Clinical Considerations of Concussion in the Military:

Created by: Larysa Petrenko, SPT

Background:

During a serendipitous tour of the Center for the Intrepid facility at Joint Base San Antonio-Fort Sam Houston while in high school, I discovered a passion for working with wounded service members through the field of physical therapy. That same passion followed me through college as I produced course research papers examining post-concussion management and return-to-duty in the military, where I ultimately came across Dr. Karen McCulloch’s work with the military related to physical therapy’s role in post-concussion management. Following my Physical Therapy School interview with her and my eventual acceptance to UNC-CH, I knew that I wanted to work with her research in my final capstone project.

As I forged through my clinical rotations in the last three years, I was lucky enough to train with many remarkable and brilliant physical therapists in military clinics. One such pivotal experience was during my time practicing at the Intrepid Spirit Center (ISC) on Fort Bragg where I was able to work first-hand with service members following a traumatic brain injury (TBI). Throughout that time, I saw firsthand how the myriad of potential impairments following a concussive event can impact those service members’ lives and occupation. I became very interested in helping those men and women through their recovery as both a clinician and a researcher. At the same time that I was dipping my toes in the waters of military medicine, Dr. McCulloch and her research team were finalizing IRB approval to begin a research study based at ISC focused on developing a return-to-duty assessment for service members following a mTBI. As part of a research elective and my final capstone project, I worked under this study by performing preliminary analyses of characteristics of service members following a concussion and performance comparisons on our dual-tasking activity, respectively.

Overview:

Mild brain injuries (aka: concussions) are increasingly prevalent in service members. Helmick notes that up to 300,000 service members have been diagnosed with a TBI since 2000, with up to 80% of those being concussions.¹While these occupational injuries can come from more “mechanical” mechanisms of injury, such as bad airborne operations or blunt trauma from a motor vehicle accident on the weekend, blast-induced TBI has been increasing in frequency, particularly with changes in modern warfare. Either etiology can produce debilitating symptoms and functional impairments that can prolong if not prevent a servicemember’s return-to-duty.

Exposure to blasts as well as blunt trauma can produce an array of orthopedic, integumentary, neurocognitive, and neurobehavioral sequelae that may be appropriate for physical therapy-driven intervention.²Patients may specifically present with pathologies of a vestibular-origin, including dizziness, unsteadiness, vertigo, and oscillopsia.²Many soldiers who are exposed to “blast syndrome” report losses of consciousness and being “stunned,” with later complaints of headaches, tinnitus, deafness, dizziness, tension or dullness, apathy, poor memory, and balance impairments.³Further cognitive and behavioral symptoms can also be present. In a clinical study comparing patients with blunt, impact, non-blast TBI to blast-induced TBI, Cernak et al reported that the latter were more irritable to sudden, loud noises and/or crowd with experiences of emotional and physical exhaustion.

Physical therapists can play a pivotal role in the evaluation and treatment of service members following TBI who present with any array of potential clinical symptoms. The Department of Defense(DoD) has developed a multidisciplinary agency called the Defense and Veterans Brain Injury Center (DVBIC) to particularly address the needs of such patients.^2,4Physical therapists within DVBIC provide rehabilitative services at ISC locations in order to address many of the complaints previously mentioned. From my own experience working at Fort Bragg’s ISC and concurred by Scherer and Weightman, many soldiers can present with PT-appropriate diagnoses including dual-task deficits, unilateral vestibular hypofunction, benign paroxysmal positional vertigo, gaze instability, cervicogenic headaches, post-traumatic headaches, gait impairment, static and/or dynamic balance dysfunctions, sensory disorganization, motion sensitivity, temporomandibular disorders, and exertional headaches.^2,4Considerations for a number of these potential deficits need to be made when treating service members in preparation for return-to-duty.

Clinical Need:

There are limited current assessments for service members returning to duty following a concussive event. Furthermore, there are very few assessments evaluating the dual-task needs of a servicemember, which is commonly impaired after experiencing a mTBI. The purpose of the current, DoD-funded study led by Dr. McCulloch is to validate a clinical test of tactical agility for active duty individuals who are recovering from concussion, entitled the Portable Warrior Test of Tactical Agility (POWAR-TOTAL). Per the overall description of the POWAR-TOTAL project itself:

The long-term goalof this program of research is to implement clinically feasible military testing approaches that can aid clinicians in return-to-duty (RTD) decisions following concussion. This project is a step toward that long-term goal. The overall objective of this projectis to assess the performance-based POWAR- TOTAL, building on standardized scoring and procedures from the previous Assessment of Military Multitasking Performance study. This test will improve clinical feasibility over AMMP tactical agility tasks by requiring less space and time while using less expensive smartphone technology as instrumentation. POWAR-TOTAL incorporates the most sensitive and provocative aspects of multiple AMMP tasks.

The central hypothesisis that POWAR- TOTAL will be sensitive enough to identify clinically significant movement differences using a combination of Principal Component Analysis, Fast Fourier Transform and Support Vector Machine analysis that can occur in real time. This approach is reliable and valid, as previous studies with laboratory equipment (laboratory grade accelerometers and post-testing engineering analyses) found that such analyses differentiated those with injury from those without at >.80.Pilot data using our smartphone accelerometer and analyses further supports our hypothesis. The rationalefor this project is to validate the POWAR-TOTAL in a manner that allows for portability, refining a RTD test that can be used to provide immediate feedback to clinicians and service members alike. Collaborators at Fort Bragg, Joint Base Louis-McChord (using Geneva Foundation as a subcontracting agency), and University of North Carolina at Chapel Hill (the initiators of the grant funded through MRMC) have worked together to accomplish the study goals. There are additional sub-goals of this overall project including determining if there is statistically significant difference in dual-task activities when comparing healthy controls and subjects with mTBI in the active duty service member population, which is ultimately the subject of my overall capstone project.

