As a young 18 year old enters the halls of the U.S. Military Academy at West Point for the first time ready to take on his new role of cadet, he is reminded of the commitment, confidence and motivation it took to get him there. This cadet is aware of his newly pledged commitment to the military services and his country; he may not, however, be aware of the medical professionals dedicated to ensuring his health and readiness as he enters his service. A unique collaboration of researchers and clinicians are working to support and protect him through an ongoing study that will follow this cadet throughout the next four years and beyond.

PARTNERSHIPS FOR RESEARCH

The Department of Defense utilizes partnerships between organizations, combining and leveraging specialized knowledge to deliver the highest quality healthcare support to our Service Members. These partnerships are critically important and can be quite complex.

The coordination of partnerships and priorities for military medical research begins with the Office of the Assistant Secretary of Defense for Health Affairs, which provides high-level guidance directing research initiatives. The U.S. Army Medical Research and Materiel Command works with the OASD(HA) and the Defense Health Agency to manage and execute appropriations for the Defense Health Program. The Congressionally Directed Medical Research Programs office within the USAMRMC provides program and award management support for a number of DHP research areas.

THE CARE CONSORTIUM

The young cadet entering West Point has a unique opportunity to join a large-scale research study focusing on concussion and TBI. The Concussion Assessment, Research and Education Consortium, known as the CARE consortium, is a major concussion/TBI research study supported by the DOD and the National Collegiate Athletic Association, as a part of the DOD-NCAA Grand Alliance.

The CARE consortium is the largest of its type, involving multiple institutions in a study of sports-related concussion and TBI in order to collect and analyze data on concussion injury and recovery for the health and safety of student athletes, Service Members and the general public.

Dr. Dwayne Taliaferro, CDMRP health sciences program manager, explained that the CARE consortium is not a study researching treatment options; it is an observational study to develop a better understanding of TBI recovery and progression.

"The CARE consortium study is enrolling a population of young, fit, motivated athletes that compare well to the active-duty population," he said.

The CARE consortium research is co-chaired by principal investigators at three research institutions. Led by Dr. Thomas W. McAllister, the Indiana University School of Medicine serves as the Administrative and Operations Core and is the central coordination center for the CARE consortium. The University of Michigan houses the Longitudinal Clinical Study Core and is led by Dr. Steven Broglio; and, led by Dr. Michael McCrea, the Medical College of Wisconsin directs the Advanced Research Core.

"The initial phase of the CARE study is designed to understand the acute natural history of concussion in a diverse sample of NCAA student-athletes and U.S. Military Service Academy cadets," said McAllister. "Previous research has predominately focused on male, contact sport athletes [e.g., football players], but CARE enrolls both male and female cadets at the service academies, as well as male and female varsity level athletes from the 30 participating CARE sites."

"The CARE protocol includes not only NCAA athletes, but club and company athletes as well. Service Academy athletes are baselined at the beginning of the school year. When injured, they are followed throughout the course of their recovery," said Broglio. "The commonalities between concussion management in NCAA student-athletes, MSA cadets and military Service Members are a driving force behind the CARE consortium. The athletes' return-to-play progression is analogous to a Service Members return-to-duty progression."

THE U.S. MILITARY ACADEMY

According to Dr. Kenneth Cameron, site principal investigator for CARE studies at the USMA, this study has shown that only 25 percent of the brain injuries that occur at the school occur in NCAA athletics. The other areas are equally 25 percent each: recreational athletics, physical education courses and free time activities/military training.

"The service academies are the only sites in the 30-school consortium enrolling recreational athletes (intramural and competitive club), intercollegiate athletes (NCAA) and military beneficiaries," said Cameron. "We are documenting concussions during sports activities, during military training and free-time activities, and we are monitoring recovery from these injuries."

Dr. Megan Houston, CARE study coordinator at the USMA, explained how the response among cadets at the USMA enrolled in the CARE studies has been positive.

"The majority of cadets are more than willing to volunteer, as is evident by the 82.2 percent consent rate over the past three years. Many of them are supportive of the research efforts here because of a personal connection they have with concussion injury; whether that be having experienced a concussion themselves, by knowing a teammate/family member that has been diagnosed with a concussion, or simply keeping abreast of current events," said Houston.

Houston noted that although in their late teens and early twenties, some of the cadets are interested in what the findings of this research will mean for the future of some sports (i.e., boxing, football) for their children, in-turn providing the ability to make an informed decision about the safety of sports participation and long-term consequences of concussion.

"The cadets participating in the CARE consortium studies ultimately recognize that there are many unanswered questions surrounding concussion and, although they may not directly benefit from the study, their participation is crucial to improving our understanding of the effects and recovery trajectory of concussion," said Houston.

RESEARCH PROVIDING RESULTS

Cameron explained how the results of the CARE consortium studies are already starting to change how the Military Health System thinks about acute concussion prevention and management.

"These changes will ensure that evidence-based best practices for the prevention and management of concussions are in place when these students enter active duty," said Cameron. "We also anticipate that we will be able to follow participants from the service academies across their military careers to evaluate the long-term impact of a single concussion, or multiple concussions, among those enrolled in the CARE consortium studies. The goal of this work is to better understand the natural history of concussion and identify factors that may be predictive of deleterious outcomes."

The CARE consortium has resulted in changes in the NCAA football contact practice guidelines and the diagnosis and management of sports-concussion. To date, there have been 33,639 unique athlete baseline evaluations completed, with 39,610 NCAA varsity sport athletes and service academy cadets enrolled and 2,722 concussed individuals evaluated.

"Now that the first phase of the project is complete, we are now looking to understand what changes may or may not take place over the course of a collegiate sports or MSA career and beyond. We believe that a truly prospective, longitudinal study, similar to the Framingham study on cardiovascular health, will be the best way to answer these questions," said Broglio.

FUTURE TBI RESEARCH

Taliaferro explained that TBI is a public health concern. There were approximately 2.8 million emergency department visits attributed to TBI in 2013. Insight from the CARE consortium will continue to inform how athletes train, and will eventually help to better identify the individuals that need additional attention.

The findings from this research may provide support for future concussive events.

In just four short years, this young cadet will transition into active duty military. He will be commissioned as a second lieutenant in the Army, and begin the next step of his journey and service.