Implementation of Progressive Return to Activity Guidelines Following Mild Traumatic Brain Injury
Deborah Kenner
Source: http://afterdeployment.t2.health.mil/library
Overview
Eighty-three percent of the brain injuries sustained by service members from 2000-2013 have been classified as mild Traumatic Brain Injury (mTBI). 1 Healthcare providers often find that service members with blast mTBI experience persistent post-concussive and exertional symptoms. These patients largely recover within the acceptable timeframe, but continue to report vertigo, diplopia, nausea, and other debilitating symptoms during physical activity. 2 The predominant recommendation for these patients was rest; however, recent literature and guidelines have supported activity limitation over complete bed rest after mTBI. 3
I decided to further investigate this concept during our Evidence-Based Practice II course during the fall of my third year in this program. I had worked with many service members with persistent post-concussive exertional symptoms during my most recent rotation, and learned from my Clinical Instructor that these patients can be treated with sub-maximal exercise so long as it does not reproduce their symptoms. My research regarding this topic was focused on answering the following PICO question: In service members with mTBI, does sub-symptom exercise lead to a quicker alleviation of persistent post-concussive exertional symptoms than rest?
As it turns out, the current literature was not sufficient to answer my question. The majority of research did not specifically mention exertional symptoms and the published evidence was not always directly applicable to service members. Nevertheless, I was pleased with my Evidence Table and Research Paper on this topic, because they revealed that sub-maximal, graded, and individualized aerobic exercise testing and exercise are both safe and potentially effective for treating persistent post-concussive symptoms.
The Defense and Veterans Brain Injury Center recently published clinical recommendations entitled, “Progressive Return to Activity Following Acute Concussion/Mild Traumatic Brain Injury”. Academic experts, sports concussion clinicians, and military TBI experts helped to develop these materials with the intent of providing a standardized medical approach for service members as they return to activity following mTBI. 4 The guidelines are essentially step-by-step recommendations for the frequency, intensity, duration, and type of activity in which a service member can partake at particular milestones after mTBI. 5
My intent for this Capstone was to create a Program Proposal that incorporates the fundamental aspects of these guidelines. The program is meant to facilitate implementation of the guidelines, especially in clinics that do not currently treat service members following mTBI. I see a true need for physical therapy clinics to participate in the care of these patients, regardless of whether the clinics have neurological or vestibular therapists on staff. I chose to focus on Eglin Air Force Base for my Capstone, but the program can be adjusted to serve any physical therapy clinic that treats service members. Ultimately, I hope that this program can facilitate confidence in therapists who are not accustomed to working with mTBI patients.
I plan to begin my career as a physical therapist in a military setting, and I hope to present and implement the program proposal and other materials from my Capstone at my future place of employment.
Literature Review
I had to take vestibular rehabilitation into account for this Capstone: Vestibular symptoms are a common comorbidity to mTBI after blast exposure. 6 I completed a literature review of the current evidence to answer the following PICO question: In soldiers with mTBI, what are the predominant evidence-based interventions to achieve alleviation of post-concussive peripheral vestibular symptoms? I examined vestibular rehabilitation in several populations, with an intentional focus on studies that provided information on service members. The results are summarized in this Evidence Table (which consists of these detailed References).
I also created a Therapist Handout, “Vestibular Examination and Treatment for the Orthopedic Physical Therapist”, given the intent of this program to facilitate return to activity guidelines implementation in clinics that do not frequently work with brain-injured patients. It is meant to be a quick reference sheet for physical therapists who are not comfortable with vestibular examinations or who may need a quick reminder of exam techniques and treatment options. If the therapist requires more detailed information, he or she should reference other resources.
Special Thanks & Feedback
I would like to thank the individuals who served on my committee for their invaluable guidance and feedback on this Capstone project. Thank you to Henry McMillan and Daniel Jayne. I would also like to thank my advisor, Karen McCulloch, for providing crucial guidance and support from initiation to conclusion of this project. Furthermore, thank you to Major Lance Mabry for taking the time to provide me with information about the physical therapy clinic at Eglin Air Force Base.
I expect to update this Capstone frequently due to the rising recognition and increased research of return to activity following mTBI. If you would like to provide additional feedback for modifications to this project, please do by emailing deborah_kenner@med.unc.edu or by filling out the comments box below.
References
1. DoD worldwide TBI numbers. Defense and Veterans Brain Injury Center Web site. http://www.dvbic.org/sites/default/files/uploads/2013 up to Q2-dod-tbi-worldwide-2000-as-of-Q1-Q2-13_01-08-13RDS.pdf. Accessed 4/4/2014.
2. Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative effects associated with recurrent concussion in collegiate football players: The NCAA concussion study. JAMA. 2003;290(19):2549-2555. doi: 10.1001/jama.290.19.2549.
3. Silverberg ND, Iverson GL. Is rest after concussion “the best medicine?”: Recommendations for activity resumption following concussion in athletes, civilians, and military service members. J Head Trauma Rehabil. 2013;28(4):250-259. doi: 10.1097/HTR.0b013e31825ad658; 10.1097/HTR.0b013e31825ad658.
4. New clinical recommendations released for traumatic brain injuries. Defense and Veterans Brain Injury Center Web site. http://dvbic.dcoe.mil/press/2014/new-clinical-recommendations-released-traumatic-brain-injuries. Updated 2014. Accessed 4/4/2014.
