The Defense and Veterans Affairs departments have published new guidelines on post-concussion care — a detailed, step-by-step road map for returning to duty that embraces rest and nixes activities such as driving and video games.
The recommendations, for doctors and rehabilitation specialists who treat troops, veterans and family members with concussions, outline a six-step approach that moves from complete rest to unrestricted activity.
According to the Defense and Veterans Brain Injury Center, the guidance is the first of its kind, spelling out treatment for concussion, also called mild traumatic brain injury, and recovery, definitively answering the question: “When is it safe to return to work (or play)?”
“These recommendations offer a standardized medical approach for service members who have sustained a mild TBI ... which facilitates optimal recovery,” said Army Col. Sidney Hinds, DVBIC director. “We created these clinical recommendations because of a need identified by our [practitioners].”
From 2000 to 2011, of the nearly 300,000 troops who received a head injury, 238,000 suffered concussions. Roughly 5 percent of all combat troops have received a mild head injury and thousands more have gotten concussions in training, sports and accidents.
The guidelines — “Progressive Return to Activity Following Acute Concussion/Mild Traumatic Brain Injury” — include a pocket card defining 22 symptoms, such as vision problems, forgetfulness, headache and hearing loss. Patients rate their symptoms on a scale of 0 to 4; if there are no symptoms after 24 hours of rest, patients are given an exertion test — running, pushups and pullups — to see if symptoms resurface.
Pass, and you can return to duty. Fail and you go back to the detailed flow chart to determine what additional care, monitoring and treatment you may need.
“We want to slowly reintegrate their activity to a place where they were before they sustained a concussion, in a safe manner,” said Kathy Helmick, DVBIC deputy director.
The process moves gradually from Stage 1, (24 hours or more of complete rest, meaning extremely light physical, cognitive and vestibular balance activities), adding daily and occupational activities along the way, to Stage 6 (unrestricted activity).
Video games are not allowed until a patient reaches Stage 4; driving is restricted until Stage 5.
Helmick said those two activities stimulate neurons and take more cognitive exertion and memory capability than is desired when the brain is injured and vulnerable.
“Its chemistry is altered,” Helmick said. “Video games and driving take a lot of cognitive ability, decisions, judgment, attention and memory. All of these can be altered when somebody has a concussion. That’s why you want to limit these activities until there are some signs that your brain is ready.”
The stages are well-defined, she said, because many doctors interpret words like “rest” differently.
“We don’t want people to think rest means going to bed, turning off the light and sleeping for four days,” she said.
Each stage lasts at least 24 hours, so those who get a concussion should expect to need at least seven days or much longer, if they are slow to recover or the injury is their second or third concussion, before returning to full activity.
While the guidelines were developed to treat troops, Helmick said they should have value to the civilian and sports communities as well because before now, “nothing such as this existed.”
“There have been statements about step-wise approaches, but no one has defined what that means,” she said.
DVBIC developed the guidelines by reviewing academic studies and literature and will assess their effectiveness at four DVBIC locations nationwide.
“It’s exciting. DoD is once again at the tip of the spear when it comes to advancing clinical care for traumatic brain injury,” she said.