The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury.

OBJECTIVE: To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings. DESIGN: Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus. PARTICIPANTS: The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations. RESULTS: The first 2 Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.' CONCLUSIONS: New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

Beliefs About the Influence of Rest During Concussion Recovery May Predict Activity and Symptom Progression Within an Active Duty Military Population.

OBJECTIVES: To evaluate relationships between beliefs about the impact of rest and the level of activities and symptoms over time among active duty Service members sustaining concussion, and whether these relationships vary by provision of concussion education. DESIGN: Longitudinal study using multilevel modeling to assess the relationship between beliefs about rest within 72 hours of concussion and change in activity and symptom level over time, as well as interaction by concussion education at the initial clinic visit. SETTING: Three military treatment facilities. PARTICIPANTS: Study participants included active duty Service members diagnosed with a concussion (N=111; median age, 24 y). Individuals with previous history of concussion within 12 months of study enrollment were excluded. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Activity questionnaire and the Neurobehavioral Symptom Inventory assessed within 72 hours of concussion; at 1 week; and at 1, 3, and 6 month(s) postinjury. RESULTS: Receipt of concussion education from providers was significantly associated with greater belief that rest influences concussion recovery. Greater belief that rest influences symptom recovery at the acute stage of concussion was associated with a greater increase in activities over time, but only among those who received education from their provider. Additionally, greater belief about the influence of rest was related to a more rapid decrease in symptoms over time. CONCLUSIONS: Concussed Service members who underestimate the influence of rest during acute recovery may be at risk for poorer recovery. Treatment of Service members with postconcussive symptoms should consider patient knowledge and/or beliefs about rest and recovery, which may influence prognosis. Our results support the provider's use of concussion education to correct potential misconceptions that may negatively impact symptom recovery.

Management of Concussion and Mild Traumatic Brain Injury: A Synthesis of Practice Guidelines.

At least 3 million Americans sustain a mild traumatic brain injury (mTBI) each year, and 1 in 5 have symptoms that persist beyond 1 month. Standards of mTBI care have evolved rapidly, with numerous expert consensus statements and clinical practice guidelines published in the last 5 years. This Special Communication synthesizes recent expert consensus statements and evidenced-based clinical practice guidelines for civilians, athletes, military, and pediatric populations for clinicians practicing outside of specialty mTBI clinics, including primary care providers. The article offers guidance on key clinical decisions in mTBI care and highlights priority interventions that can be initiated in primary care to prevent chronicity.

Activity Level During Acute Concussion May Predict Symptom Recovery Within an Active Duty Military Population.

OBJECTIVE: To evaluate the impact on symptom resolution of activity acutely following a concussion and the role of acute-phase symptoms on this relationship among active duty service members (SMs). SETTING: Three military installations. PARTICIPANTS: Sixty-two SMs aged 18 to 44 years who sustained a concussion within 72 hours of enrollment. DESIGN: Longitudinal design with data collected within 72 hours of injury (baseline, n = 62) and at 1 week (n = 57), 1 month (n = 50), 3 months (n = 41), and 6 months (n = 40) postinjury. MAIN MEASURES: Baseline activity level using a 60-item Activity Questionnaire. Symptom level at baseline and during follow-up using Neurobehavioral Symptoms Inventory. RESULTS: Significant interaction (Pi < .05) was found, with significant main effects (P < .05) limited to SMs with elevated baseline symptomatology. Among these participants, greater baseline total activity was significantly related to greater vestibular symptoms at 1, 3, and 6 months (ß = .61, .63, and .59, respectively). Significant associations were also found for particular types of baseline activity (eg, physical; vestibular/balance; military-specific) and symptoms at 1, 3, and/or 6 months postinjury. CONCLUSION: These results provide support for clinical guidance that symptomatic SMs, particularly those with high levels of acute symptoms, may need to avoid excessive activity acutely following concussion.

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.

Outcome Measures for Persons With Moderate to Severe Traumatic Brain Injury: Recommendations From the American Physical Therapy Association Academy of Neurologic Physical Therapy TBI EDGE Task Force.

