Association Between Symptom Burden at Initiation of a Graduated Return to Activity Protocol and Time to Return to Unrestricted Activity After Concussion in Service Academy Cadets

Background: Current consensus and position statements recommend that concussed patients be asymptomatic upon the initiation of the graduated return to activity (RTA) protocol. However, a significant number of concussed patients are beginning their RTA protocols while endorsing symptoms. Purpose: To characterize symptom endorsement at the beginning of the RTA protocol and examine the association between symptom endorsement and RTA protocol duration in service academy cadets. Study Design: Cohort study; Level of evidence, 2. Methods: A prospective cohort study was conducted with cadets at 3 US service academies. Postconcussion symptom inventories were recorded upon the initiation of an RTA protocol. The Sport Concussion Assessment Tool Symptom Inventory was used to classify participants into 3 groups (0 symptoms, 1 symptom, and ≥2 symptoms) upon the initiation of the RTA protocol. The primary outcome of interest was RTA protocol duration. Kaplan-Meier survival estimates were calculated to estimate RTA protocol duration by symptom endorsement, sex, varsity status, academic break, and time to graduated RTA initiation. Univariate and multivariable Cox proportional hazards models were used to estimate the association between symptom endorsement at the initiation of the RTA protocol and RTA protocol duration (α < .05). Results: Data were analyzed from 966 concussed cadets (36% women). Headache (42%) and faintness/dizziness (44%) were the most commonly endorsed symptoms on the Sport Concussion Assessment Tool-Third Edition and the Brief Symptom Inventory-18, respectively. Univariate results revealed a significant association between endorsing ≥2 symptoms and RTA protocol duration. In the multivariable model, endorsing ≥2 symptoms maintained a statistically significant association with RTA protocol duration. Significant associations were observed between RTA protocol duration and nonvarsity status (27% longer), women (15% longer), academic breaks (70% longer), and time to the initiation of the RTA protocol (1.1% longer daily incremental increase) after controlling for covariates. Conclusion: Symptom endorsement at the initiation of an RTA protocol was associated with RTA protocol duration. Cadets who had returned to preinjury baseline symptom burden or improved from baseline symptom burden and endorsed ≥2 symptoms at the initiation of the RTA protocol took longer to RTA.

Investigation of Aerobic and Muscular Fitness and Concussion Among Service Academy Cadets at the United States Air Force Academy: Results from the CARE Consortium

ABSTRACT Introduction Concussion has become the signature injury facing the U.S. military. However, little is understood about the relationship between military fitness and concussion recovery. The current study examined the recoveries of cadets at a U.S. Service Academy to determine whether preinjury physical fitness improved recovery and whether recovery was associated with post-injury physical fitness measures. Methods Participants were enrolled in a longitudinal study of concussion. Aerobic Fitness Test (AFT) and Physical Fitness Test (PFT) data were used to estimate cadet fitness. Survival analysis evaluated significant estimators of concussion recovery time. Linear regression models were used to explore the relationship between recovery duration and change in physical fitness scores. Results Between 2014 and 2017, 307 (n = 70; 22.80% Women) cadets who had sustained a concussion were enrolled. Preinjury physical fitness was not significantly associated with recovery duration (P &gt; .05). Men and intercollegiate cadets took fewer days to reach recovery milestones. Compared to women, men had greater decrements in the Aerobic Fitness Test total score (P &lt; .05) and increased 1.5-mile time postconcussion (P &lt; .05). Women had greater decreases in push-ups postconcussion compared to males (P &lt; .05). There was a trend for a negative association between days until asymptomatic and change in the Physical Fitness Test score (P = .07). Conclusion Preconcussion physical fitness levels do not appear to impact concussion recovery time among a highly physically fit cohort. Possible methods to reduce the effect of symptom duration on strength-related physical fitness should be investigated along with evaluating reductions in strength as a possible mechanism for postconcussion injury risk.

Heightened Sexual Misconduct Victimization Rates among Reserve Officers’ Training Corps Women: Results From a Campus Climate Survey

Sexual assault, harassment, and stalking are commonplace among college students, with identified subgroups being particularly at risk (e.g., Greek-life organizations and intercollegiate athletics). Despite higher rates of sexual misconduct among active-duty military and service academy women, no research has examined the risk for Reserve Officers’ Training Corps (ROTC) women. A total of N = 1,562 college women were sampled from a sexual misconduct campus climate survey. ROTC women reported higher victimization rates for all variants of sexual misconduct and violence relative to the broader student population, as well as previously established high-risk groups. Directions for future research and implications for prevention programming/response are presented and discussed.

Pluralistic Ignorance as a Contributing Factor to Concussion Underreporting

Background Concussion underreporting is endemic, and social norms are an established predictor of concussion reporting behavior. However, pluralistic ignorance—a situation in which most individuals in a group hold the belief that their peers’ views differ from their own, despite views actually being similar—has not been studied in this context. Aim To assess whether pluralistic ignorance contributes to concussion underreporting. Method We surveyed 2,504 military service academy cadets. Each cadet was presented with a survey asking about their willingness to self-report a concussion, their perception of other cadets’ willingness to report a concussion, and personal and demographic factors. Results Most cadets viewed themselves as more willing to report a concussion than others (mean difference = 1.12, 95% CI [1.02, 1.21]), a belief consistent with pluralistic ignorance. Demographic characteristics were associated with holding this belief. For example, female cadets and upper-class cadets were more likely to show this disparity than male or under-class cadets, respectively. Collegiate athletes not only showed similar willingness to report concussion as nonathletes but also perceived other cadets as less likely to report concussions. Meanwhile, future pilots showed less self-report willingness and perceived that others were similarly unwilling to report concussions. Discussion A majority of this economically and geographically diverse population displays characteristics of pluralistic ignorance: They largely share proconcussion reporting sentiments but incorrectly perceive that others do not. This belief is not held uniformly in all subpopulations, which may inform how these beliefs are developed and maintained. Conclusions Pluralistic ignorance is an important consideration in concussion education efforts.