Use of a multi-level mixed methods approach to study the effectiveness of a primary care progressive return to activity protocol after acute mild traumatic brain injury/concussion in the military

Gregory, Emma; West, Therese; Cole, Wesley R.; Bailie, Jason M.; McCulloch, Karen; Ettenhofer, Mark L.; Cecchini, Amy; Qashu, Felicia

doi:10.1016/j.cct.2016.11.005

Cited by 12 publications

(13 citation statements)

References 31 publications

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“…The short-and long-term consequences of TBI represent one of the most significant and complex challenges for the military healthcare system. 22,23 A TBI impacts force readiness in the short term, while a substantial number of veterans experience the consequences of TBI (and post-traumatic stress disorder [PTSD]) in the long term. 24 Dominant use of improvised explosive devices (IEDs) by insurgents against United States (US) military personnel during the latest military conflicts (and their continued use) have resulted in a staggering number of blast-induced TBI (bTBI) cases.…”

Section: Blast Scenariosmentioning

confidence: 99%

Modeling the Long-Term Consequences of Repeated Blast-Induced Mild Traumatic Brain Injuries

Agoston

2017

Journal of Neurotrauma

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Repeated mild traumatic brain injury (rmTBI) caused by playing collision sports or by exposure to blasts during military operations can lead to late onset, chronic diseases such as chronic traumatic encephalopathy (CTE), a progressive neurodegenerative condition that manifests in increasingly severe neuropsychiatric abnormalities years after the last injury. Currently, because of the heterogeneity of the clinical presentation, confirmation of a CTE diagnosis requires post-mortem examination of the brain. The hallmarks of CTE are abnormal accumulation of phosphorylated tau protein, TDP-43 immunoreactive neuronal cytoplasmic inclusions, and astroglial abnormalities, but the pathomechanism leading to these terminal findings remains unknown. Animal modeling can play an important role in the identification of CTE pathomechanisms, the development of early stage diagnostic and prognostic biomarkers, and pharmacological interventions. Modeling the long-term consequences of blast rmTBI in animals is especially challenging because of the complexities of blast physics and animal-to-human scaling issues. This review summarizes current knowledge about the pathobiologies of CTE and rmbTBI and discusses problems as well as potential solutions related to high-fidelity modeling of rmbTBI and determining its long-term consequences.

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Section: Blast Scenariosmentioning

confidence: 99%

Modeling the Long-Term Consequences of Repeated Blast-Induced Mild Traumatic Brain Injuries

Agoston

2017

Journal of Neurotrauma

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“…Data for this study were drawn from the broader DVBIC (Defense and Veterans Brain Injury Center, RRID:SCR_004505) PRA CR Study, which investigated the impact of implementing the DVBIC PRA CR focused on gradual return to unrestricted activity post-concussion among SMs (1, 14). The parent study has been previously described in detail (15). Data from the current study included only concussed SM participants who received “usual treatment” from providers who had not yet received focused training on the PRA CR.…”

Section: Methodsmentioning

confidence: 99%

Activity Level and Type During Post-acute Stages of Concussion May Play an Important Role in Improving Symptoms Among an Active Duty Military Population

