Provider Training in the Management of Headache Following Concussion Clinical Recommendation: Promoting a Standardized Means for Efficient Patient Recovery and Timely Return to Duty

Abstract

Background: Headache is a common symptom reported following concussion/mild traumatic brain injury. The Department of Defense's clinical recommendation (CR) describes guidance for primary care providers for the management of post-traumatic headache (PTH) in Service members. Objective: The objective of this study is to examine the association between training on the CR with provider clinical practice, patient behaviors, and symptom recovery. Methods: Participants were healthcare providers and two patient groups (one receiving care as usual [CAU] and another receiving care after provider training on PTH CR [CR+]). Providers were interviewed at three time points: (1) prior to CAU enrollment; (2) after CAU enrollment, but prior to training; and (3) after CR+ follow-up. Data from the second and third provider interview were used to evaluate a potential difference between provider practices pre-and post-training (n = 13). Patients were enrolled within 6 months of concussion. Patient outcomes (including neurobehavioral and headache symptoms) were assessed at three time-points: within 72 h (n = 35), at 1-week (n = 34) and at 1-month post-enrollment (n = 27). Results: Most follow-up care reported by providers were recommended within 72 h of initial visit post-training vs. >1 week pre-training. Additionally, providers reported a greater number of visits based on patient symptoms after training than before. Post-training, most providers reported referring patients to higher level of care "as needed," if not "very rarely," compared to 25% reported referrals prior to training. At 1-week post-enrollment the CR+ patient group reported more frequent medical provider visits compared to the CAU group. This trend was reversed at the 1-month follow-up whereby more CAU Remigio-Baker et al. Post-concussive Headache Management Training Impact reported seeing a medical provider compared to CR+. By 1-week post-enrollment, fewer patients in the CR+ group reported being referred to any other providers or specialists compared to the CAU group. No differences in patient outcomes by provider training was found. Conclusion: The study results demonstrate the feasibility of training on the Management of Headache Following Concussion CR in order to change provider practices by promoting timely care, and promoting patient compliance as shown through improvement in follow-up visits and more monitoring within the primary care clinic.

Designing research on concussion treatment in the military setting: Important challenges to consider

“…These fluctuations are often unpredictable. Thus, recruitment in military concussion studies have been performed in a “catch-all” manner ( Gregory et al, 2017 , Remigio-Baker et al, 2020b ), in which all opportunities of encounters were targeted and not limited to timing. Unfortunately, this strategy hinders investigators from knowing the number of potential participants lost due to lack of interest or scheduling conflict.…”

“…In previous military concussion studies, this was done by a “catch-all” recruitment where individuals were recruited from many military venues and at different time periods. ( Gregory et al, 2017 , Remigio-Baker et al, 2020b ) It is important to note, however, that attrition due to PCS is not voluntary nor systematic, thus mitigating selection bias as attrition is somewhat randomized.…”

“…This option has been effectively used by studies previously for ADSMs who return from deployment to a MTF approved for data collection. ( Remigio-Baker et al, 2020b , Remigio-Baker et al, 2020c ) Failure to incorporate such verbiage in the initial IRB-approved protocol would require an amendment, risking additional PCS or the delay of potential treatment and data capture.…”

“…Although previous concussion studies in the military may have established strong rapport with site leadership during proposal development, a built-in education component specific for the commands was not usually included, which could have attenuated data attrition. ( Gregory et al, 2017 , Remigio-Baker et al, 2020b ) Such education of command is necessary as it provides a better understanding of the importance of such research work among ADSMs and force readiness. As ADSMs update their supervisor on their mTBI treatment, information on study participation is often also discussed.…”

“…One approach with demonstrated success with military personnel during in-person sessions is the train-the-trainer method in which a subject-matter expert trains additional staff in the delivery of an educational intervention to further widen the distribution of such education. ( Remigio-Baker et al, 2020b ) As a virtual approach is a relatively novel means to distribute an educational intervention, a comparison between an in-person and virtual delivery has yet to be conducted. It is important to understand differences specific to each approach.…”