BACKGROUND AND PURPOSE: The use of standardized outcome measures (OMs) is essential in assessing the effectiveness of physical therapy (PT) interventions. The purposes of this article are (1) to describe the process used by the TBI EDGE task force to assess the psychometrics and clinical utility of OMs used with individuals with moderate to severe traumatic brain injury (TBI); (2) to describe the consensus recommendations for OM use in clinical practice, research, and professional (entry-level) PT education; and (3) to make recommendations for future work. METHODS: An 8-member task force used a modified Delphi process to develop recommendations on the selection of OMs for individuals with TBI. A 4-point rating scale was used to make recommendations based on practice setting and level of ambulation. Recommendations for appropriateness for research use and inclusion in entry-level education were also provided. RESULTS: The TBI EDGE task force reviewed 88 OMs across the International Classification of Functioning, Disability, and Health (ICF) domains: 15 measured body functions/structure only, 21 measured activity only, 23 measured participation only, and 29 OMs covered more than 1 ICF domain. DISCUSSION AND CONCLUSIONS: Recommendations made by the TBI EDGE task force provide clinicians, researchers, and educators with guidance for the selection of OMs. The use of these recommendations may facilitate identification of appropriate OMs in the population with moderate to severe TBI. TBI EDGE task force recommendations can be used by clinicians, researchers, and educators when selecting OMs for their respective needs. Future efforts to update the recommendations are warranted in order to ensure that recommendations remain current and applicable.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A140).

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.

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.

Symptom Exacerbation and Adverse Events during a Randomized Trial of Early-stage Concussion Rehabilitation.

CONTEXT: Few studies utilize randomized clinical trials (RCT) to quantify clinical intervention safety of rehabilitation after sport-related concussion across sport levels. OBJECTIVE: Describe symptom exacerbation and adverse events (AEs) associated with two concussion rehabilitation interventions. DESIGN: Cluster Randomized Controlled Trial (XXX). SETTING: Sports medicine clinic and field settings. PARTICIPANTS: The RCT enrolled 251 concussed athletes (median age=20 years; female n=48) across 28 sites from New Zealand professional rugby (n=31), Canadian professional football (n=52), United States (U.S.)/Canadian colleges (n=128) and U.S. high schools (n=40). INTERVENTIONS: Two medically supervised interventions: 1) Enhanced Graded Exertion (EGE): international return to sport strategy and sport specific activities only (EGE-only n=119) and 2) Multidimensional Rehabilitation (MDR) followed by EGE: early symptom-directed exercises once symptoms were stable, followed by EGE after symptoms resolved (MDR+EGE n=132). MAIN OUTCOME MEASURES: Primary outcomes were intrasession total symptom severity score exacerbation and significant intersession (increase 10+ severity points) sustained total symptom severity exacerbation, each measured with a Postconcussion Symptom Scale (132 total severity points on scale). Reported AEs were also described. Activity-based rehabilitation sessions (n=1437) were the primary analysis unit. Frequencies, proportions, medians, and Interquartile Ranges (IQRs) were calculated for outcomes by treatment group. RESULTS: The 251 post-injury participants completed 1437 (MDR+EGE=819, EGE-only=618) activity-based intervention sessions. A total of 110 and 105 participants contributed data (those missing had no documented session data) to at least 1 activity-based session in the MDR+EGE and EGE-only arms respectively. Intrasession symptom exacerbations were equivilantly low in MDR+EGE and EGE-only arms (MDR+EGE: 16.7%, 95% CI:14.1%,19.1%; EGE-only: 15.7%, 95% CI: 12.8%,18.6%). In total, 9/819 MDR+EGE sessions (0.9%) and 1/618 EGE-only sessions (0.2%) resulted in a pre- to post-session symptom exacerbation beyond a 10+ severity point increase; 8/9 resolved to <10 points by the next session. Two study-related AEs (1 in each arm) were reported. CONCLUSIONS: Participants in MDR+EGE and EGE-only activities reported equivalently low rates of symptom exacerbation.

Wearable Sensors Detect Movement Differences in the Portable Warrior Test of Tactical Agility After mTBI in Service Members.

INTRODUCTION: Assessment of functional recovery of service members following a concussion is central to their return to duty. Practical military-relevant performance-based tests are needed for identifying those who might need specialized rehabilitation, for evaluating the progress of recovery, and for making return-to-duty determinations. One such recently developed test is the 'Portable Warrior Test of Tactical Agility' (POWAR-TOTAL) assessment designed for use following concussion in an active duty population. This agility task involves maneuvers used in military training, such as rapid stand-to-prone and prone-to-stand transitions, combat rolls, and forward and backward running. The effect of concussion on the performance of such maneuvers has not been established. MATERIALS AND METHODS: The Institutional Review Board-approved study was conducted at Ft. Bragg, North Carolina, on 57 healthy control (HC) service members (SMs) and 42 well-matched SMs who were diagnosed with concussion and were referred for physical therapy with the intent to return to duty. Each study participant performed five consecutive trials of the POWAR-TOTAL task at full exertion while wearing inertial sensors, which were used to identify the constituent task maneuvers, or phases, and measure their durations. Statistical analyses were performed on durations of three main phases: (1) rising from prone and running, (2) lowering from vertical to prone, and (3) combat rolls. RESULTS: None of the three phases showed significant correlation with age (range 18-45 years) in either group. Gradual improvement in all three phase durations across five trials was observed in the HC group, but not in the concussed group. On average, control subjects performed significantly faster (P < .004 or less) than concussed subjects in all trials in the lowering and rolling phases, but less so in the rising/running phase. Membership in the concussed group had a strong effect on the lowering phase (Cohen's d = 1.05), medium effect on the rolling phase (d = 0.72), and small effect on the rising/running phase (d = 0.49). Individuals in the HC group who had a history of prior concussions were intermediate between the concussed group and the never-concussed group in the lowering and rolling phases. Duration of transitional movements (lowering from standing to prone and combat rolls) was better at differentiating individuals' performance by group (receiver operating characteristic area under the curve [AUC] = 0.83) than the duration of the entire POWAR-TOTAL task (AUC = 0.71). CONCLUSIONS: Inertial sensor analysis reveals that rapid transitional movements (such as lowering from vertical to prone position and combat rolls) are particularly discriminative between SMs recovering from concussion and their concussion-free peers. This analysis supports the validity of POWAR-TOTAL as a useful tool for therapists who serve military SMs.

