Use of the Progressive Return to Activity Guidelines May Expedite Symptom Resolution After Concussion for Active Duty Military

Abstract

Background: Clinical recommendations for concussion management encourage reduced cognitive and physical activities immediately after injury, with graded increases in activity as symptoms resolve. Empirical support for the effectiveness of such recommendations is needed. Purpose: To examine whether training medical providers on the Defense and Veterans Brain Injury Center’s Progressive Return to Activity Clinical Recommendation (PRA-CR) for acute concussion improves patient outcomes. Study Design: Cohort study; Level of evidence, 2. Methods: This study was conducted from 2016 to 2018 and compared patient outcomes before and after medical providers received an educational intervention (ie, provider training). Patients, recruited either before or after intervention, were assessed at ≤72 hours, 1 week, 1 month, 3 months, and 6 months after a concussion. The participant population included 38 military medical providers and 106 military servicemembers with a diagnosed concussion and treated by one of the military medical providers: 58 patient participants received care before the intervention (ie, provider training) and 48 received care after intervention. The primary outcome measure was the Neurobehavioral Symptom Inventory. Results: The patients seen before and after the intervention were predominantly male (89.7% and 93.8%, respectively) of military age (mean ± SD, 26.62 ± 6.29 years and 25.08 ± 6.85 years, respectively) and a mean ± SD of 1.92 ± 0.88 days from injury. Compared with patients receiving care before intervention, patients receiving care after intervention had smaller increases in physical activities (difference in mean change; 95% CI, 0.39 to 6.79) and vestibular/balance activities (95% CI, 0.79 to 7.5) during the first week of recovery. Although groups did not differ in symptoms at ≤72 hours of injury ( d = 0.22; 95% CI, –2.21 to 8.07), the postintervention group reported fewer symptoms at 1 week ( d = 0.61; 95% CI, 0.52 to 10.92). Postintervention patients who completed the 6-month study had improved recovery both at 1 month ( d = 1.55; 95% CI, 5.33 to 15.39) and 3 months after injury ( d = 1.10; 95% CI, 2.36 to 11.55), but not at 6 months ( d = 0.35; 95% CI, 5.34 to 7.59). Conclusion: Training medical providers on the PRA-CR for management of concussion resulted in expedited recovery of patients.

Best Practices for Progressive Return to Activity after Concussion: Lessons Learned from a Prospective Study of U.S. Military Service Members

“…11 Results suggested that this training had a significant positive impact on clinical practices as well as on patients' recovery from concussion. 27 Interview data and informal feedback indicated that the training was well received and impacted concussion clinical practices as intended. Quantitative results were even more compelling; compared with patients who received concussion treatment before providers received the PRA training, patients who were treated after provider training were 59% more likely to receive education from their providers, and they had lower levels of physical and vestibular activity during the first week of concussion recovery.…”

“…25 As shown in Figure 1, concussed SMs in the DVBIC PRA study engaged in relatively low levels of activity (and high levels of rest) immediately after injury, followed by gradual increases in activity over the following 3 to 6 months, with an average increase in total activity of 63% over the full study time frame. 26,27 Physical, vestibular/balance, and military-specific activities increased most rapidly, whereas cognitive and lifestyle activities (i.e., reading, socializing, watching television) increased more slowly (Fig. 2).…”

“…[51][52][53][54] Results from the DVBIC PRA study show how these previous findings may apply to implementation of PRA guidelines within a primary care setting: patients who received education from their providers during the acute stage of injury were not only more likely to believe that early rest is important to concussion recovery, but they were also more likely to increase their levels of activity appropriately over time, and they experienced a more rapid reduction in symptoms than patients who did not receive education. 27,32 Training providers on progressive return to activity guidelines As discussed, information about stage of concussion recovery can be used to guide patients through the process of PRA and may hasten their overall recovery toward pre-injury levels of functioning. However, many providers are responsible for providing care for a wide range of different conditions, and so they may lack up-to-date knowledge of best practices for management of concussion.…”

“…In a second phase of the DVBIC PRA study, we sought to evaluate the effects of directly training primary care providers on the DVBIC PRA CR. 11,27,32 Although the DVBIC PRA CR was publicly available online prior to training, providers indicated relatively low rates of exposure to this information before enrollment in the study. Concussion management clinical practices (including the likelihood of providing patient education) varied among primary care managers, both within and between the three military treatment facilities investigated.…”

“…Quantitative results were even more compelling; compared with patients who received concussion treatment before providers received the PRA training, patients who were treated after provider training were 59% more likely to receive education from their providers, and they had lower levels of physical and vestibular activity during the first week of concussion recovery. 27 Importantly, these differences translated into expedited recovery. 27 Despite comparable levels of symptoms immediately after injury, symptomatic patients receiving care from providers who had received PRA CR training exhibited better symptom recovery at 1 week, 1 month, and 3 months after injury, as compared with similar patients who received care from providers who had not yet completed PRA CR training 27 (see Fig.…”