Impact of Physical Therapy on Post-Concussive Symptoms in Military Service
This systematic review explores the effects of physical therapy interventions on post-concussive symptoms in military personnel with mild traumatic brain injuries (mTBIs). It discusses the common types and symptoms of mTBIs, emphasizing the importance of a multidisciplinary approach to treatment. Physical therapists have a crucial role in evaluating and addressing impairments to enhance the quality of life for individuals with mTBIs sustained during military service.
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The Impact of Physical Therapy Interventions on Post Concussive Symptoms Sustained During Military Service: A Systematic Review LSUHSC-NO SAHP Research Symposium Dr. Rachel Wellons, Adam Crawford, Emily Dares, Scott LeJeune, Tommy Nguyen, Cameron Troxler, Sarah Uzee
Mild Traumatic Brain Injuries (mTBIs)1,2,3,4 Make up for 70-90% of all treated brain injuries in non-military populations In 2012, there were over 400,000 traumatic brain injuries (TBIs) reported in deployed US troops Plaguing military service members Physical burden and financial burden
Types of mTBIs2,5,6,7,8 Blast-induced mTBIs: Typically sustained from exposure to an explosion Common in the military population due to participation in combat, hazards, and explosives Can result in more detrimental post-concussive sequelae Blunt-induced mTBIs: Typically sustained from physical trauma Common in the sports population
Symptoms of mTBIs1,5,8,9 Common symptoms associated with mTBIs: Cognitive symptoms Somatic symptoms Musculoskeletal symptoms Symptoms are usually temporary resolving within days or weeks, but this is not always the case Post-concussive disorder (PCD): at least 3 symptoms persists after normal healing time for adults (7-10 days) 5% of military members who have sustained a mTBI experience PCD
mTBIs Within the Military Population1,5,7,8,9,10,11 Complex health problem due to unique psychological challenges More likely to develop chronic concussive symptoms while struggling with psychological factors Anxiety, depression, post-traumatic stress disorder (PTSD) Signature injury in the military PTSD along with a TBI Certain PTSD symptoms present similar to PCD Fatigue, social withdrawal, sleep disturbance, sadness, difficulty concentrating
Treatment of mTBIs1,5,6,12 Multidisciplinary approach Physical therapy (PT) treatment is just a slice of the pie when it comes to treating mTBIs However, physical therapists (PTs) play a significant role in regard to treatment of mTBIs in the military population Evaluate and treat common symptoms that occur after sustaining a mTBI Provide an array of interventions to address impairments and improve quality of life
Physical Therapists Role in Treating mTBIs12 Common symptoms/impairments PTs treat: Cervical musculoskeletal impairments Vestibulo-oculomotor impairments Exertional intolerance Motor dysfunction Benign paroxysmal positional vertigo Type of PT treatment depends on symptoms/impairments: Manual therapy Neuromotor and sensorimotor retraining exercises Static and dynamic balance exercises Habituation and adaptation exercises Canalith repositioning
Are PT Interventions Effective? PT interventions for post-concussive symptoms (PCS) are commonly discussed and agreed upon in non-military populations. There is limited consensus regarding effectiveness of PT interventions on the active military and veteran population Study Purpose: Systematically review the literature on PT interventions on mTBI in the military population to determine the impact on PCS sustained during military service.
