By Sandra Basu
SILVER SPRING, MD — How and when should a servicemember return to activity after a concussion?
That question has troubled clinicians, especially with mild traumatic brain injury (mTBI) so common during recent military actions.
Now, the Defense and Veterans Brain Injury Center (DVBIC) is offering advice on how healthcare providers can help patients navigate this process safely in the newly released “Progressive Return to Activity Following Acute Concussion/Mild Traumatic Brain Injury: Guidance for the Primary Care Manager and the Rehabilitation Provider in Deployed and Non-deployed Setting Clinical Recommendations.”
“The [recommendations] are the first of its kind and are tailored for primary care managers and rehabilitation providers. These recommendations offer a standardized medical approach for servicemembers who have sustained a mild TBI to return to activity in a manner which facilitates optimal recovery,” DVBIC National Director Army Col. Sidney Hinds II, MD, said in a written statement.
According to DVBIC, since 2000, more than 287,000 troops have sustained a TBI, with 83% of these classified as mTBIs. Currently, the “Concussion Management in Deployed Settings Algorithms” and DoD Instruction (DoDI) 6490.11 provide guidance for the evaluation and care of mTBI patients in the deployed setting. DoD guidelines, for example, mandate that a servicemember diagnosed with a concussion requires a mandatory 24-hour recovery period.
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In addition, consensus guidelines from the 4th International Conference on Concussion in Sport held in Zurich, Switzerland, and the “VA/DoD Clinical Practice Guideline for Management of Concussion/Mild Traumatic Brain Injury” recommend that patients with mTBI gradually return to normal activity using a progressive activity protocol.
What is missing from the literature, however, is clear guidance on how to progressively return to activity following mTBI after the mandatory recovery period, DVBIC Deputy Director Kathy Helmick, ANP, CNRN, told U.S. Medicine.
“That is what this document does. This document is a ‘how-to manual,’ how to resume your pre-injury activity going through six stages of activity that are organized by physical activities, cognitive activities and vestibular activities,” she explained.
The stages defined include:
- Stage 1- rest;
- Stage 2- light routine activity;
- Stage 3- light occupation-oriented activity;
- Stage 4- moderate activity;
- Stage 5- intensive activity; and,
- Stage 6- unrestricted activity.
The recommendations define what activities are permissible during these stages so all care providers are on the same page about what these stages mean.
For example, Helmick pointed out that some individuals might define playing videogames as fitting into the definition of “rest.” These recommendations, however, clarify that patients should not work, exercise, play video games, study or drive during this stage.
“So what these do, these clinical recommendations, provide is an opportunity to define operationally what rest looks like — what to do and what not to do,” she said. “It also provides correct time parameters for how long certain activities should be done before taking a break. The standardized approach is that we are all on the same page,” she said.
Despite the overall standardization of definitions, each patient’s path forward is individualized, and not all patients will require completion of all stages after the mandatory recovery period, according to Helmick.
The recommendations explain that the progressive return to activity process “is based upon the servicemember’s history of concussion in the past 12 months and symptom report.”
“Some servicemembers who sustain their first concussion in 12 months will be able to move through exertional testing and return to pre-injury activity in 24 hours. Others will require an additional 24 hours to become asymptomatic before and after exertional testing. Still others will require the completion of Stages 1-6 of the progressive activity process,” the recommendations note.
Injured servicemembers also play a role in how their recovery proceeds. A patient education handout, “Acute Concussion TBI Educational Brochure,” “should be given to and reviewed with all servicemembers at the time that they are diagnosed with a concussion. The PCM [primary care manager] should provide the critical educational intervention using this brochure during the initial 24 hour mandatory recovery period to establish the expectation for recovery,” the recommendations state.
The recommendations further advise, “If the patient remains symptomatic after 24 hours, is symptomatic after exertional testing, or if this is the second concussion within the past 12 months, the PCM should review the “Return to Activity Educational Brochure.”
“The “Return to Activity Educational Brochure” gives the servicemember instruction for the allowable level of activity for each stage, the criteria for progression and when to return to the PCM. The expectation for recovery through a staged progressive activity process should be explained,” according to the recommendations.
The new clinical recommendation products are geared toward primary-care managers and rehabilitation managers. Products for each include educational brochures for patients, provider training slides, the recommendations and a clinical support tool. The products are available through the DBVIC website at http://dvbic.dcoe.mil/resources/progressive-return-to-activity.
“It is an easy, user-friendly, how-to manual that can navigate the progressive return to activity for you, and I think that is really the piece that is appreciated for busy providers out in the field that really don’t have a lot of time to sift through larger documents trying to find out the state of science,” Helmick said.
The recommendations are based on “a review of currently published literature and expert contributions obtained by DCoE in collaboration with clinical subject matter experts representing the services, VA, as well as academic, research and civilian sectors.”
Helmick said that, while the clinical recommendations were written with the military patient in mind, the tools also can be used in the civilian sector and can be used internationally.
“When we developed this tool in close collaboration with the Army, Navy, Air Force and Marine Corps and VA, we also invited several civilian experts to participate. They shared with us they couldn’t wait for this to come out because they planned to implement this in the civilian sector as well,” she said.
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