title: Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers.
abstract: 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.
  
  
  METHODS
  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.
authors.affiliation: Division of Physical Therapy, Department of Allied Health Sciences, School of Medicine, UNC-Chapel Hill, Chapel Hill, North Carolina (Dr McCulloch); Office of the Surgeon General, Rehabilitation and Reintegration Division, Defense Health Headquarters, Falls Church, Virginia (Drs Goldman and Lowe); Sister Kenny Research Center, Minneapolis, Minnesota (Dr Radomski); George C. Marshall High School, Fairfax County Public Schools, Virginia (Mr Reynolds); Coordination and Compliance Division, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Silver Spring, Maryland (Dr Shapiro); Defense and Veterans Brain Injury Center Clinical Affairs, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Silver Spring, Maryland (Dr West).
authors.forename: Karen L
authors.initials: KL
authors.lastname: McCulloch
authors.forename: Sarah
authors.initials: S
authors.lastname: Goldman
authors.forename: Lynn
authors.initials: L
authors.lastname: Lowe
authors.forename: Mary Vining
authors.initials: MV
authors.lastname: Radomski
authors.forename: John
authors.initials: J
authors.lastname: Reynolds
authors.forename: Rita
authors.initials: R
authors.lastname: Shapiro
authors.forename: Therese A
authors.initials: TA
authors.lastname: West
mesh_terms: D000203:Activities of Daily Living; D001930:Brain Injuries / Q000534:rehabilitation*; D002985:Clinical Protocols; D006801:Humans; D008889:Military Personnel; D009483:Neuropsychological Tests; D020127:Recovery of Function; D012017:Referral and Consultation; D012046:Rehabilitation / Q000458:organization & administration; D012720:Severity of Illness Index