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. 2025 Jul;55(7):1743-1755.
doi: 10.1007/s40279-024-02168-0. Epub 2025 Jan 19.

Factors Associated with Persisting Post-Concussion Symptoms Among Collegiate Athletes and Military Cadets: Findings from the NCAA-DoD CARE Consortium

Lauren T Rooks  1 , Giulia Bertò  2 , Paul F Pasquina  3 , Steven P Broglio  4 , Thomas W McAllister  5 , Michael A McCrea  6 , Franco Pestilli #  2 , Nicholas L Port #  7 ; CARE Consortium Investigators
Affiliations

Factors Associated with Persisting Post-Concussion Symptoms Among Collegiate Athletes and Military Cadets: Findings from the NCAA-DoD CARE Consortium

Lauren T Rooks et al. Sports Med. 2025 Jul.

Abstract

Background: Persisting post-concussion symptoms (PPCS) is a condition characterized by prolonged recovery from a mild traumatic brain injury (mTBI) and compromised quality of life. Previous literature, on the basis of small sample sizes, concludes that there are several risk factors for the development of PPCS.

Objective: We seek to identify protective and risk factors for developing slow recovery or persisting post-concussion symptoms (PPCS) by analyzing medical history, contact sport level, setting, and the Sport Concussion Assessment Tool (SCAT) and Brief Symptom Inventory (BSI-18) assessments at baseline and post-injury.

Patients and methods: We studied 47,860 unique collegiate athletes and Military Service Academy (MSA) cadets enrolled in the 30-site National Collegiate Athletic Association and Department of Defense (NCAA-DoD) Concussion Assessment Research and Education (CARE) Consortium prospective cohort study of baseline and post-injury data from 2014 to 2019. Medical histories and preseason baselines (n = 60,720), along with SCAT and BSI-18 examinations (n = 5379) conducted within 48 h post-injury, were analyzed. PPCS is defined as cleared for return to play (RTP) > 29 days.

Results: Of 5073 concussions, the median (95% CI) and mean (SD) RTP were 15.2 (4.8-82.6) days and 22.2 (23.0) days, respectively, with 891 developing PPCS. Sex, high SCAT score, high BSI-18 score, and delayed reporting produced small effect sizes on RTP (d = 0.22-0.44). Adjusted odds ratios (OR) of developing PPCS indicated the following risk factors: SCAT total score > 45 (OR = 1.91, 95% CI: 1.58-2.30), female sex (OR = 1.80, 95% CI: 1.53-2.13), concussion history (OR = 1.80, 95% CI: 1.29-2.52), and delayed reporting (OR = 1.42, 95% CI: 1.20-1.67). In contrast, protective factors against developing PPCS were: being a limited-contact (OR = 0.34, 95% CI: 0.25-0.47), noncontact (OR = 0.35, 95% CI: 0.24-0.51) or contact sport athlete (OR = 0.34, 95% CI: 0.28-0.41); and receiving the concussion at practice (OR = 0.64, 95% CI: 0.53-0.77) or in competition (OR = 0.44, 95% CI: 0.34-0.56). Athletes diagnosed with a learning disability and taking a neurostimulant were more protected than those who were not (OR = 0.44, 95% CI: 0.26-0.76 versus OR = 0.72, 95% CI: 0.49-1.05, respectively). A prognostic model using these variables offers poor sensitivity (9%) but high specificity (98%) in identifying PPCS (AUC = 0.72).

Conclusions: This study of 5073 concussions indicates that female sex, high symptom burden, and prior concussion are risk factors for slow recovery. In addition, learning disability, contact sport, and concussion in competition are protective against slow recovery. The neurostimulant results suggest that clinicians should keep their attention deficit disorder (ADD) and attention-deficit/hyperactivity disorder (ADHD) patients on their current neurostimulant medication after a concussion. A prognostic logistic regression model based on behavioral clinical findings did a poor job of identifying PPCS.

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Conflict of interest statement

Declarations. Funding: This research was supported with a grant by the Department of Defense (DoD) to Nicholas Port and Franco Pestilli (W81XWH-20-1-0717). Franco Pestilli was also funded by grants from the National Institutes of Health (NIMH R01MH126699, NIBIB R01EB030896, NIBIB R01EB029272), the National Science Foundation (OAC-1916518, IIS-1912270, IIS-1636893, BCS-1734853), The Wellcome Trust (226486/Z/22/Z), and by a Microsoft Investigator Fellowship and a gift from the Kavli Foundation. Nicholas Port was also funded by the Indiana Spinal Cord and Brian Injury Research Fund and access to unrestricted funds from StateSpace Inc. This research was also made possible, in part, with support from the Grand Alliance Concussion Assessment, Research, and Education (CARE) Consortium, funded in part by the National Collegiate Athletic Association (NCAA) and the DoD. The US Army Medical Research Acquisition Activity was the awarding and administering acquisition office, and 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. Conflict of Interests: LTR: None. GB: None. PFP: None. SPB: has current research funding from the National Institutes of Health; Centers for Disease Control and Prevention; Department of Defense—USA Medical Research Acquisition Activity, and the National Collegiate Athletic Association. He has past research funding from the National Athletic Trainers’ Association Foundation; National Football League/Under Armour/GE; Simbex; and ElmindA. He has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), and is the President Elect of the Concussion in Sport Group (unpaid). He has received compensation for medicolegal litigation, and received speaker honorarium and travel reimbursements for talks given. He is co-author of Biomechanics of Injury (3rd edition, Human Kinetics) and holds patents on “Brain Metabolism Monitoring through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” (U.S. US 11,529,091 B2) and “Organ or Tissue Hemodynamic and Metabolic Function Measured Using Super-Continuum Light Sources” (US 12,089,945 B2). He is on the scientific advisory board for C3Logix (stock options). He is/was on the editorial boards (all unpaid) for the Journal of Athletic Training (2015–present), Concussion (2014–present), Athletic Training & Sports Health Care (2008–present), and British Journal of Sports Medicine (2008–2019). TWM: book royalties from American Psychiatric Association, funding from NIH and US DoD. MAM: Funding from Abbott Laboratories; book royalties from Oxford University Press; consultant Neurotrauma Sciences & Green Bay Packers. FP: None. NLP: None. Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Data Availability: All of the analysis code is publicly available at: https://github.com/Nicholas-Port/Persistent-Post-Concussion-Symptoms . Most of the CARE 1.0 dataset is available at: https://fitbir.nih.gov/ . The additional CARE 2.0 dataset should be available on the Federal Interagency Traumatic Brain Injury Research (FITBIR) repository in the future. Author Contributions: LTR and NLP made substantial contributions to the conception of the study, the acquisition and interpretation of data, the drafting of the work, critical revision for important intellectual content, and the provision of final approval of the version published. They are accountable for all aspects of the work. GB and FP made substantial contributions to the conception of the study, the analysis and interpretation of data, critical revision for important intellectual content, and the provision of final approval of the version published. PFP, SPB, TMA, and MAMC made substantial contributions to the conception of the study, the acquisition and interpretation of data, critical revision of the manuscript for important intellectual content, and the provision final approval of the version published. They are accountable for all aspects of the work. The CARE Consortium investigators HJB, TAB, KC, JC, MWC, CD, JTE, AH, TWK, LAK, AK, DL, LL, CLM, JPM, JM, CM, PO, JO, SR, AJS, and SJS made substantial contributions to the acquisition of data, critical revision for important intellectual content, and the provision of final approval of the version published.

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