Literature Search Strategy Time Period: January-August 2021, February 2022 Databases: LSUHSC-NO library and Ovid Pub Med Search Terms:Table 1 Table 1: Search Terms Used Population Concussion Physical Therapy Vestibular Rehabilitation Musculoskeletal Intervention Aerobic Intervention - Military - Veterans - Active duty - Concussion - Mild traumatic brain injury - Brain injury - Blunt injury - Blast injury - Nonpenetrating wound - Post concussive symptom - Post concussive syndrome - 3PD - Dizziness - Motion sensitivity - Vertigo - Physical therapy - Physiotherapy - Rehabilitation - Physical therapy modalities - Vestibular rehab - Vestibular rehabilitation - Adaptation - Habituation - Substitution - Vestibulo-oculomotor reflex - VOR - Vision therapy - Oculomotor training - Oculomotor exercises - Oculomotor therapy - Musculoskeletal - Cervical - Soft tissue - Soft tissue mobilization - Manual therapy - Manipulation - Aerobic exercise - Graded aerobic exercise
Study Selection and Literature Criteria After systematic literature search, there were 404 total articles Screening Process: Identify duplicates Read abstract Inclusion Criteria: Population was United States of America active duty military and/or inactive veterans Population sustained a mTBI during military service Treatment included PT intervention Exclusion Criteria: Sports population who sustained a mTBI Design of systematic review, cohort study, and/or case series Subjects other than humans Articles not written in the English language After screening process, there were 4 articles to be analyzed
Quality Assessment9 American Physical Therapy Association Critical Appraisal Tool for Experimental Intervention Studies (CAT-EI): Designed specifically to evaluate PT intervention effectiveness Each outcome measure separately evaluated for level of evidence Establishing Grader Validity and Reliability: Researched the tool Individually graded a practice article and compared their results to Dr. Rachel Wellons Grader was considered to be valid and reliable when the score was within 5% of Dr. Wellons score Process was repeated with a different article
Data Extraction and Analysis16,17 Grading Process: All 4 articles graded individually, then compared as a group for unanimous agreement Data Extracted from APTA CAT-EI: Study purpose Setting IRB compliance Quality of the research design Individual outcome measures Impacts Quality Rating: High, acceptable, low, or unacceptable CAT-EI scores >70% = high quality study 30%-70% = intermediatequality study <30% = low quality study
Articles Graded Janak et al. Hammerle et al. Studied cognitive rehabilitation, vestibular interventions, headache management, and integrated behavioral healthcare to address co-occurring psychiatric conditions such as PTSD, depression, and sleep disturbance Compared vestibular rehabilitation therapy and cervical spine proprioceptive retraining as interventions for dizziness in a military population with a mTBI Kontos et al. Loftin et al. Studied the effects of targeted interventions including behavioral, vestibular, vision, and exertion on a variety of outcomes including symptoms, cognitive, dizziness, neck related issues, and vestibular/oculomotor Studied the effects of a generalized vestibular rehabilitation approach on vestibular dysfunction in the military population as the result of traumatic brain injury, blast exposure, and/or repetitive acoustic insult
CAT-EI Score Summary Table 2: CAT-EI Score Summary Title Authors CAT-EI Score Effectiveness of Cervical Proprioception Retraining for Dizziness After mTBI Injury in a Military Population with Abnormal Cervical Proprioception Hammerle M, Swan AA, Nelson JT, Treleaven JM Dizziness 22% Preliminary Evidence for Improvement in Symptoms, Cognitive, Vestibular, and Oculomotor Outcomes Following Targeted Interventions with Chronic mTBI Patients Kontos AP, Colins MW, Holland CL, Reeves VL, Edelman K, Benso S, Schneider W, Okonkwo D Dizziness 18.8% Cognitive 17.6% Vestibular/Oculomotor 17.6% Balance 31.3% Neck-Related Issues 31.3% Completion of Multidisciplinary Treatment for Persistent Post-Concussive Symptoms is Associated with Reduced Symptom Burden Janak JC, Cooper DB, Bowles AO, Alamgir AH, Cooper SP, Gabriel KP, Perez A, Orman JA PPCS 41.2% PTSD 41.2% Implementation of a Generalized Vestibular Rehabilitation Approach Loftin MC, Arango JI, Bobula S, Hill-Pearson C, Pazdan RM, Souvignier AR Patient Satisfaction 20% Provider Comfort 20% Resource Utilization 25% Tolerance to Intervention 25%