The Portable Warrior Test of Tactical Agility: A Novel Functional Assessment That Discriminates Service Members Diagnosed With Concussion From Controls.

INTRODUCTION: Return-to-duty (RTD) readiness assessment for service members (SM) following concussion requires complex clinical considerations. The Portable Warrior Test of Tactical Agility (POWAR-TOTAL) is a functional assessment which improves on previous laboratory-based RTD assessments. METHODS: Sixty-four SM diagnosed with concussion and 60 healthy control (HC) SM participated in this study. Group differences were analyzed to validate the POWAR-TOTAL. The High-level Mobility Assessment Test (HiMAT) was used to examine concurrent construct validity. An exploratory logistic regression analysis examined predictive validity. RESULTS: The groups were demographically well-matched except for educational level. POWAR-TOTAL measures were statistically significantly different between the groups with moderate to large effect sizes. Concussed participants were less likely to be able to complete all trials of the POWAR-TOTAL. Motor scores correlated highly with HiMAT scores. POWAR-TOTAL motor task performance and membership in the control group was significantly associated with self-reported physical readiness to deploy. CONCLUSION: The POWAR-TOTAL is a clinically feasible, military relevant assessment that is sensitive to differences between concussed and HC SM. This analysis supports the discriminant and construct validity of the POWAR-TOTAL, and may be useful for medical providers evaluating RTD readiness for SM who have sustained a concussion.

Validity and Responsiveness of the Portable Warrior Test of Tactical Agility After Rehabilitation in Service Members With Mild Traumatic Brain Injury.

OBJECTIVE: The Portable Warrior Test of Tactical Agility (POWAR-TOTAL) is a performance-based test designed to assess active-duty service members diagnosed with mild traumatic brain injuries (mTBIs) and could potentially inform return to duty decisions. To examine the validity and responsiveness of the POWAR-TOTAL measure, this study collected self-reported and performance measures by active-duty service members before and after an episode of physical therapist care. METHODS: Seventy-four individuals, enrolled in care for mTBI symptoms at 1 of 2 concussion specialty Intrepid Spirit Centers, were examined the week that they initiated physical therapy with the intention to return to active duty. Self-reported measures of concussion symptoms, pain, posttraumatic stress, headache, dizziness, and sleep quality were used, as were concurrent measures of mobility and balance. The POWAR-TOTAL task (motor and cognitive skills in single and dual-task conditions) was administered. Forty-nine active-duty service members returned for posttherapy testing using the same test battery. Effect sizes for change in measures were calculated. Construct validity was assessed by correlating change scores on POWAR with concurrent self-report and mobility measures. Responsiveness was evaluated using an anchor-based approach. RESULTS: Significant improvements in self-reported and performance-based measures, including POWAR, were observed after therapy with moderate to large effect sizes. Improvement in POWAR performance correlated with improvement in both performance and self-reported measures. After therapy, individuals who registered improvement on the Patient Global Impression of Change scale demonstrated significantly faster POWAR motor performance than those who rated little or no improvement in their condition. CONCLUSION: The POWAR-TOTAL captured improvement on a military-specific task after completing physical therapy for mTBI and could serve as an indicator of physical recovery and readiness for return to duty. IMPACT: Challenging cognitive and motor measures for service members may aid in the assessment of recovery and the ability to successfully return to duty after concussion as part of a comprehensive examination approach.

A pilot study on exertional tasks with physiological measures designed for the assessment of military concussion.

