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

Clinical validation of an optimized multimodal neurocognitive assessment of chronic mild TBI

ObjectivePrevious laboratory-based studies have shown that neurocognitive eye-tracking metrics are sensitive to chronic effects of mild traumatic brain injury (mTBI), even in individuals with normal performance on traditional neuropsychological measures. In this study, we sought to replicate and extend these findings in a military medical environment. We expected that metrics from the multimodal Fusion n-Back test would successfully distinguish chronic mTBI participants from controls, particularly eye movement metrics from the more cognitively challenging "1-Back" subtest.MethodsWe compared performance of participants with chronic mTBI (n = 46) and controls (n = 33) on the Fusion n-Back test and a battery of conventional neuropsychological tests. Additionally, we examined test reliability and the impact of potential confounds to neurocognitive assessment.ResultsOur results supported hypotheses; Fusion 1-Back metrics were successful in multimodal (saccadic and manual) classification of chronic mTBI versus control. In contrast, conventional neuropsychological measures could not distinguish these groups. Additional findings demonstrated the reliability of Fusion n-Back test metrics and provided evidence that saccadic metrics are resistant to confounding influences of age, intelligence, and psychiatric symptoms.InterpretationThe Fusion n-Back test could provide advantages in differential diagnosis for complex brain injury populations. Additionally, the rapid administration of this test could be valuable for screening patients in clinical settings where longer test batteries are not feasible

Increased risk for age-related impairment in visual attention associated with mild traumatic brain injury: Evidence from saccadic response times.

It was hypothesized that risk for age-related impairment in attention would be greater among those with remote history of mild TBI than individuals without history of head injury. Twenty-seven adults with remote history of mild TBI and a well-matched comparison group of 54 uninjured controls completed a computerized test of visual attention while saccadic and manual response times were recorded. Within the mild TBI group only, older age was associated with slower saccadic responses and poorer saccadic inhibition. Saccadic slowing was mitigated in situations where the timing and location of attention targets was fully predictable. Mild TBI was not associated with age-related increases in risk for neuropsychological impairment or neurobehavioral symptoms. These results provide preliminary evidence that risk for age-related impairment in visual attention may be higher among those with a history of mild TBI. Saccadic measures may provide enhanced sensitivity to this subtle form of cognitive impairment

Participant Characteristics.

<p>Participant Characteristics.</p

Linear regressions of age on individual BEAM trial types for controls (solid line) and mild TBI (dotted line).

<p>Linear regressions of age on individual BEAM trial types for controls (solid line) and mild TBI (dotted line).</p

Best Practices for Progressive Return to Activity after Concussion: Lessons Learned from a Prospective Study of U.S. Military Service Members

Primary care providers can play a crucial role in the clinical management of concussion. However, many providers lack up-to-date information about best practices for rest and return to activity after these injuries. Most research on this topic has been conducted in athletes, and so less is known about how to assist patients with returning to activity in other settings and populations. This article provides a review of best practices for management of progressive return to activity after concussion, with an emphasis on "lessons learned" from the Defense and Veterans Brain Injury Center (DVBIC) Progressive Return to Activity (PRA) study, a multi-site longitudinal research project conducted to evaluate concussion management practices and the effectiveness of provider training on DVBIC clinical recommendations (CRs). Provider clinical practices and patient outcomes were examined at three U.S. military treatment facilities before and after providers completed a standardized training on DVBIC PRA CRs. In summary, research findings provide additional support that concussion recovery can be influenced by patients' activity levels after injury. Patients with concussion may experience poorer outcomes if they return to pre-injury levels of activity too rapidly, but they may also be at risk for prolonged symptoms if they fail to increase activity levels over time after an initial period of rest. Additionally, training primary care providers in return to activity guidelines can result in more effective patient education and better clinical outcomes. This knowledge can be used to inform best practices for progressive return to activity in both civilian and military settings