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Balancing rest, activity key to recovering from concussion

Image of 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).

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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Last Updated: July 11, 2023
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