Toward Return to Duty Decision-Making After Military Mild Traumatic Brain Injury: Preliminary Validation of the Charge of Quarters Duty Test.

Introduction: Determining duty-readiness after mild traumatic brain injury (mTBI) remains a priority of the United States Department of Defense as warfighters in both deployed and non-deployed settings continue to sustain these injuries in relatively large numbers. Warfighters with mTBI may experience unresolved sensorimotor, emotional, cognitive sequelae including problems with executive functions, a category of higher order cognitive processes that enable people to regulate goal-directed behavior. Persistent mTBI sequelae interfere with warfighters' proficiency in performing military duties and signal the need for graded return to activity and possibly rehabilitative services. Although significant strides have been carried out in recent years to enhance the identification and management of mTBI in garrison (EXORD 165-13) and deployed settings (EXORD 242-11; DoDI 6,490.11), the Department of Defense still lacks reliable, valid, and clinically feasible functional assessments to help inform duty-readiness decisions. Traditional functional assessments lack face validity for warfighters and may have ceiling effects, especially as related to executive functions. Performance-based multitasking assessments have been shown to be sensitive to executive dysfunction after acquired brain injury but no multitasking assessments have been validated in adults with mTBI. Existing multitasking assessments are not ecologically valid relative to military contexts. A multidisciplinary military-civilian team of researchers developed and evaluated a performance-based assessment called the Assessment of Military Multitasking Performance. One of the Assessment of Military Multitasking Performance multitasks, the Charge of Quarters Duty Test (CQDT), was designed to challenge the divided attention, foresight, and planning dimensions of executive functions. Here, we report on the preliminary validation results of the CQDT. Materials and Methods: The team conducted a measurement development study at Fort Bragg, NC, enrolling 83 service members (33 with mTBI and 50 healthy controls). Discriminant validity was evaluated by comparing differences in CQDT sub-scores of warfighters with mTBI and healthy controls. Associations between CQDT sub-scores and neurocognitive measures known to be sensitive to mTBI were examined to explore convergent validity. The study was approved by the Womack Army Medical Center Institutional Review Board (Fort Bragg). Results: There were significant between-group differences in two of the four CQDT sub-scores (number of visits, p = 0.012; and performance accuracy, p = 0.020). Correlations between the CQDT sub-scores and some neurocognitive measures were statistically significant but weak, ranging from 0.287 (CQDT performance accuracy and NAB Numbers and Letters, Part D) to -0.421 (CQDT total number of visits and Automated Neuropsychological Assessment Metrics Tower Task). There were group differences in terms of participants' reading level, education, years in military, and stress symptoms; some of these characteristics may have influenced CQDT performance. Conclusions: The CQDT demonstrated initial evidence of discriminant validity. Further study is warranted to more formally evaluate convergent/divergent validity and ultimately how and whether this performance-based multitasking measure can inform readiness to return to duty after mTBI.

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.

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.

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.

A robotic home telehealth platform system for treatment adherence, social assistance and companionship - an overview.

Well-known difficulties of making patients adhere to assigned treatments have made engineers and clinicians look towards technology for possible solutions. Recent studies have found that cell phone-based text messaging can help drive positive changes in patients' disease management and preventive health behavior. Furthermore, work in the area of assistive robotics indicates benefits for patients although robotic solutions tend to become expensive. However, continued improvement in sensor, computer and wireless technologies combined with decreases in cost is paving the way for development of affordable robotic systems that can help improve patient care and potentially add value to the healthcare system. This paper provides a high-level design overview of SKOTEE, the Sister Kenny hOme ThErapy systEm, an inexpensive robotic platform system designed to provide adherence support for home exercise programs, taking medication, appointment reminders and clinician communication. SKOTEE will also offer companionship as well as entertainment and social networking opportunities to the patient in their home. A video of the system is presented at the conference.

Guidelines for supervision, roles, and responsibilities during the delivery of occupational therapy services.

These guidelines about supervision, roles, and responsibilities are to assist in the appropriate utilization of occupational therapists, occupational therapy assistants, and occupational therapy aides and in the appropriate and effective provision of occupational therapy services. It is expected that occupational therapy services are delivered in accordance with applicable state and federal regulations, relevant workplace policies, the Occupational Therapy Code of Ethics (AOTA, 2005), and continuing competency and professional development guidelines.

Guidelines for supervision, roles, and responsibilities during the delivery of occupational therapy services (2004).

These guidelines about supervision, roles, and responsibilities are to assist in the appropriate utilization of occupational therapy personnel and in the appropriate and effective provision of occupational therapy services. All personnel are expected to meet applicable state and federal regulations, adhere to relevant workplace policies and the Occupational Therapy Code of Ethics (AOTA, 2000), and participate in ongoing professional development activities to maintain continuing competency.