5. Progressive return to activity following acute concussion/mild traumatic brain injury: Guidance for the rehabilitation provider in deployed and non-deployed settings: Clinical recommendation. Defense and Veterans Brain Injury Center Web site. http://dvbic.dcoe.mil/sites/default/files/2013_PRA_Rehab_CR_FINAL.pdf. Updated 2014. Accessed 4/4/2014.
6. Scherer MR, Schubert MC. Traumatic brain injury and vestibular pathology as a comorbidity after blast exposure. Phys Ther. 2009;89(9):980-992. doi: 10.2522/ptj.20080353; 10.2522/ptj.20080353.
5 Responses to “Implementation of Progressive Return to Activity Guidelines Following Mild Traumatic Brain Injury”
Karen
Hi Deborah,
Nice job pulling this all together. I’ve got my fingers crossed for you for a job interview at Eglin, so you can put the materials to use. Would you be willing to share the clinician “cheat sheet” with future eDPT students when we do vestibular content? We would of course reference you if we were to do so….
kmac
Deborah Kenner
Allison,
Thank you for taking an interest in my Capstone! I am so happy that you all plan to use the handout if the need arises. I hope it serves to increase your comfort level with this population!
Deborah
Allison Rowe
Deborah,
I am truly impressed by your capstone material that you have presented here. This is a very interesting topic to me, and I have been curious to follow what you did with your PICO question since EBP II. I’m going to reiterate what Susie said – that I am in awe of the handout you created! I will absolutely be using that in my clinical practice if I ever come across a patient with vestibular symptoms.
I also wanted to commend you for taking the information that you found and doing something so meaningful with it. Your passion for this subject and for your future patients is clearly evident. Both of your evidence tables were thorough, but I was happy to see that you took it a step further to propose this program. By drawing attention to the fact that this needs to be addressed in clinics, you are potentially helping so many people!!
Major kudos 🙂
Allison
Deborah Kenner
Susie,
Thank you so much for your comment and interest in my Capstone! I am thrilled that you found the handout comprehensive and useful; please utilize it as a reference whenever you need it. I do want to address the program proposal versus the Guidelines themselves: The Progressive Return to Activity Guidelines were established by a large group of very intelligent and hard-working individuals and I absolutely do not take credit for them. A majority of the specific activity do’s and don’t’s that I listed in the appendix to my program proposal were extracted from materials published with the Guidelines as well.
I did however create the program proposal to implement the guidelines with advice from my committee (who are much more familiar with military proposals than I!). I suppose the information I gleaned from my needs assessment of Eglin AFB is a bit of a double-edged sword: On one hand, I was excited that there was definitely a need for what I had in mind…on the other, the mTBI patients are not currently treated by physical therapists. So far, I have shared this Capstone site with my advisor, committee, classmates, and cover letter as part of an application. I still find myself making minor tweaks to the information and attachments, but I intend to share it with Major Lance Mabry and others soon!
To answer your final question regarding return to combat as simply as possible, yes. One concept I learned from my CI (Henry McMillan) in my last rotation was as follows: mTBI used to be a somewhat taboo topic in the military. If an individual acquired a brain injury, he or she could often say goodbye to a military career. However, we can treat these individuals with a comprehensive approach that oftentimes includes everything from neurology to physical and occupational therapy to speech and language pathology. As you saw in the Guidelines, Stage 6 aims for a pre-injury level of activity. Our patients were often apprehensive about seeking treatment because they assumed it would have a negative impact on their career. We countered this by asking them to consider, “Why would the military have such treatment programs in place if the intent was not to achieve pre-injury status?”
As with any patient we treat in physical therapy, not every one of these patients will return to combat or achieve that pre-injury status. Many other factors come into play, including the pathology, shear number of injuries, comorbid conditions, and patient willingness and motivation (just to name a few). I would be interested in future data describing the number of service members who do return to combat after successful completion of the Guidelines!
Thank you again for your comments, questions, and words of encouragement!
Deborah
Susie Williams
Deborah,
Your handout for therapists is AWESOME! Thank you so much for taking the time to not only create a program we can implement to treat this population, but for also creating such an easy-to-navigate, beneficial, quick reference for the clinicians. There is everything you could want on there – symptoms to look for/ask about, components of the exam, red flags, potential causes that will help initiate this conversation with our patients, and most importantly (especially to us beginning clinicians, or those of us new to this population) intervention ideas to get started. I am very impressed with the layout you chose and the organization of this handout and will definitely use it as a reference in the future.
In reference to the program you created, I think you did a great job establishing a need at Eglin Air Force Base for physical therapy to be involved in the treatment of mTBI. It was definitely apparent within the first few sentences that PT should be playing a more prominent role for efficient recovery in this population. Did you have the opportunity to implement this program at Eglin Air Force Base or hand it off to Major Lance Mabry? I appreciated that you had both recommended activities in your program proposal but also, and possibly more importantly, that you included activities that should NOT be done at the various stages. My only question for you: Is this population expected to be able to return to combat after successful implementation of this program and symptom management and treatment?
Thank you for sharing this, I definitely will be utilizing it in my future career and commend you for a job well done!
Susie