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Balancing rest, activity key to recovering from concussion

Two football teams facing off in the middle of a play Proper concussion recovery protocols are critical to returning service members and trainees and students such as these U.S. Military Academy cadets and U.S. Naval Academy midshipmen during the annual Army Navy football game (Photo by: Navy Petty Officer 2nd Class Alexander Kubitza, Office of the Secretary of the Navy).

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A newly revised suite of tools and resources for military health care providers will help improve the treatment of service members with concussions, and ensure their safe return to full duty, according to the Defense Health Agency's Traumatic Brain Injury Center of Excellence.

"The Progressive Return to Activity Following Acute Concussion (PRA)" clinical recommendation updates a previous version and incorporates another guide called the Concussion Management Tool.

The clinical recommendation features a six-step approach for providers to smoothly transition service members from a concussion diagnosis to managing their symptoms through recovery. Each stage focuses not only on returning patients to physical activity, but also on the gradual return to normal brain function.

If a service member returns to duty too soon after a concussion, research suggests there is a greater risk of accidents and falls, prolonged symptoms, more concussions, poor marksmanship, and decreased readiness. In one recent study, published in September 2020, medical professionals followed 508 U.S. Naval Academy midshipmen with concussions until they exhibited normal balance and had no symptoms at rest or with exertion. When the midshipmen were given a mental test, however, 25% had not fully recovered, demonstrating underlying concerns with a premature return to duty.

"The PRA walks you through that process of what to expect, what do you need to achieve before you go to the next stage, (and) what are the restrictions for each stage in both of those components - cognitively and physically," said Navy Cmdr. (Dr.) Adam Susmarski, medical director of the U.S. Naval Academy Concussion Center of Excellence and a member of the Traumatic Brain Injury Center of Excellence (TBICoE) group that assessed the clinical recommendations in practice.

Among significant changes to the recommendations are:

  • Updating evaluation criteria for the advancement to increased levels of activity; patients will now rate their symptoms daily as the same, better, or worse. Completing the longer self-assessment questionnaire, called the Neurobehavioral Symptom Inventory, will now take place at follow-up provider visits.
  • Replacing "rest" with "relative rest" in the first stage of the PRA to reflect recent research showing prolonged complete rest may extend recovery.
  • Enhancing activity recommendations and developing guidelines for duty modification at each stage.
  • Clarifying and expanding return to duty screening to include testing both physical and cognitive skills.

TBICoE developed its recommendations by collaborating with military service branches, an expert working group, and an end user group. TBICoE is a division aligned under the DHA's Research and Development Directorate.

Recent studies have found concussion recovery is a gradual process, indicating the need to strike a balance between rest and activity in the early stages of recovery. While overexertion slows recovery, so can too much rest, according to TBICoE.

TBICoE researchers found patients cared for by providers who had completed a two-hour, in-person training at three military installations using a progressive return to activity process reported a greater overall reduction in symptoms after one week, one month, and three months, compared to patients who were treated by providers who had not received the instructions.

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What's the best way to recover from a concussion? Returning to duty too soon after a concussion can lead to prolonged symptoms, decreased readiness, poor marksmanship, accidents and falls, and increased risk of more concussions. Progressively increasing activity in a step-wise manner can help you resolve your symptoms and return to duty safely. Ask your primary health care provider about TBICoE's Progressive Return to Activity to help you return to duty as quickly and safely as possible. Visit health.mil/TBICoE.

This TBICoE infographic gives an overview of the risks of returning to duty too soon after a concussion and explains how a progressive increase in activity can help get you back to duty safely. Returning to duty too soon after concussion can lead to prolonged symptoms, poor marksmanship, decreased readiness, accidents and falls, and increased risk of more concussions.

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Traumatic Brain Injury (TBI) is structural alteration of the brain or physiological disruption of brain function caused by an external force.  TBI, particularly mild TBI or concussion, is the most common traumatic injury in the U.S. military. This analysis provides the estimated rates of incident TBIs among service members before their first-ever deployment as well as separately among service members during deployments/ after deployments. It also mentions factors that may explain why the TBI incidence rates among the previously deployed were higher than those of the never-deployed group. Moreover, it describes the demographic and military traits of service members diagnosed as TBI cases (before/after deployment). Categorization of person time during surveillance period included four categories: Group 1 (Never deployed/TBI before first-ever deployment), Group 2 (Currently deployed or within 30 days of return), Group 3 (previously deployed but not currently deployed nor within 30 days of return) and Censored after Diagnosis of TBI. From 2001-2016, 276,858 active component service members received first-time diagnoses of TBI. The crude overall incidence rate of TBI among deployed service members was 1.5 times that of service members assigned to Group 1 and 1.2 times that of service members in Group 3 during the surveillance period.  Total TBI cases by group were Group 1 42.8%, Group 2 13.2% and Group 3 44.0%. Incidence rates by group (per 100,000 person-years) were Group 1 1,141.3, Group 2 1,690.5, and Group 3 1,451.2. Learn more at www.Health.mil/MSMR and see fact sheets at www.Health.mil/AFHSB

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