Impact of Prior Brain Injury on Concussion Recovery in Military Personnel: Evaluation of Timing Between Concussions.

OBJECTIVE: To evaluate the potential impact of timing between the current and the most recent previous concussions on symptom severity among acutely concussed active duty military Service members (SMs). SETTING: Three military installations. PARTICIPANTS: Eighty-four SMs aged 18 to 44 years who sustained a concussion within 72 hours of enrollment. No previous concussion within 1 year preenrollment. DESIGN: Longitudinal study with enrollment within 72 hours of injury, and follow-up at 1 week and 1 month postinjury. MAIN MEASURES: Lifetime concussion history (yes/no) and recency of the latest concussion (no history, relatively more recent [1 to <6 years ago], and more remote [6+ years ago]) from the current concussion using the Ohio State University Traumatic Brain Injury Identification Method-Interview Form. Symptom severity (total and by categories: cognitive, affective, somatosensory, vestibular) at all time points using the Neurobehavioral Symptoms Inventory. RESULTS: Concussion history assessed as having any previous concussion was not found significantly related to symptom severity (total or by categories) following a current concussion. However, when timing between concussion was taken into account, time since previous concussion was significantly related to symptomatology, whereby those with relatively more recent previous concussion had greater total symptoms within 72 hours of injury and at 1 week postinjury (though not at 1 month) than those with more remote previous concussion (≤72 hours: difference = 15.4, 95% CI = 1.8 to 29.1; 1 week: difference = 15.2, 95% CI = 1.2 to 29.2) or no history (≤72 hours: difference = 11.6, 95% CI = 0.4 to 22.8; 1 week: difference = 13.9, 95% CI = 2.4 to 25.4). When evaluated by symptom category, this relationship was particularly important on affective and somatosensory symptoms. CONCLUSION: In recently concussed active duty SMs, the timing between the current and previous concussions may be an important factor in determining prognosis. Clinical assessment of concussion history that accounts for the timing of the most recent event may be necessary to identify patients who may require a more conservative plan of care and more gradual return to activity in the acute recovery stage.

Use of the Progressive Return to Activity Guidelines May Expedite Symptom Resolution After Concussion for Active Duty Military.

BACKGROUND: Clinical recommendations for concussion management encourage reduced cognitive and physical activities immediately after injury, with graded increases in activity as symptoms resolve. Empirical support for the effectiveness of such recommendations is needed. PURPOSE: To examine whether training medical providers on the Defense and Veterans Brain Injury Center's Progressive Return to Activity Clinical Recommendation (PRA-CR) for acute concussion improves patient outcomes. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: This study was conducted from 2016 to 2018 and compared patient outcomes before and after medical providers received an educational intervention (ie, provider training). Patients, recruited either before or after intervention, were assessed at ≤72 hours, 1 week, 1 month, 3 months, and 6 months after a concussion. The participant population included 38 military medical providers and 106 military servicemembers with a diagnosed concussion and treated by one of the military medical providers: 58 patient participants received care before the intervention (ie, provider training) and 48 received care after intervention. The primary outcome measure was the Neurobehavioral Symptom Inventory. RESULTS: The patients seen before and after the intervention were predominantly male (89.7% and 93.8%, respectively) of military age (mean ± SD, 26.62 ± 6.29 years and 25.08 ± 6.85 years, respectively) and a mean ± SD of 1.92 ± 0.88 days from injury. Compared with patients receiving care before intervention, patients receiving care after intervention had smaller increases in physical activities (difference in mean change; 95% CI, 0.39 to 6.79) and vestibular/balance activities (95% CI, 0.79 to 7.5) during the first week of recovery. Although groups did not differ in symptoms at ≤72 hours of injury (d = 0.22; 95% CI, -2.21 to 8.07), the postintervention group reported fewer symptoms at 1 week (d = 0.61; 95% CI, 0.52 to 10.92). Postintervention patients who completed the 6-month study had improved recovery both at 1 month (d = 1.55; 95% CI, 5.33 to 15.39) and 3 months after injury (d = 1.10; 95% CI, 2.36 to 11.55), but not at 6 months (d = 0.35; 95% CI, 5.34 to 7.59). CONCLUSION: Training medical providers on the PRA-CR for management of concussion resulted in expedited recovery of patients.

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.

