Skip to main content

Military Health System

Test of Sitewide Banner

This is a test of the sitewide banner capability. In the case of an emergency, site visitors would be able to visit the news page for addition information.

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.

You also may be interested in...

MACE 2 Provider Training: Instructor Guide

Publication
7/31/2020

The MACE 2 Instructor Guide provides the curriculum needed for medical providers to train peers on how to properly use the MACE 2.

Vestibular Ocular Motor Screening (VOMS)

Publication
7/31/2020

The VOMS for Concussion Instructions is a clinical support tool for use with the MACE 2.

MACE 2 Provider Training: Student Workbook

Publication
7/31/2020

The MACE 2 Student Workbook is for use with the MACE 2 training slides to learn how to properly use the MACE 2.

ICD-10 Coding Guidance for TBI

Publication
7/31/2020

TBICoE developed this quick reference resource based on the latest coding guidance and the Military Health System Professional Services and Specialty Medical Coding Guidelines Version 5.0, to facilitate consistent and accurate coding for TBI diagnoses and related symptoms and conditions.

Provider Training Slides for Management of Headache Following Concussion/Mild TBI

Publication
7/31/2020

Presentation that educates health care providers about the intent of and how to use the Management of Headache Following Concussion/Mild TBI clinical recommendation (includes knowledge tests and case studies).

Management of Sleep Disturbances Following Concussion/mTBI Clinical Recommendation

Publication
7/31/2020

This TBICoE clinical recommendation outlines how to identify and assess sleep disturbances following a concussion; primary care manager initial treatment options; and recommended conditions for referral to sleep medicine.

Cognitive Rehabilitation Following Mild to Moderate TBI Clinical Recommendation - Short

Publication
7/30/2020

This short version of the Cognitive Rehabilitation Following Mild to Moderate TBI Clinical Recommendation provides an at-a-glance overview of the full-length version for quick access and use on the job.

Cognitive Rehabilitation Following Mild to Moderate TBI Clinical Recommendation Appendices

Publication
7/30/2020

The appendices to the Cognitive Rehabilitation Following Mild to Moderate TBI Clinical Recommendation include a glossary of terms, outcome measures, evidence tables, and other useful resources.

Cognitive Rehabilitation for Following Mild to Moderate TBI Clinical Recommendation - Full

Publication
7/30/2020

This TBI clinical recommendation is broken down into three primary categories: Modifications for Service Members and Veterans; Interventions and Strategies to Address Cognitive Dysfunction; and, Delivery of Rehabilitation for Patients with Cognitive Challenges. Each category contains clinical recommendations, the background and rationale behind them, evidence review references, and clinical resources.

Cognitive Rehabilitation Following Mild to Moderate TBI - Referring Provider Resource

Publication
7/30/2020

This resource answers common questions that referring providers may have, such as how to determine if a patient is having cognitive difficulties or whether the patient is a good candidate for cognitive rehabilitation following a mild to moderate traumatic brain injury.

Military Acute Concussion Evaluation 2 (MACE 2)

Publication
7/30/2020

The 2018 Military Acute Concussion Evaluation 2 (MACE 2) is an acute assessment tool for all medically trained personnel who treat service members involved in a potentially concussive event. The MACE 2 incorporates current state-of-the-science traumatic brain injury information, including vestibular-ocular-motor screening. The MACE 2 is an update to and replaces the original MACE.

Recurrent Concussion Evaluation

Publication
7/30/2020

The TBICoE Recurrent Concussion Evaluation card is designed to guide providers in the management of patients with a history of three or more documented concussions within a 12-month span.

Page 6 of 6 , showing items 76 - 87
First < ... 6 > Last 
Refine your search
Last Updated: December 28, 2022
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery