procedures were reviewed and approved by the University of Michigan IRB, the US Army Medical Research and Materiel Command Human Research Protection Office (HRPO), as well the local IRB at each of the performance sites.

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Participants provided written informed consent prior to participation.

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Lempke, L.B., Ermer, E., Boltz, A.J. et al. Initial Mild Traumatic Brain Injury Characteristics and Recovery Patterns Among Females Across the United States Military Service Academies: A Report from the NCAA-DoD CARE Consortium. Ann Biomed Eng (2023).

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