et al. 2019

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Background: Previous research demonstrates that early rest and gradual increases in activity after concussion can improve symptoms; however, little is known about the intensity and type of activity during post-acute time periods—specifically months post-injury—that may promote optimal recovery in an active duty service member (SM) population. Objective: The objectives of this study were to investigate how activity level and type at the post-acute stages of concussion (at 1 and 3 month[s] post-injury) impact subsequent symptoms among SMs, and how this relationship might differ by the level of symptoms at the time of injury. Methods: Participants included 39 SMs ages 19–44 years from 3 military installations who were enrolled within 72 h after sustaining a concussion. Linear regression was used to evaluate whether the association between activity level at 1 or 3 month(s) post-injury (as measured by a multi-domain Activity Questionnaire) and subsequent symptoms at 3 and/or 6 months (as measured by the Neurobehavioral Symptom Inventory) varied by the level of symptoms at acute stages of concussion. Partial correlation was used to evaluate relationships that did not differ by acute symptom level. Symptoms at the time of activity assessment (1 or 3 month[s]) were accounted for in all models, as well as activity level at acute stages of concussion. Results: Greater physical and vestibular/balance activity at 1 month were significantly correlated with lower symptoms at 3 months, but not at 6 months post-injury. There were no significant associations found between activity (total or by type) at 3 months and symptoms at 6 months. The association between activity level at either 1 or 3 months and subsequent symptoms at 3 and/or 6 months did not differ by the level of acute symptoms. Conclusion: The intensity and type of activities in which SMs engage at post-acute stages of concussion may impact symptom recovery. Although low levels of activity have been previously shown to be beneficial during the acute stage of injury, higher levels of activity may provide benefit at later stages. These findings provide support for the importance of monitoring and managing activity level beyond the acute stage of concussion.

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“…Provider clinical practices and patient outcomes were examined before and after providers completed the training. 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.…”

Section: Changes In Neurobehavioral Symptoms and Activity Levels Acromentioning

confidence: 96%

“…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.…”

Section: Changes In Neurobehavioral Symptoms and Activity Levels Acromentioning

confidence: 99%

“…In 2015, following publication by the Defense and Veterans Brain Injury Center (DVBIC) of ''Progressive Return to Activity Following Acute Concussion/Mild Traumatic Brain Injury: Guidance for the Primary Care Manager in Deployed and Nondeployed Settings,'' 10 DVBIC launched the Progressive Return to Activity (PRA) study. 11 This multi-site longitudinal research project collected information about primary care providers' clinical practices and concussion patients' outcomes at three major U.S. military treatment facilities serving U.S. Army, Navy, and Marine Corps populations. The principal goals of the project were to improve understanding of concussion care and recovery for active duty SMs, and to identify methods to enhance patient outcomes by increasing adherence to clinical recommendations (CRs) for PRA after injury.…”

Section: Introductionmentioning

confidence: 99%

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

Ettenhofer

Remigio-Baker

Bailie

et al. 2020

Neurotrauma Reports

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Primary care providers can play a crucial role in the clinical management of concussion. However, many providers lack up-to-date information about best practices for rest and return to activity after these injuries. Most research on this topic has been conducted in athletes, and so less is known about how to assist patients with returning to activity in other settings and populations. This article provides a review of best practices for management of progressive return to activity after concussion, with an emphasis on ''lessons learned'' from the Defense and Veterans Brain Injury Center (DVBIC) Progressive Return to Activity (PRA) study, a multi-site longitudinal research project conducted to evaluate concussion management practices and the effectiveness of provider training on DVBIC clinical recommendations (CRs). Provider clinical practices and patient outcomes were examined at three U.S. military treatment facilities before and after providers completed a standardized training on DVBIC PRA CRs. In summary, research findings provide additional support that concussion recovery can be influenced by patients' activity levels after injury. Patients with concussion may experience poorer outcomes if they return to pre-injury levels of activity too rapidly, but they may also be at risk for prolonged symptoms if they fail to increase activity levels over time after an initial period of rest. Additionally, training primary care providers in return to activity guidelines can result in more effective patient education and better clinical outcomes. This knowledge can be used to inform best practices for progressive return to activity in both civilian and military settings.

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Use of a multi-level mixed methods approach to study the effectiveness of a primary care progressive return to activity protocol after acute mild traumatic brain injury/concussion in the military

Cited by 12 publications

References 31 publications

Modeling the Long-Term Consequences of Repeated Blast-Induced Mild Traumatic Brain Injuries

Modeling the Long-Term Consequences of Repeated Blast-Induced Mild Traumatic Brain Injuries

Activity Level and Type During Post-acute Stages of Concussion May Play an Important Role in Improving Symptoms Among an Active Duty Military Population

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

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