Mary Vining Radomski

Returning Service Members to Duty Following Mild Traumatic Brain Injury: Exploring the Use of Dual-Task and Multitask Assessment Methods

Within the last decade, more than 220,000 service members have sustained traumatic brain injury (TBI) in support of military operations in Iraq and Afghanistan. Mild TBI may result in subtle cognitive and sensorimotor deficits that adversely affect warfighter performance, creating significant challenges for service members, commanders, and clinicians. In recent conflicts, physical therapists and occupational therapists have played an important role in evaluating service member readiness to return to duty (RTD), incorporating research and best practices from the sports concussion literature. Because premorbid (baseline) performance metrics are not typically available for deployed service members as for athletes, clinicians commonly determine duty readiness based upon the absence of postconcussive symptoms and return to “normal” performance on clinical assessments not yet validated in the military population. Although practices described in the sports concussion literature guide “return-to-play” determinations, resolution of symptoms or improvement of isolated impairments may be inadequate to predict readiness in a military operational environment. Existing clinical metrics informing RTD decision making are limited because they fail to emphasize functional, warrior task demands and they lack versatility to assess the effects of comorbid deficits. Recently, a number of complex task-oriented RTD approaches have emerged from Department of Defense laboratory and clinical settings to address this gap. Immersive virtual reality environments, field-based scenario-driven assessment programs, and militarized dual-task and multitask-based approaches have all been proposed for the evaluation of sensorimotor and cognitive function following TBI. There remains a need for clinically feasible assessment methods that can be used to verify functional performance and operational competence in a variety of practice settings. Complex and ecologically valid assessment techniques incorporating dual-task and multitask methods may prove useful in validating return-to-activity requirements in civilian and military populations.

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.

Composition of a vision screen for servicemembers with traumatic brain injury: consensus using a modified nominal group technique

Vision impairment is common in the first year after traumatic brain injury (TBI), including among service members whose brain injuries occurred during deployment in Iraq and Afghanistan. Occupational therapy practitioners provide routine vision screening to inform treatment planning and referral to vision specialists, but existing methods are lacking because many tests were developed for children and do not screen for vision dysfunction typical of TBI. An expert panel was charged with specifying the composition of a vision screening protocol for servicemembers with TBI. A modified nominal group technique fostered discussion and objective determinations of consensus. After considering 29 vision tests, the panel recommended a nine-test vision screening that examines functional performance, self-reported problems, far-near acuity, reading, accommodation, convergence, eye alignment and binocular vision, saccades, pursuits, and visual fields. Research is needed to develop reliable, valid, and clinically feasible vision screening protocols to identify TBI-related vision disorders in adults.

Effectiveness of Interventions to Address Cognitive Impairments and Improve Occupational Performance After Traumatic Brain Injury: A Systematic Review.

OBJECTIVE To determine the effectiveness of interventions addressing cognitive impairments to improve occupational performance for people with traumatic brain injury. METHOD A total of 37 studies met inclusion criteria: 9 Level I systematic reviews, 14 Level I studies, 5 Level II studies, and 9 Level III studies. RESULTS Strong evidence supports use of direct attention training, dual-task training, and strategy training to optimize executive functioning, encoding, and use of memory compensations, including assistive technology. However, in most studies, occupational performance was a secondary outcome, if it was evaluated at all. CONCLUSION Although evidence supports many intervention approaches used by occupational therapy practitioners to address cognitive impairments of adults with traumatic brain injury, more studies are needed in which occupational performance is the primary outcome of cognitive intervention.

Development and preliminary reliability of a multitasking assessment for executive functioning after concussion.

OBJECTIVES. Executive functioning deficits may result from concussion. The Charge of Quarters (CQ) Duty Task is a multitask assessment designed to assess executive functioning in servicemembers after concussion. In this article, we discuss the rationale and process used in the development of the CQ Duty Task and present pilot data from the preliminary evaluation of interrater reliability (IRR). METHOD. Three evaluators observed as 12 healthy participants performed the CQ Duty Task and measured performance using various metrics. Intraclass correlation coefficient (ICC) quantified IRR. RESULTS. The ICC for task completion was .94. ICCs for other assessment metrics were variable. CONCLUSION. Preliminary IRR data for the CQ Duty Task are encouraging, but further investigation is needed to improve IRR in some domains. Lessons learned in the development of the CQ Duty Task could benefit future test development efforts with populations other than the military.

Further Development of the Assessment of Military Multitasking Performance: Iterative Reliability Testing.

