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. 2024 Nov;54(11):2955-2964.
doi: 10.1007/s40279-024-02068-3. Epub 2024 Jul 12.

Sex Differences Across Concussion Characteristics in US Service Academy Cadets: A CARE Consortium Study

Louise A Kelly  1 , J B Caccese  2 , D Jain  3 , C L Master  4 , L Lempke  5 , A K Memmini  6 , T A Buckley  7 , J R Clugston  8 , A Mozel  9 , J T Eckner  10 , A Susmarski  11 , E Ermer  12 , K L Cameron  13 , S Chrisman  14 , P Pasquina  12 , S P Broglio  5 , T W McAllister  15 , M McCrea  16 , C Esopenko  3 ; CARE Consortium Investigators
Affiliations

Sex Differences Across Concussion Characteristics in US Service Academy Cadets: A CARE Consortium Study

Louise A Kelly et al. Sports Med. 2024 Nov.

Abstract

Objective: To describe sex differences in concussion characteristics in US Service Academy cadets.

Design: Descriptive epidemiology study.

Setting: Four US service academies.

Participants: 2209 cadets (n = 867 females, n = 1342 males).

Independent variable: Sex.

Outcome measures: Injury proportion ratios (IPR) compared the proportion of injuries by sex (females referent) for injury situation, certainty of diagnosis, prolonged recovery, recurrent injuries, mental status alterations, loss of consciousness (LOC), posttraumatic amnesia (PTA), retrograde amnesia (RGA), motor impairments, delayed symptom presentation, and immediate reporting.

Main results: Concussions from varsity/intercollegiate sports [IPR of 1.73, 95% confidence interval (CI) 1.43-2.10] and intramurals (IPR of 1.53, 95% CI 1.02-2.32) accounted for a larger proportion in males, whereas concussions outside of sport and military activities accounted for a smaller proportion among males (IPR of 0.70, 95% CI 0.58-0.85). The proportion of concussions with prolonged recovery was lower among males (IPR of 0.69, 95% CI 0.60-0.78), while concussions with altered mental status (IPR of 1.23, 95% CI 1.09-1.38), LOC (IPR of 1.67, 95% CI 1.17-2.37), PTA (IPR of 1.94, 95% CI 1.43-2.62), and RGA (IPR of 2.14, 95% CI 1.38-3.31) accounted for a larger proportion among males. A larger proportion of concussions that were immediately reported was observed in males (IPR of 1.15, 95% CI 1.00-2.31). Proportions of other characteristics (e.g., recurrent injuries) were not different between sexes.

Conclusions: A higher proportion of concussions occurred outside of sport and military training for female cadets, who also displayed proportionally longer recovery times than males, despite males demonstrating a higher proportion of LOC, PTA, and RGA. Possible factors may include different mechanisms of injury outside of sport and military training, different biopsychosocial states associated with sex or injury context, and delayed injury reporting when outside of an observed environment, possibly secondary to perceived stigma about reporting injuries.

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Conflict of interest statement

Declarations Funding 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). Conflicts of Interest J.R.C. receives research support from the National Football League. M.P. is the Chief Medical Officer for Major League Soccer, Senior Advisor National Football League Head, Neck and Spine Committee, Football Association Research Task Force, Concussion in Sport Group Expert Group, National Operating Committee on Standards for Athletic Equipment Scientific Advisory Committee. S.P.B. has current or past research funding from the National Institutes of Health, Centers for Disease Control and Prevention, Department of Defense—USA Medical Research Acquisition Activity, National Collegiate Athletic Association, National Athletic Trainers’ Association Foundation, National Football League, Under Armour, GE, Simbex, and ElmindA. He has consulted for US Soccer, US Cycling, University of Calgary SHRed Concussions external advisory board, and medicolegal litigation. He is coauthor of “Biomechanics of Injury (3rd edition)” and has a patent on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” (US 11,529,091 B2). T.W.M. receives grant support for concussion research studies from the NCAA, the US Department of Defense, and the NIH. He also receives royalties for a TBI textbook from American Psychiatric Association Publishing, Inc. M.M. receives research funding to the Medical College of Wisconsin from the National Institutes of Health, Department of Veterans Affairs, Centers for Disease Control and Prevention, Department of Defense, National Collegiate Athletic Association, National Football League, and Abbott Laboratories. He receives book royalties from Oxford University Press. He serves as clinical consultant to Milwaukee Bucks, Milwaukee Brewers, and Green Bay Packers, and is Co-Director of the NFL Neuropsychology Consultants without compensation. He serves as a consultant for Neurotrauma Sciences, Inc. The other authors have no potential conflicts of interest with the content of this article. J.B.C. is an Editorial Board member of Sports Medicine. J.B.C. was not involved in the selection of peer reviewers for the manuscript or any of the subsequent editorial decisions. Availability of Data and Materials Deidentified CARE data can be accessed via the Federal Interagency Traumatic Brain Injury Research database https://fitbir.nih.gov. Ethics Approval This study was approved by the institutional review board at each study site, in conjunction with approval from the US Army Human Research Protection Office (see also Supplementary Table 1 for ethics approval numbers for individual institutions). This study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Consent to Participate All participants gave written informed consent. Consent for Publication N/A. Code Availability N/A. Author Contributions All authors contributed to the drafting and editing of the manuscript. All authors approved the final manuscript.

Figures

Fig. 1
Fig. 1
Sex differences in concussion characteristics by injury situation.  a Concussions from competition accounted for a larger proportion of concussions in males than in females, whereas concussions from outside of sport accounted for a smaller proportion of concussions in males than in females.  b Concussions from varsity/intercollegiate sports and intramurals accounted for a larger proportion of concussions in males than in females, whereas concussions from activities outside of sport and military training accounted for a larger proportion of concussions in females than in males. *Indicates statistically significant differences between sexes
Fig. 2
Fig. 2
Sex differences in concussion characteristics by observable clinical signs. Concussions with altered mental status (a), loss of consciousness (LOC) (b), posttraumatic amnesia (PTA) (c), and retrograde amnesia (RGA) (d) accounted for a larger proportion of concussions in males than in females. e There was no difference in the proportion of concussions with motor impairments between male and female cadets. *Indicates statistically significant differences between sexes
Fig. 3
Fig. 3
Sex differences in concussion characteristics by reporting time (a), time to removal from play (b), and delayed symptom presentation (c). Concussions reported immediately accounted for a larger proportion of concussions in males than in females, but there was no difference in the proportion of concussions immediately removed from play or with delayed symptom onset between male and female cadets. *Indicates statistically significant differences between sexes
Fig. 4
Fig. 4
Sex differences in concussion characteristics by sport type (a), recurrent injury (b), and slow to recover (c). Concussions from contact sports accounted for a larger proportion of concussions in males than in females, whereas concussions from limited-contact and non-contact sports accounted for a smaller proportion of concussions in males than in females. There was no difference in the proportion of recurrent concussions between male and female cadets, although concussions that were slow to recover accounted for a smaller proportion of concussions in males than in females. *Indicates statistically significant differences between sexes
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