Clinical Utility and Analysis of the Run-Roll-Aim Task: Informing Return-to-Duty Readiness Decisions in Active-Duty Service Members

Development of a multidimensional military readiness assessment

There is a need to be able to accurately evaluate whether an injured service member is able to return to duty. An effective assessment would challenge and measures physical and cognitive performance in a military-relevant context. Current assessments are lacking in one or more of these aspects. The simulation and data capture abilities of virtual reality systems are promising for use as the basis of multidimensional assessments. The team has previously developed a military-specific assessment in the Computer Assisted Rehabilitation Environment (CAREN) called the Readiness Evaluation During simulated Dismounted Operations (REDOp). Due to notable limitations in the original assessment, we have developed the next iteration, REDOp2. The assessment is able to challenge and measure a broader range of physical and cognitive performance domains in a more streamlined fashion. While limited to facilities with a CAREN, REDOp2 has the potential to provide an effective tool for highly trained and experienced wounded service members that require thorough assessment prior to returning to duty to ensure the safety of the team and mission. This methods paper describes the specific limitations in REDOp, how they were addressed in REDOp2, and suggested next steps to prepare the assessment for implementation.

An Augmented Reality Rifle Qualification Test for Return-to-Duty Assessment in Service Members

INTRODUCTION

Variability in return-to-duty (RTD) decision-making following mild traumatic brain injury (mTBI) is a threat to troop readiness. Current RTD assessments lack military-specific tasks and quantitative outcomes to inform stakeholders of a service member's (SM) capacity to successfully perform military duties. Augmented reality (AR), which places digital assets in a user's physical environment, provides a technological vehicle to deliver military-relevant tasks to a SM to be used in the RTD decision-making process. In addition to delivering digital content, AR headsets provide biomechanical data that can be used to assess the integrity of the central nervous system in movement control following mTBI. The objective of this study was to quantify cognitive and motor performance on an AR rifle qualification test (RQT) in a group of neurologically healthy military SMs.

MATERIALS AND METHODS

Data were collected from 111 healthy SMs who completed a basic (single-task) and complex (dual-task) RQT with a simulated M4 rifle. The complex scenario required the SM to perform the RQT while simultaneously answering arithmetic problems. Position data from the AR headset were used to capture postural sway, and the built-in microphone gathered responses to the arithmetic problems.

RESULTS

There were no differences in the number of targets hit, trigger pull reaction time, and transition time from kneeling to standing between the basic and complex scenarios. A significant worsening in postural sway following kneel-to-stand transition was observed in the complex scenario. The average reaction time to answer the arithmetic problems was nearly 2 times slower than the average reaction time to pull the trigger to a displayed target in the complex scenario.

CONCLUSION

The complex scenario provoked dual-task interference in SMs as evidenced by worsening postural sway and reaction time differences between the cognitive and motor tasks. An AR RQT provides objective and quantitative outcomes during a military-specific task. Greater precision in evaluating cognitive and motor performance during a military-relevant task has the potential to aid in the detection and management of SMs and their RTD following MTBI.

Leveraging Technology for Vestibular Assessment and Rehabilitation in the Operational Environment: A Scoping Review

INTRODUCTION

The vestibular system, essential for gaze and postural stability, can be damaged by threats on the battlefield. Technology can aid in vestibular assessment and rehabilitation; however, not all devices are conducive to the delivery of healthcare in an austere setting. This scoping review aimed to examine the literature for technologies that can be utilized for vestibular assessment and rehabilitation in operational environments.

MATERIALS AND METHODS

A comprehensive search of PubMed was performed. Articles were included if they related to central or peripheral vestibular disorders, addressed assessment or rehabilitation, leveraged technology, and were written in English. Articles were excluded if they discussed health conditions other than vestibular disorders, focused on devices or techniques not conducive to the operational environment, or were written in a language other than English.

RESULTS

Our search strategy yielded 32 articles: 8 articles met our inclusion and exclusion criteria whereas the other 24 articles were rejected.

DISCUSSION

There is untapped potential for leveraging technology for vestibular assessment and rehabilitation in the operational environment. Few studies were found in the peer-reviewed literature that described the application of technology to improve the identification of central and/or peripheral vestibular system impairments; triage of acutely injured patients; diagnosis; delivery and monitoring of rehabilitation; and determination of readiness for return to duty.

CONCLUSIONS

This scoping review highlighted technology for vestibular assessment and rehabilitation feasible for use in an austere setting. Such technology may be leveraged for prevention; monitoring exposure to mechanisms of injury; vestibular-ocular motor evaluation; assessment, treatment, and monitoring of rehabilitation progress; and return-to-duty determination after vestibular injury.

FUTURE DIRECTIONS

The future of vestibular assessment and rehabilitation may be shaped by austere manufacturing and 3D printing; artificial intelligence; drug delivery in combination with vestibular implantation; organ-on-chip and organoids; cell and gene therapy; and bioprinting.

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.

Validity and Reliability of Methods to Assess Movement Deficiencies Following Concussion: A COSMIN Systematic Review

BACKGROUND

There is an increased risk of subsequent concussion and musculoskeletal injury upon return to play following a sports-related concussion. Whilst there are numerous assessments available for clinicians for diagnosis and during return to play following concussion, many may lack the ability to detect these subclinical changes in function. Currently, there is no consensus or collated sources on the reliability, validity and feasibility of these assessments, which makes it difficult for clinicians and practitioners to select the most appropriate assessment for their needs.

OBJECTIVES

This systematic review aims to (1) consolidate the reliability and validity of motor function assessments across the time course of concussion management and (2) summarise their feasibility for clinicians and other end-users.