CAT-EI Score Summary Table 2: CAT-EI Score Summary Title Authors CAT-EI Score Effectiveness of Cervical Proprioception Retraining for Dizziness After mTBI Injury in a Military Population with Abnormal Cervical Proprioception Hammerle M, Swan AA, Nelson JT, Treleaven JM Dizziness 22% Preliminary Evidence for Improvement in Symptoms, Cognitive, Vestibular, and Oculomotor Outcomes Following Targeted Interventions with Chronic mTBI Patients Kontos AP, Colins MW, Holland CL, Reeves VL, Edelman K, Benso S, Schneider W, Okonkwo D Dizziness 18.8% Cognitive 17.6% Vestibular/Oculomotor 17.6% Balance 31.3% Neck-Related Issues 31.3% Completion of Multidisciplinary Treatment for Persistent Post-Concussive Symptoms is Associated with Reduced Symptom Burden Janak JC, Cooper DB, Bowles AO, Alamgir AH, Cooper SP, Gabriel KP, Perez A, Orman JA PPCS 41.2% PTSD 41.2% Implementation of a Generalized Vestibular Rehabilitation Approach Loftin MC, Arango JI, Bobula S, Hill-Pearson C, Pazdan RM, Souvignier AR Patient Satisfaction 20% Provider Comfort 20% Resource Utilization 25% Tolerance to Intervention 25%
CAT-EI Score Summary Table 2: CAT-EI Score Summary Title Authors CAT-EI Score Effectiveness of Cervical Proprioception Retraining for Dizziness After mTBI Injury in a Military Population with Abnormal Cervical Proprioception Hammerle M, Swan AA, Nelson JT, Treleaven JM Dizziness 22% Preliminary Evidence for Improvement in Symptoms, Cognitive, Vestibular, and Oculomotor Outcomes Following Targeted Interventions with Chronic mTBI Patients Kontos AP, Colins MW, Holland CL, Reeves VL, Edelman K, Benso S, Schneider W, Okonkwo D Dizziness 18.8% Cognitive 17.6% Vestibular/Oculomotor 17.6% Balance 31.3% Neck-Related Issues 31.3% Completion of Multidisciplinary Treatment for Persistent Post-Concussive Symptoms is Associated with Reduced Symptom Burden Janak JC, Cooper DB, Bowles AO, Alamgir AH, Cooper SP, Gabriel KP, Perez A, Orman JA PPCS 41.2% PTSD 41.2% Implementation of a Generalized Vestibular Rehabilitation Approach Loftin MC, Arango JI, Bobula S, Hill-Pearson C, Pazdan RM, Souvignier AR Patient Satisfaction 20% Provider Comfort 20% Resource Utilization 25% Tolerance to Intervention 25%
CAT-EI Score Summary Table 2: CAT-EI Score Summary Title Authors CAT-EI Score Effectiveness of Cervical Proprioception Retraining for Dizziness After mTBI Injury in a Military Population with Abnormal Cervical Proprioception Hammerle M, Swan AA, Nelson JT, Treleaven JM Dizziness 22% Preliminary Evidence for Improvement in Symptoms, Cognitive, Vestibular, and Oculomotor Outcomes Following Targeted Interventions with Chronic mTBI Patients Kontos AP, Colins MW, Holland CL, Reeves VL, Edelman K, Benso S, Schneider W, Okonkwo D Dizziness 18.8% Cognitive 17.6% Vestibular/Oculomotor 17.6% Balance 31.3% Neck-Related Issues 31.3% Completion of Multidisciplinary Treatment for Persistent Post-Concussive Symptoms is Associated with Reduced Symptom Burden Janak JC, Cooper DB, Bowles AO, Alamgir AH, Cooper SP, Gabriel KP, Perez A, Orman JA PPCS 41.2% PTSD 41.2% Implementation of a Generalized Vestibular Rehabilitation Approach Loftin MC, Arango JI, Bobula S, Hill-Pearson C, Pazdan RM, Souvignier AR Patient Satisfaction 20% Provider Comfort 20% Resource Utilization 25% Tolerance to Intervention 25%
Discussion It is essential for research to be conducted on interventions for PCS in military service members mTBIs is one of the most common conditions that members of the military experience while in service Our results have demonstrated that the evidence needed to determine the effects of different PT interventions on these mTBIs are only in the preliminary stage Most of the research reviewed consists of interventions that are either not effective or not reproducible
Quality Rating The APTA CAT-EI tool discussed earlier consists of yes or no questions that help determine the quality of a study More yes answers means higher quality More no answers mean lower quality The 4 articles reviewed had a majority no answers Most of the interventions utilized in these studies were deemed ineffective or were not described in sufficient enough detail in order for them to be reproducible Demonstrates that the research for PT interventions for mTBIs is significantly lacking Specifically in military populations
