New Guidelines: Six-Step Recovery Program Recommended for Military mTBI

by U.S. Medicine

June 8, 2015

Annette M. Boyle

CHAPEL HILL, NC — Traumatic brain injury has been a signature injury of recent military engagements, with nearly 300,000 documented since 2000. Four out of five of those were mild traumatic brain injuries (mTBI) or concussions.


Despite the prevalence of mTBI among servicemembers, however, guidelines for return to activity have until recently relied on recommendations for athletes who suffered concussions during the course of games or practice.

The appropriateness of those athletic recommendations depends on the context of the injury, according to Karen McCulloch, PhD, PT, of the University of North Carolina at Chapel Hill. “Most of the concussions that happen in the military don’t happen in combat, so they could occur playing sports, too. In that case, the recovery would be very similar to an injury in an athletic setting. Less driven by the need to get ready for the ‘the next game,’ perhaps, as the sport activity may be more recreational for servicemembers.”

Karen McCulloch, PhD, PT

Karen McCulloch, PhD, PT

Yet, in other circumstances, the “the injury can also be very different, as a result of a hard landing in an airborne exercise, as a result of an IED explosion, as a result of combatives training,” McCulloch told U.S. Medicine. In these instances, the appropriate response needs to include an assessment of serious risk, the possibilities of additional, more serious injuries to the servicemember or other unit members, as well as acute or chronic stress responses.

To reflect the difference in setting and function required for return to activity for those in the military, the Progressive Activity Working Group established by the Defense and Veterans Brain Injury Center issued new clinical recommendations that delineate a six-stage return to activity. The guidelines were published earlier this year in The Journal of Head Trauma Rehabilitation.1

The Working Group consisted of DoD representatives from all service branches and the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, in addition to other experts on military mTBI. McCulloch was the lead author.

Previous DoD guidelines mandated 24-hour rest for any servicemember who experienced a potentially concussive event and seven days of rest for those who had two concussions in a year. Three concussions in a 12-month period warranted rest and recurrent comprehensive concussion evaluation.

Asymptomatic servicemembers could gradually return to activity, but the previous guidelines did not specify the activity progression for servicemembers who continued to experience symptoms beyond the 24-hour rest period.

“The main changes with the Progressive Return to Activity guidance and previous practice is that there is an attempt to be more explicit about what rest really means, that there is a progression of activity that includes more detailed and military specific information about physical exercise but also describes cognitive activity and balance/vestibular activity,” McCulloch said.

The new guidelines outline six stages of increasing activity — rest, light routine activity, light occupation-oriented activity, moderate activity, intensive activity and unrestricted activity. Progression is measured across physical, cognitive and vestibular domains employing the Neurobehavioral Symptom Inventory, with resting heart rate and blood pressure used to evaluate activity tolerance. The Neurobehavioral Symptom Inventory includes 22 common symptoms of mild traumatic brain injury, which are reported on a scale of 0 to 4, with 4 being very severe.

The Progressive Activity Working Group defined rest as “extremely light physical, cognitive and vestibular-balance activity with the goal of symptom resolution.” Patients may walk on level surfaces and perform basic activities of daily living and extremely light leisure activity, but no work, exercise, video games, studying or driving.

Patients who suffered their first concussion in a year and have no symptoms following exertional testing after 24 hours of rest may return to pre-injury activity with follow-up guidance. Military personnel who have had a second mTBI in 12 months have 48 hours of rest and stay at Stage 2 for at least five days before beginning the progressive return to activity process. Those who have had three concussions in a year should be referred to a higher level of care for recurrent-concussion evaluation.

Servicemembers who continue to report some symptoms after 48 hours of rest or who become symptomatic during exertional testing must restart the progressive return to activity process, according to the new guidelines.

Each stage lasts at least a day and increases the length and intensity of exercise, cognitive and vestibular activities, with specified durations and required rest periods. Video games and jogging, for instance, are not permitted until Stage 4; driving and problem solving are reintroduced at Stage 5.

After Stage 5, a primary care manager conducts exertional testing before releasing the servicemember to unrestricted activity.

If symptoms are moderate or more severe or the number of symptoms increases, the patient returns to the last tolerated stage and consults with a primary care manager. Failure to progress for more than seven days requires referral to a rehabilitation provider or concussion care specialist, as is the case when symptoms arise during exertional testing after Stage 5.

In a notable change from other guidelines, “this guidance allows for gradual return to activity with the presence of low level symptoms as long as the activities performed don’t exacerbate the symptoms,” McCulloch noted. “Some prior guidance encouraged waiting until one was completely asymptomatic at rest prior to returning to activity.”

The Progressive Return to Activity process balances an expectation that the majority of servicemembers with mTBI will be able to return to duty with a clear process for rehabilitation with identification of those who require more direct and sustained support.

At the same time, the authors said they hoped the guidelines would provide even greater future benefits. They noted that “the activity progression, by standardizing language and challenges that are pertinent to the military, may allow for the complexity of post-concussion intervention to be studied more systematically, and for targeted treatments to be developed.”

1 McCulloch KL, Goldman S, Lowe L, Radomski MV, Reynolds J, Shapiro R, West TA. Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers. J Head Trauma Rehabil. 2015 Jan-Feb;30(1):56-67.



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