The Assessment of Military Multitasking Performance (AMMP) is a battery of functional dual-tasks and multitasks based on military activities that target known sensorimotor, cognitive, and exertional vulnerabilities after concussion/mild traumatic brain injury (mTBI). The AMMP was developed to help address known limitations in post concussive return to duty assessment and decision making. Once validated, the AMMP is intended for use in combination with other metrics to inform duty-readiness decisions in Active Duty Service Members following concussion. This study used an iterative process of repeated interrater reliability testing and feasibility feedback to drive modifications to the 9 tasks of the original AMMP which resulted in a final version of 6 tasks with metrics that demonstrated clinically acceptable ICCs of > 0.92 (range of 0.92–1.0) for the 3 dual tasks and > 0.87 (range 0.87–1.0) for the metrics of the 3 multitasks. Three metrics involved in recording subject errors across 2 tasks did not achieve ICCs above 0.85 set apriori for multitasks (0.64) and above 0.90 set for dual-tasks (0.77 and 0.86) and were not used for further analysis. This iterative process involved 3 phases of testing with between 13 and 26 subjects, ages 18–42 years, tested in each phase from a combined cohort of healthy controls and Service Members with mTBI. Study findings support continued validation of this assessment tool to provide rehabilitation clinicians further return to duty assessment methods robust to ceiling effects with strong face validity to injured Warriors and their leaders.

Occupational therapy for servicemember and veteran recovery, resilience, and reintegration: opportunities for societal contribution and professional transformation.

LTC Teresa L. Brininger, PhD, OTR/L, CHT, is Clinical Scientist, U.S. Army War College, Carlisle, PA; Teresa.Brininger@us.army.mil Approximately 2.6 million members of the all-volunteer Armed Forces have served in the wars in Afghanistan and Iraq since 2001, and almost half have been deployed more than once (Carino, 2013). Many return home with traumatic brain injury, stress disorders, amputations, burns, and musculoskeletal injuries and attendant occupational dysfunction. Although many servicemembers easily adjust to life after deployment, others with and without injuries struggle to resume family life, work, and community engagement (i.e., occupations of daily life; Institute of Medicine [IOM], 2010); the concurrent disruption and strain are multiplied manyfold when one considers the implications for spouses and children, including health effects, family violence, and economic burden (IOM, 2013). These facts present fundamental questions: What can we do as a profession to honor the service and sacrifice of our fellow citizens? What are the societal responsibilities of our profession? We propose that two parallel strategies have the transformative potential of post– WorldWar I reconstruction aides (Gutman, 1995; Low, 1992) in terms of improving client outcomes and shaping the profession itself: (1) the use of traditional and novel methods of therapeutic occupation to address occupational dysfunction among servicemembers and veterans and (2) the rigorous study of its impact on recovery, resilience, and reintegration. The articles included in this special issue of the American Journal of Occupational Therapy suggest that we are making inroads toward the first objective.Hwang, Peyton, Kim,Nakama-Sato, and Noble (2014) describe postdeployment driving stress, and Classen, Monahan, Canonizado, and Winter (2014) offer preliminary evidence regarding results of an intervention for driving-related errors. Rogers, Mallinson, and Peppers (2014) showcase the feasibility of a high-intensity sports intervention and its potential impact on symptoms of posttraumatic stress disorder (PTSD) and transition to civilian life. Tomar and Stoffel (2014) elucidate the experience of veterans who assume student roles. Speicher, Walter, and Chard (2014) describe occupational performance outcomes of a residential treatment program for PTSD and traumatic brain injury, and Smith et al. (2014) provide a preliminary report on the development of a multitasking assessment to inform readiness for duty after concussion. Finally, Cogan (2014) articulates the needs of military families and an expanded role for occupational therapy in mental health care. Much work remains to be done in establishing the impact of occupational therapy on recovery, resilience, and reintegration related to war injuries and the transition to civilian life. In general, even though many servicemembers and veterans LTC Teresa L. Brininger, PhD, OTR/L, CHT Mary Vining Radomski, PhD, OTR/L, FAOTA

Military-civilian collaborations for mTBI rehabilitation research in an active duty population: lessons learned from the assessment of Military Multitasking Performance Project

This article describes lessons learned in the planning, development, and administration of a collaborative military-civilian research project, the Assessment of Military Multitasking Performance, which was designed to address a gap in clinical assessment for active duty service members with mild traumatic brain injury who wish to return to active duty. Our team worked over the course of multiple years to develop an assessment for military therapists to address this need. Insights gained through trial and error are shared to provide guidance for civilian researchers who may wish to collaborate with active duty researchers.

Implementing evidence-based practice: A context analysis to examine use of task-based approaches to upper-limb rehabilitation:

Statement of context Many occupational therapists experience challenges in implementing evidence-based practice, which may be best approached as a context-specific enterprise. Critical reflection on practice This practice analysis article reports the results of analyzing 24 home programs that occupational therapists issued to rehabilitation inpatients with stroke upon their discharge home. Home programs did not reflect a task-based approach to upper-limb recovery, even though this is supported by established evidence. Examination of contextual factors provides a framework to facilitate evidence implementation. Implications for practice Occupational therapists may optimize evidence-based practice implementation by first evaluating and addressing practice-specific contextual factors.