Products:

Throughout this final year of Physical Therapy School, I have spent the majority of my coursework furthering my knowledge as related to working with service members. Beyond typical forum posts related to the military population, I focused my final research paper in the Advanced Orthopedic Assessment on the effects of Cervicalgia in the military, including the role of mTBI on this clinical prevalence. Furthermore, I focused my final paper in the TBI module of our Advanced Patient Management course on the role of physical therapy in post-concussion treatment in the military.

During the spring semester, I focused the majority of my time working with Dr. McCulloch in the overall POWAR-TOTAL study, assisting with data-quality checks and preliminary analysis of the results of the on-going study. As part of my final product for the research elective, I analyzed characteristics of the active duty service members who were being seen in our study and presented a poster presentation at UNC-CH’s Human Movement Science Day. For my overall capstone project, I performed analyses of our initial group of mTBI and healthy controls, ultimately comparing and proving statistically significant differences between the groups in our dual-tasking activity. I have applied for a poster presentation of our initial results at the Military Health System Research Symposium, which will occur in August 2019.

• Capstone Project – “Comparison of Subjects with mTBI and Healthy Control Group in the Development of the POWAR-TOTAL: a Test of Return-to-Duty Readiness Following Concussion”
  • MHSRS Abstract Submission
  • MHSRS Poster
• Research Project – “Characteristics of Service Members with Concussion Referred to Physical Therapy Who Seek to Return to Active Military Duty”
  • HMSC Abstract Submission
  • HMSC Poster
• Advanced Patient Management I (PHYT 820) – TBI Module Final Paper
• Advanced Orthopedics Assessment (PHYT 875) – Final Paper: Cervicalgia in the Military

Evaluation:

I worked closely with Dr. McCulloch, PT, PhD, MS, NCS, FAPTA and her current PhD student, the delightful Ms. Julianna Prim, MS, throughout the course of project. Both provided exceptional advice and feedback when approaching data analysis and preparing my poster presentations through phone calls, meetings, and emails. Additionally, I received helpful feedback from Mr. Robert “Shaun” Carlson, PT, MS and LCDR Michael Krok, PT, DPT, OCS, CSCS in perfecting my poster and advising on how to best reflect the clinical utility of our findings. Specifically, my capstone committee—consisting of Dr. McCulloch, Ms. Prim, and Mr. Carlson—evaluated my poster presentation utilizing UNC-CH’s Health Science Library poster evaluation tool. The primary feedback I received was related to the presentation of results and aesthetics of my poster, which I incorporated into my final product.

Self-Reflection:

My ultimate goals for my capstone project was to further my knowledge related to concussion management and research while contributing valuable information to physical therapy practice within the military. I felt very confident about my ability to be timely and self-motivated with completing the majority of the project. I am very pleased with the results of my focused coursework and the overall final products of my capstone.

The entire experience of working alongside such brilliant clinical and academic minds during this capstone project has been truly unforgettable and has bolstered my resolve to improve the lives of service members through the field of physical therapy. I feel honored to have been a part of developing a RTD assessment that will undoubtedly improve therapists’ ability to assess the clinical needs of service members.

Acknowledgements :

First and foremost, I would like to thank my advisor, Dr. Karen McCulloch, for seeing some kind of potential in me after I “passionately” (albeit, maybe creepily) obsessed about her research during that fateful interview back in the Spring of 2016. KMac, thank you so much for allowing me to be a part of your research study and pick your brain about all things concussion for the past three years.

I also would like to show my appreciation to Julianna Primm for being so readily available to answer all my rookie research questions and providing her tireless support and wisdom throughout this project.

Thank you also to Shaun Carlson for allowing me to glean so much practical and clinical knowledge related to concussion management and physical therapy during my rotation at ISC as well as providing advice on making this project clinically meaningful.

Shout out to (soon to be) Dr. Kellie Adams, DPT for going through the trenches with me both literally and figuratively while on clinical rotation at Fort Bragg and working on this research project. You are truly superior.

I would also like to thank my family for supporting and believing in me throughout this entire, winding, and bumpy road to my DPT. I truly would not be here without the encouragement and opportunities you have provided for me, including reminding me to not get “combat ineffective” with stress from school.

Finally, I want to show my appreciation to my classmates (especially the soon to be Doctors of Physical Therapy: Jenna Kazmaier, Alison Berglund, and Deanna Sipes) who have put up with three years of my endless chatter and obsession with the military.

I am forever grateful for the relationships I forged and opportunities I have had during my time at UNC. As always, it’s a great day to be a Tar Heel!

 

References:

1. Helmick KM, Spells CA, Malik SZ, Davies CA, Marion DW, Hinds SR. Traumatic brain injury in the US military: epidemiology and key clinical and research programs. Brain Imaging Behav.2015;9(3):358-366. doi:10.1007/s11682-015-9399-z.
2. Scherer MR, Schubert MC. Traumatic brain injury and vestibular pathology as a comorbidity after blast exposure. Phys. Ther.2009;89(9):980-992. doi:10.2522/ptj.20080353.
3. Cernak I. Understanding blast-induced neurotrauma: how far have we come? Concussion2017;2(3):CNC42. doi:10.2217/cnc-2017-0006.
4. Weightman MM, Bolgla R, McCulloch KL, Peterson MD. Physical therapy recommendations for service members with mild traumatic brain injury. J. Head Trauma Rehabil.2010;25(3):206-218. doi:10.1097/HTR.0b013e3181dc82d3.