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Improving training of healthcare providers boosts post-concussion care

Elizabeth Fuentes (left), physical therapist assistant, Fort Bliss Traumatic Brain Injury Clinic, William Beaumont Army Medical Center, provides information and educates medical professionals about TBI symptoms, treatments and assessments, during the TBI Clinic’s open house event, in observance of Brain Injury Awareness Month. (U.S. Army photo by Marcy Sanchez) Elizabeth Fuentes (left), physical therapist assistant, Fort Bliss Traumatic Brain Injury Clinic, William Beaumont Army Medical Center, provides information and educates medical professionals about TBI symptoms, treatments and assessments, during the TBI Clinic’s open house event, in observance of Brain Injury Awareness Month. (U.S. Army photo by Marcy Sanchez)

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Traumatic Brain Injury

What happens when the Defense and Veterans Brain Injury Center disseminates a new clinical recommendation? Is it adopted by practitioners? Does training health care providers lead to improved patient outcomes?

DVBIC scans the latest research about TBI findings, and then recruits TBI experts from the scientific community who meet regularly to develop clinical guidelines to inform health care decisions. This specialized function supports the Military Health System’s objectives of improving warfighter care and readiness. DVBIC is a division of the Defense Health Agency Research and Development Directorate.

These questions are at the heart of a recent study by DVBIC who asked whether teaching providers about state-of-the-science tools for concussion treatment improves patient care and rehabilitation. A concussion is a blow or jolt to the head that disrupts the normal function of the brain. Most traumatic brain injuries in the military are mild and most service members return to duty after recovering from their injuries.

The study compared two groups of TBI patients: those treated after primary care managers at various military hospitals received an interactive two-hour training, and those treated before providers received instruction. At the end of the study, patients completed a questionnaire that asked how soon they began to engage in physical and mental activity.

DVBIC found that patients in the group cared for by providers who had received the intensive training reported an overall reduction in symptoms after one week, one month and at three months, when compared to patients who were treated by the providers who had not yet received the intensive training.

This study highlights the importance of integrating research, clinical affairs, and education activities at DVBIC.

“One of the things that DVBIC has done, of late, is take many of our clinical tools . . . and actually study them,” Navy Captain Scott Pyne, DVBIC division chief. “The tools are based on the state-of-the-science, which is current research. Not only do we create the tool, but we throw it out there for the providers to use, and then we evaluate the effectiveness of its use. That's been very helpful.”

The “Progressive Return to Activity Following Acute Concussion/Mild Traumatic Brain Injury” clinical recommendation is focused on a six-stage approach to manage recovery.

The first stage involves rest, followed by light routine activity, light work-related activity, moderate activity, intensive activity, and finally unrestricted activity.

Each stage lasts a minimum of 24 hours and the service member should be re-evaluated each day. Patients with a mild TBI, often described as a concussion, should begin with less physical and mental activity and gradually move from one stage to the next.

“We have been able to show two critical things for military medicine,” said Jason Bailie, DVBIC’s senior clinical research director at Camp Pendleton. “Our frontline medical practitioners need to be taught how to treat concussed patients with a progressive return to activity approach” and “we can enhance our force readiness by helping our warfighters get better faster following a concussion.”

In addition to improved health among patients, the study finds more consistent treatment options offered by the trained physicians – including giving their patients special brochures focused on different parts of their rehabilitation. As one physician said in a post-study survey, “It’s been a pretty big difference, not only in my comfort with treating these patients, but educating them as well.”

Dr. Keith Stuessi, a DVBIC subject matter expert who provided the two-hour training sessions, underscored the implications of these findings for DVBIC’s future training efforts. “By doing this study, in this way,” Stuessi said, “we showed the effectiveness of this educational intervention.”

These findings could not be timelier. In June 2019, the U.S. Army directed medical personnel who would be treating patients with concussions use updated management tools designed by DVBIC, including the progressive return to activity process.

The progressive return to activity clinical suite is designed to help primary care managers, rehabilitation providers, and service members.

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In the first of TBICoE's Progressive Return to Activity (PRA) video training series, you will learn about the reasons for using a progressive return to activity process and receive an overview of the 2021 PRA algorithm and its associated tools. By the end of lesson one, providers will better understand the PRA process, and explain that process to service members diagnosed with concussion. Each video in the PRA training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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In this lesson we review the six major changes in the TBICoE's revised 2021 Progressive Return to Activity (PRA) Clinical Recommendation that differ from the original recommendation. The changes reflect the latest TBI research, and will make it easier for providers to manage the recovery process and return service members with concussion to full duty as quickly and safely as possible. Each video in the PRA training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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