BACKGROUND: Guidelines for clinicians treating military concussion recommend exertional testing before return-to-duty, yet there is currently no standardized task or inclusion of an objective physiological measure like heart rate variability (HRV). METHODOLOGY & RESULTS: We pilot-tested two clinically feasible exertional tasks that include HRV measures and examined reliability of a commercially available heart rate monitor. Testing healthy participants confirmed that the 6-min step test and 2-min pushup test evoked the targeted physiological response, and the Polar H10 was reliable to the gold-standard electrocardiogram. CONCLUSION: Both tasks are brief assessments that can be implemented into primary care setting including the Polar H10 as an affordable way to access HRV. Additional research utilizing these tasks to evaluate concussion recovery can validate standardized exertional tasks for clinical use.

Factors influencing hip protector use among community-dwelling older adults.

PURPOSE: To obtain a better understanding of the issues that influence hip protector use among community-dwelling older adults. METHODS: The study used a longitudinal, crossover design. A convenience sample of 32 participants used four different brands of hip protectors, each for a 1-week period. Data were collected by weekly telephone interviews and a mailed questionnaire administered at baseline and follow-up. Participant perceptions regarding hip protectors were assessed using both open-ended questions and Likert-type items. RESULTS: The most common concerns about hip protectors mentioned in response to open-ended questions involved: discomfort, poor fit, inconvenience and unfavourable effects on appearance. Participants spontaneously mentioned at least one of these barriers in over 70% of the interviews. In contrast, participants spontaneously mentioned the protective benefits offered by hip protectors in only 16% of the interviews. The intention to continue using a particular hip protector after the study ended was associated with the number of hours the hip protector was worn during the study (p<0.01). After controlling for other variables, beliefs concerning the amount of protection that a hip protector provided was positively associated with the number of hours the hip protector was worn during the study (p<0.05) and the intention to continue using the hip protector after the study (p<0.01). CONCLUSION: Study findings suggest that the use of hip protectors by community-dwelling older adults is influenced by beliefs about both barriers to use and the amount of protection provided.

Balance, attention, and dual-task performance during walking after brain injury: associations with falls history.

OBJECTIVE: To examine the relationship between balance, attention, and dual-task performance in individuals with acquired brain injury. DESIGN: Cross-sectional study. SETTING: Rehabilitation center and supported living program. PARTICIPANTS: Twenty-four individuals aged 18 to 58 years (mean = 39 years) with acquired brain injury who were able to ambulate 40 ft with (29%) or without an assistive device. Fifty-eight percent were independent community ambulators. Fifty-four percent had fallen in the past 6 months; and 42% reported feeling unsteady with standing or walking. INTERVENTIONS: Participants completed a battery of balance, attention, and dual-task assessments. MAIN OUTCOME MEASURES: Balance: Berg Balance Scale (BBS), Four Square Step Test (FSST), High Level Mobility Assessment Test (HiMAT); Attention: Symbol Digit Modalities Test (SDMT), Moss Attention Rating Scale (MARS), modified for a single test session; and a walking dual-task assessment, the Walking and Remembering Test. RESULTS: Mean scores: BBS, 48 of 56; FSST, 19.6 seconds; HiMAT, 20 of 54; SDMT, 30 correct; and MARS, 80. Dual-task costs were observed with variable patterns across subjects: 48% demonstrated primarily motor slowing, 9% had reduced cognitive accuracy without motor slowing, and 35% demonstrated decrements in both tasks. Subjects with a falls history had more impaired balance (HiMAT, BBS, and FSST, all P <.026) but were not significantly different in dual-task performance or attention measures. CONCLUSIONS: The test battery matched the range of motor and cognitive abilities of the sample. Balance was more strongly related to falls history than measures of attention or dual-task performance. Injury chronicity may have allowed some subjects to develop strategies to optimize dual-task performance. Alternatively, motor slowing in dual-task conditions may be an adaptive strategy, allowing performance of multiple tasks with reduced safety risk. Further investigation in this area is warranted to clarify the utility of dual-task methods in identifying falls risk after brain injury.

Physical therapy recommendations for service members with mild traumatic brain injury.

Mild traumatic brain injuries (MTBIs) are of increasing concern in both the military and civilian populations as the potential long-term effects and costs of such injuries are being further recognized. Injuries from conflicts in Afghanistan and Iraq have increased public awareness and concern for TBI. The Proponency Office for Rehabilitation and Reintegration, Office of the Surgeon General, US Army tasked a team of physical and occupational therapists to assemble evidence-informed guidelines for assessment and intervention specific to MTBI. Given the paucity of specific guidelines for physical therapy related to MTBI, we focused on literature that dealt with the specific problem area or complaint of the Service member following MTBI. Recommendations, characterized as practice standards or practice options based on strength of evidence, are provided relative to patient/client education, activity intolerance, vestibular dysfunction, high-level balance dysfunction, posttraumatic headache, temporomandibular disorder, attention and dual-task performance deficits, and participation in exercise. While highlighting the need for additional research, this work can be considered a starting point and impetus for the development of evidence-based practice in physical therapy for our deserving Service members.

Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury.

Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.