Quality Rating In these 4 articles, 12 different outcomes of interest were analyzed with the CAT-EI tool 8 of them presented with low quality of evidence (<30%) Dizziness improvement Symptoms Cognitive Vestibular/oculomotor Tolerance to exercise Patient satisfaction Provider comfort Resource utilization 4 of them presented with intermediate quality of evidence (30%-70%) Balance Neck-related domains PPCS resolution PTSD resolution
Vestibular Rehabilitation Therapy (VRT)18,21,22 Hammerle et al. -VRT effects on dizziness Consisted of VOR training and various balance exercises HEP given to subjects; included different VOR exercise progressions and balance interventions The interventions performed were not described in sufficient detail, thus deeming them not reproducible Loftin et al. -VRT effects on PCS Consisted of 10 different visual, vestibular, balance, habituation, and cervicogenic exercises Detailed program provided; included session layout, exercise description, exercise progression, equipment needed, and individual exercise prescriptions. Outcomes included patient satisfaction, provider comfort, resource utilization, and patient tolerance While the interventions performed were described adequately in order to be reproducible, the outcomes of these interventions were not provided
Vestibular Rehabilitation Therapy (VRT)18,21,22 Kleffelgaard et al. -VRT effects on dizziness and mobility Nonspecific population Dizziness Handicap Inventory (DHI), High-Level Mobility Assessment Tool for TBI Interventions included habituation, gaze-stabilization, and balance exercises HEP included walking and/or biking and several other modified exercises Follow-ups performing after 3-and 5-months 3 months: Statistically significant between-group differences in favor of intervention group 5 months:Intervention group maintained improvement, control group also displayed decreased dizziness and improved mobility
Cervical Spine Proprioception Retraining (CSPR)18 Hammerle et al. -CSPR effects on dizziness Structurally designed as a game Aimed to improve cervical proprioception Required patients to practice head relocation to neutral with feedback from light-emitting diode beam Two distinct tests utilized to determine impact on dizziness Cervical Joint Position Error (JPE) -determines cervical proprioception Smooth Pursuit Neck Torsion (SPNT) -determines effects of cervical spine on ocular control Improvements in dizziness noted when CSPR program initiated in patients with at least 1 positive JPE or SPNT test
Targeted Evaluation, Action, and Monitoring of TBI (TEAM-TBI)19 Kontos et al. -TEAM-TBI effects on patients suffering from mTBIs Initial and 6 month post-intervention comprehensive, multimodal assessment Symptoms: Post-Concussion Symptom Scale (PCSS), DHI Cognitive: Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) Vestibular/Oculomotor: Vestibular/Ocular Motor Screening (VOMS) Balance: Activities-specific Balance Confidence (ABC), Balance Error Scoring System (BESS) Cervical: Neck Disability Index (NDI) Targeted interventions given to subjects after their completion of the multimodal clinical assessment Improvements seen in cognitive, vestibular, oculomotor, and balance impairment and symptoms
Multimodal Approach20 Multimodal approach: Optimize treatment by delivering different types of therapy together Janak et al. -Vestibular interventions, cognitive rehabilitation, headache management, and integrated behavioral healthcare Reduced self-reported persistent PCS and PTSD symptoms Intermediate quality of evidence Interventions not reproducible
Limitations Time Frame: January 2021 to August 2021, and February 2022 Language: English publication Population: Military members who experienced mTBI Lack of follow-up information from participants Lack of reproducible PT interventions in articles
Conclusion Preliminary evidence when comparing the effects of VRT, CSPR, multimodal approach, and TEAM-TBI on PCS More research needs to be conducted to determine effective PT interventions for PCS sustained during military service
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