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New return-to-activity guidelines developed for military personnel with minor TBI
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Recommendations for a new a six-step process of progressive activity for military personnel who have suffered a minor traumatic brain injury prior to their return to active duty have recently been published.
Developed by the Progressive Activity Working Group established by the Defense and Veterans Brain Injury Center, the guidelines include recommendations for rest and activity, based on minimal or absent symptoms at each stage of the progression.
“Although service members share similarities with athletes, guidance for sports-related concussion is not always relevant to military contexts and does not incorporate the complexities of military demands, decision-making under stressful conditions and multitasking in extreme environments,” lead author, Karen L. McCulloch, PT, PhD, NCS, of the University of North Carolina-Chapel Hill, and colleagues wrote in the guidelines.
The updated guidelines are based on current evidence and expert opinions. For example, after a minor traumatic brain injury (mTBI), a 24-hour rest period is mandated for all service members following a first injury, and a longer rest period is mandated for each subsequent mTBI, according to the release.
The working group’s guidelines include a progression from rest to light routine activity and from light occupation-oriented activity to moderate, intensive and unrestricted activity. All of the stages last at least 24 hours and consist of specific activities.
Patients cannot progress to the next stage of recovery if they are still exhibiting concussion-like symptoms, according to the release. If the patients still exhibit symptoms after 24 hours, he or she is sent back to the previous step in the recovery process.
“Individuals whose symptoms are worsening, are not progressing as anticipated, or do not progress in 7 days are referred to a higher level of care,” the working group wrote.
According to the working group, additional research is needed to test and refine the proposed recommendations, and for clinical judgment in managing individual patients.
Estimates suggest more than 294,000 service members sustained TBI between 2000 and 2013. More than 80% of these injuries were mTBI, also known as concussion. These injuries are a major concern for military personnel, according to the press release. – by Robert Linnehan
References: www.headtraumarehab.com, www.dvbic.dcoe.mil.
Perspective
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Vincent John Miele, Jr., MD, FAANS
The Office of The Army Surgeon General and the Progressive Return to Activity Following Mild TBI Working Group are to be commended for this important work that will improve the lives of our service members after their military careers. Almost all guidelines to date are based on our experience in sports. This six-step return-to-activity guide molds this information into a more usable form for the military.
My single critique of the article is the lack of baseline and follow-up computerized post-concussion neuropsychological and vestibular/balance testing — powerful and objective tools for determining a patient’s recovery. Such testing, now readily available and easy to perform, should be an integral part of any post-concussion evaluation.
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