METHODS

A systematic search of five databases was conducted. Eligible studies were: (1) original research; (2) full-text English language; (3) peer-reviewed with level III evidence or higher; (4) assessed the validity of lower-limb motor assessments used to diagnose or determine readiness for athletes or military personnel who had sustained a concussion or; (5) assessed the test-retest reliability of lower-limb motor assessments used for concussion management amongst healthy athletes. Acceptable lower-limb motor assessments were dichotomised into instrumented and non-instrumented and then classified into static (stable around a fixed point), dynamic (movement around a fixed point), gait, and other categories. Each study was assessed using the COSMIN checklist to establish methodological and measurement quality.

RESULTS

A total of 1270 records were identified, with 637 duplicates removed. Titles and abstracts of 633 records were analysed, with 158 being retained for full-text review. A total of 67 records were included in this review; 37 records assessed reliability, and 35 records assessed the validity of lower-limb motor assessments. There were 42 different assessments included in the review, with 43% being non-instrumented, subjective assessments. Consistent evidence supported the use of instrumented assessments over non-instrumented, with gait-based assessments demonstrating sufficient reliability and validity compared to static or dynamic assessments.

CONCLUSION

These findings suggest that instrumented, gait-based assessments should be prioritised over static or dynamic balance assessments. The use of laboratory equipment (i.e. 3D motion capture, pressure sensitive walkways) on average exhibited sufficient reliability and validity, yet demonstrate poor feasibility. Further high-quality studies evaluating the reliability and validity of more readily available devices (i.e. inertial measurement units) are needed to fill the gap in current concussion management protocols. Practitioners can use this resource to understand the accuracy and precision of the assessments they have at their disposal to make informed decisions regarding the management of concussion.

TRAIL REGISTRATION

This systematic review was registered on PROSPERO (reg no. CRD42021256298).

Use of accelerometers and inertial measurement units to quantify movement of tactical athletes: A systematic review

The dynamic work environments of tactical athletes are difficult to replicate in a laboratory. Accelerometers and inertial measurement units provide a way to characterize movement in the field. This systematic review identified how accelerometers and inertial measurement units are currently being used to quantify movement patterns of tactical athletes. Seven research and military databases were searched, producing 26,228 potential articles with 78 articles included in this review. The articles studied military personnel (73.1%), firefighters (19.2%), paramedics (3.8%), and law enforcement officers (3.8%). Accelerometers were the most used type of sensor, and physical activity was the primarily reported outcome variable. Seventy of the studies had fair or poor quality. Research on firefighters, emergency medical services, and law enforcement officers was limited. Future research should strive to make quantified movement data more accessible and user-friendly for non-research personnel, thereby prompting increased use in tactical athlete groups, especially first responder agencies.

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.

Multi-domain assessment of sports-related and military concussion recovery: A scoping review

OBJECTIVE

This review explores the literature on multi-domain assessments used in concussion recovery, to inform evidence-based and ecologically valid return-to-play. It asks: What simultaneous, dynamic multi-domain paradigms are used to assess recovery of youth and adults following concussion?

METHODS

Five databases were searched (CINAHL, EMBASE, MEDLINE, PsycInfo, SPORTDiscus) until September 30, 2021. Records were limited to those published in peer-reviewed journals, in English, between 2002 and 2021. Included studies were required to describe the assessment of concussion recovery using dynamic paradigms (i.e., requiring sport-like coordination) spanning multiple domains (i.e., physical, cognitive, socio-emotional functioning) simultaneously.

RESULTS

7098 unique articles were identified. 64 were included for analysis, describing 36 unique assessments of 1938 concussed participants. These assessments were deconstructed into their constituent tasks: 13 physical, 17 cognitive, and one socio-emotional. Combinations of these "building blocks" formed the multi-domain assessments. Forty-six studies implemented level walking with a concurrent cognitive task. The most frequently implemented cognitive tasks were 'Q&A' paradigms requiring participants to answer questions aloud during a physical task.

CONCLUSIONS

A preference emerged for dual-task assessments, specifically combinations of level walking and Q&A tasks. Future research should balance ecological validity and clinical feasibility in multi-domain assessments, and work to validate these assessments for practice.

R2Play development: Fostering user-driven technology that supports return-to-play decision-making following pediatric concussion

Objective

To design a multi-domain return-to-play assessment system (R2Play) for youth athletes with concussion.

Methods

The R2Play system was developed using an overarching user-centered approach, the Design Thinking Framework, and research activities included: 1) structured brainstorming within our research team, 2) interviews with clinician and youth sports coaches, 3) building a testable prototype, and 4) interface testing through cognitive walkthroughs with clinician partners.

Results

Clinician and coach participants provided feedback on the R2Play concept, which was integrated into the design process and provided future directions for research. Examples of feedback-driven design choices included reducing assessment time, increasing ecological validity by adding in background noise, and developing youth-friendly graphical results screens. Following refinement based on stakeholder feedback, the R2Play system was outlined in detail and a testable prototype was developed. It is made up of two parts: a clinician tablet, and a series of tablet "buttons" that display numbers and letters. Youth athletes run between the buttons to connect a "trail" in ascending alphanumeric order, 1-A-2-B, etc. Their performance across a series of levels of increasing difficulty is logged on the clinician tablet. Initial testing with five clinicians showed the system's interface to have excellent usability with a score of 81% (SD = 8.02) on the System Usability Scale.

Conclusion

Through this research, a prototype of the R2Play system was innovated and evaluated by clinician and coach stakeholders. Initial usability was excellent and directions for future iterations were highlighted. Outcomes suggest the potential benefits of using technologies to assist in complex clinical assessment, as well as utilizing a user-centered approach to design.

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.