The large number of U.S. service members diagnosed with concussion/mild traumatic brain injury each year underscores the necessity for clear and effective clinical guidance for managing concussion. Relevant research continues to emerge supporting a gradual return to pre-injury activity levels without aggravating symptoms; however, available guidance does not provide detailed standards for this return to activity process. To fill this gap, the Defense and Veterans Brain Injury Center released a recommendation for primary care providers detailing a step-wise return to unrestricted activity during the acute phase of concussion. This guidance was developed in collaboration with an interdisciplinary group of clinical, military, and academic subject matter experts using an evidence-based approach. Systematic evaluation of the guidance is critical to ensure positive patient outcomes, to discover barriers to implementation by providers, and to identify ways to improve the recommendation. Here we describe a multi-level, mixed-methods approach to evaluate the recommendation incorporating outcomes from both patients and providers. Procedures were developed to implement the study within complex but ecologically-valid settings at multiple military treatment facilities and operational medical units. Special consideration was given to anticipated challenges such as the frequent movement of military personnel, selection of appropriate design and measures, study implementation at multiple sites, and involvement of multiple service branches (Army, Navy, and Marine Corps). We conclude by emphasizing the need to consider contemporary approaches for evaluating the effectiveness of clinical guidance.

Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers.

OBJECTIVE: Previously published mild traumatic brain injury (mTBI) management guidelines provide very general recommendations to return individuals with mTBI to activity. This lack of specific guidance creates variation in military rehabilitation. The Office of the Army Surgeon General in collaboration with the Defense and Veterans Brain Injury Center, a component center of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, convened an expert working group to review the existing literature and propose clinical recommendations that standardize rehabilitation activity progression following mTBI. PARTICIPANTS: A Progressive Activity Working Group consisted of 11 Department of Defense representatives across all service branches, 7 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury representatives, and 8 academic/research/civilian experts with experience assessing and treating individuals with mTBI for return to activity. An expert working group meeting included the Progressive Activity Working Group and 15 additional subject matter experts. METHODS: In February 2012, the Progressive Activity Working Group was established to determine the need and purpose of the rehabilitation recommendations. Following literature review, a table was created on the basis of the progression from the Zurich consensus statement on concussion in sport. Issues were identified for discussion with a meeting of the larger expert group during a July 2012 conference. Following development of rehabilitation guidance, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury coordinated a similar process for military primary care providers. RESULTS: End products for rehabilitation and primary care providers include specific recommendations for return to activity after concussion. A 6-stage progression specifies activities in physical, cognitive, and balance/vestibular domains and allows for resumption of activity for those with low-level or preinjury symptom complaints. CONCLUSIONS: The clinical recommendations for progressive return to activity represent an important effort to standardize activity progression across functional domains and offer providers duty-specific activities to incorporate into intervention. Recommendations were released in January 2014.

Current recommendations for the diagnosis and treatment of concussion in sport: a comparison of three new guidelines.

Currently, there is considerable debate within the sports medicine community about the role of concussion and the risk of chronic neurological sequelae. This concern has led to significant confusion among primary care providers and athletic trainers about how to best identify those athletes at risk and how to treat those with concussion. During the first quarter of 2013, several new or updated clinical practice guidelines and position statements were published on the diagnosis, treatment, and management of mild traumatic brain injury/concussion in sports. Three of these guidelines were produced by the American Medical Society for Sports Medicine, The American Academy of Neurology, and the Zurich Consensus working group. The goal of each group was to clearly define current best practices for the definition, diagnosis, and acute and post-acute management of sports-related concussion, including specific recommendations for return to play. In this article, we compare the recommendations of each of the three groups, and highlight those topics for which there is consensus regarding the definition of concussion, diagnosis, and acute care of athletes suspected of having a concussion, as well as return-to-play recommendations.

Access to specialty care in autism spectrum disorders-a pilot study of referral source.

BACKGROUND: In the United States, a medical home model has been shown to improve the outcomes for children with special health care needs. As part of this model, primary care physicians provide comprehensive medical care that includes identification of delayed and/or atypical development in children and coordination of care with specialists. However, it is not clear if families of children with Autism Spectrum Disorder (ASD) rely on the medical home model for care of their child to the same extent as families of children with other special health care needs. This study aims to add to the understanding of medical care for children with ASD by examining the referral source for specialty care. METHODS: This retrospective study was accomplished by evaluating parent completed intake data for children with ASD compared to those with other neurological disorders in a single physician Pediatric Neurology Practice at a major urban medical center in Northern New Jersey. To account for referral bias, a similar comparison study was conducted using a multispecialty ASD practice at the same medical center. Parent reported "source of referral" and "reason for the referral" of 189 ASD children and 108 non-ASD neurological disordered children were analyzed. RESULTS: The specialty evaluations of ASD were predominantly parent initiated. There were significantly less referrals received from primary care physicians for children with ASD compared to children with other neurodevelopmental disorders. Requirement of an insurance referral was not associated with a primary care physician prompted specialty visit.We identified different patterns of referral to our specialty clinics for children with ASD vs. children with other neurolodevelopmental disorders. CONCLUSION: The majority of the families of children with ASD evaluated at our autism center did not indicate that a primary care physician initiated the specialty referral. This study suggests that families of children with ASD interface differently with the primary care provider than families of children with other neurological disorders.