Since the mid-1990s, American universities have routinely obtained millions of dollars in annual government funding by using athletes, primarily those involved in high-risk collision sports such as football, as research subjects. A significant amount of the brain injury research comes from sports medicine and relies on the college athlete population.
In 2014, the National Collegiate Athletic Association (NCAA) and the U.S. Department of Defense (DoD) signed a cooperative research and development agreement (CRADA) to jointly fund concussion research using the college population, with an ostensible mission to “enhance the health and safety of NCAA student-athletes and service members.” Dubbed the “CARE Consortium,” the ongoing project includes as study subjects college athletes from various sports among 30 universities and service academies across the country.
To date, the CARE Consortium has received millions in DoD funding. The claimed benefit to service members is critical for the NCAA to obtain DoD funding for this research. Military funding for the CARE Consortium occurs through the Psychological Health and Traumatic Brain Injury Research Program (PH/TBIRP), a congressionally directed medical research program (CDMRP). The key requirement to obtain funding through this program is that the research must “benefit Service members, veterans, and other beneficiaries of the military health system.”
The benefit for the population of collegiate athletes is another matter. The preferred end state would be fewer individuals with concussions, not more. There’s no reason the research grant should affect measures to make collegiate athletics safer, even though funding relies on a stream of test subjects with concussions. But the existence of the financial benefit and the potential for that entering into thinking about policies to prevent concussions should worry athletes and their families.
But the bigger question lies in whether this research carries any benefit to concussion research for military subjects.
According to NCAA Chief Medical Officer Brian Hainline, the justification for extrapolating results from concussion research using college athletes, who constitute the majority of CARE Consortium study subjects, to the military is that college sports is a much more controlled environment than the military theater and the two populations are “similar in age, athleticism, risk taking and pushing to the edge of excellence.”
Not only has the NCAA produced scant evidence to support such claims, but its own CARE Consortium research shows just the opposite. Recent research from the CARE Consortium has acknowledged that military cadets are a unique population and that findings likely cannot be generalized beyond NCAA Division I athletes. Another study using football players observed that not only were results unlikely to generalize to other settings; they were unlikely to generalize even to other sports.
Service members can be placed at great risk if results from a noncomparable population are applied to them and used to make medical-care decisions. One standard medical-care component of return-to-activity following a brain injury involves comparing pre-injury (baseline) tests to post-injury. When an individual’s post-injury scores approach their pre-injury baseline (e.g., 95 percent), then a gradual return to activity can proceed.
However, individual testing, as required by the 2008 National Defense Authorization Act, is expensive. As a result, the military has explored the cost-benefit trade-offs of other alternatives. One such alternative is reliance on “normative” baseline average scores from a similar population of individuals. The problem with comparing service members’ post-injury test scores to normative baselines from college athletes rather than military-specific normative data is that college athletes are not a similar population.
For example, individuals with learning disabilities and attention deficit disorder (LD/ADHD) have lower baseline scores on neurocognitive tests. LD/ADHD are prevalent among college athletes. At one university, over 39 percent of tested incoming athletes in some sports were diagnosed with LD/ADHD. One CARE Consortium study found approximately 27 percent of football players at a member university were diagnosed with LD/ADHD.
Further, use of stimulant medication (e.g., Adderall or Ritalin) is known to affect neurocognitive test scores and is common among college athletes. It is noteworthy that the use of such medications is an exclusionary criterion for military enlistment.
The characteristic differences between the military and college athlete population were discussed in some detail in a 2018 Ph.D. dissertation of Kathryn Van Pelt (née O’Connor), whose committee included various CARE Consortium researchers. Dr. Van Pelt offered strong evidence that the cadet population was “substantially different” from the traditional NCAA athlete.
Service members can be placed at great risk if results from noncomparable populations are applied to them and used to make medical-care decisions. When comparison benchmarks are set too low, injured service members can be prematurely declared ready for return to activity and still be symptomatic. In other words, this can have a negative impact on clinical decision-making.
Where does that leave us? It is clear that the CARE Consortium involves three different populations: college athletes, service academy cadets, and enlisted service members. The differences among them mean that the college athlete population cannot, and should not, be used to produce normative baseline data for service members. The solution that best protects military personnel is for the DoD to focus research efforts on its service member population instead.
Stephen Casper is currently retained in concussion litigation pending against the NCAA in multiple cases as an expert witness in history. The authors were not paid for this piece.