Progressive Return To Activities Clinical Recommendation
The Progressive Return to Activities Clinical Recommendation (PRA CR) also was developed by DVBIC for the DoD to assist military HCPs in managing SMs with concussion by providing systematic and evidence-based guidance to both prevent extended rest and promote return to full duty as quickly and safely as clinically indicated. The general guidance is to monitor the SM at each of the 6 stages in the process and safely and gradually increase activity to the next stage as tolerated. Daily symptoms are measured using the Neurobehavioral Symptom Inventory (NSI), which SMs self-administer every morning at each stage within the process.
Prior to initiation of the progressive return to activity, SM education using the educational brochure is strongly encouraged, as previous evidence suggests that it is an effective intervention during the acute stages of injury.10,11 Return to activity follows a 6 stage process, from stage 1 (rest) through stage 6 (unrestricted activity) (Table 4). Referral to rehabilitation providers (RPs) or higher care is left to the discretion of the PCM when (1) recovery is not progressing as anticipated; (2) progression is not being made within a 7-day period; or (3) symptoms worsen with time. The guidance outlined in the PRA CR is consistent with current policies and medical literature, and undergoes reviews as updates in the field emerge. The PRA for PCM, PRA for RP, Clinical Support Tool for PCM, Clinical Support Tool for RP, Training Slides for PCM, Training Slides for RP, Educational Brochure for PCM, and Patient Educational Tool for RP can be found on the DVBIC website (dvbic.dcoe.mil).
Description
To improve the clinical utility, 2 separate PRA CRs were developed specifically for PCMs (Figure 2) and RPs (Figure 3). The PRA CR for PCMs provides the initial framework to monitor SMs during recovery and gradually increase physical, cognitive, and vestibular/balance activities as symptoms improve in order to return to preinjury activities. The PRA CR for RPs outlines the approach for treating SMs who meet 1 of the following criteria: recovery is not progressing as anticipated, there is no progression in 7 days, symptoms are worsening, the SM is symptomatic after exertional testing following stage 5, or referral made per PCM judgment. Following the mandatory 24-hour rest period after a diagnosis of a concussion, progression through the PRA algorithm is based on history of concussion within the past 12 months (ie, 1, 2, or ≥ 3 concussions) and symptomatology, with varying treatment pathways depending on the SM’s responses to history and symptomology.
Guidelines
• One Concussion within Past 12 Months. Following the mandatory 24-hour rest period, if the SM is asymptomatic, then exertional testing (eg, activities such as push-ups, sit-ups, running in place, step aerobics, stationary bike, treadmill and/or hand crank) is performed at 65 to 85% of target heart rate for 2 minutes and symptoms are reassessed. If still asymptomatic, the SM may return to preinjury activity; however, if exertional testing provokes symptoms > 1 (mild) on the NSI, the SM should return to stage 1 with an additional 24 hours of rest. A second exertional test can be performed after stage 1, and if symptoms are provoked, progression through the remaining stages 2 to 5 is encouraged. Symptoms are continually monitored throughout each stage to determine whether the SM is recovered sufficiently to proceed to the next stage.
• Two Concussion Within Past 12 Months. Following the mandatory 24-hour rest period, no exertional testing is performed, and SMs move directly into stage 1 and remain at stage 1 or stage 2 for 7 consecutive days with no symptoms > 1 on the NSI before advancing through the remaining stages. Some defining features are longer rest periods (eg, 5 additional days of rest at stage 2) and additional patient education, symptom management, and follow-up.
• Three or more Concussions Within Past 12 Months. Following the 24 hour mandatory rest period, in cases where ≥ 3 concussions have occurred within a 12 month period, the recommendation is to provide guidance for symptom management rest and refer the SM to a higher level of care.