Physical therapists must screen all individuals who have experienced a potential concussive event and document the presence or absence of symptoms, impairments, and functional limitations that may relate to a concussive event. Screening for Indicators of Emergency ConditionsA Physical therapists must screen patients who have experienced a recent potential concussive event for signs of medical emergency or severe pathology (eg, more serious brain injury, medical conditions, or cervical spine injury) that warrant further evaluation by other health care providers. Referral for further evaluation should be made as indicated (FIGURE 1). Differential DiagnosisA Physical therapists must evaluate for potential signs and symptoms of an undiagnosed concussion in patients who have experienced a concussive event but have not been diagnosed with concussion. Evaluation should include triangulation of information from patient/family/witness reports, the patient's past medical history, physical observation/examination, and the use of an age-appropriate symptom scale/checklist (see FIGURE 1 for diagnostic criteria).

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 (β = .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.

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.

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 &lt; .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 large number of U.S. service members diagnosed with concussion/mild traumatic brain injury each year underscores the necessity for clear and effective clinical guidance for managing concussion. Relevant research continues to emerge supporting a gradual return to pre-injury activity levels without aggravating symptoms; however, available guidance does not provide detailed standards for this return to activity process. To fill this gap, the Defense and Veterans Brain Injury Center released a recommendation for primary care providers detailing a step-wise return to unrestricted activity during the acute phase of concussion. This guidance was developed in collaboration with an interdisciplinary group of clinical, military, and academic subject matter experts using an evidence-based approach. Systematic evaluation of the guidance is critical to ensure positive patient outcomes, to discover barriers to implementation by providers, and to identify ways to improve the recommendation. Here we describe a multi-level, mixed-methods approach to evaluate the recommendation incorporating outcomes from both patients and providers. Procedures were developed to implement the study within complex but ecologically-valid settings at multiple military treatment facilities and operational medical units. Special consideration was given to anticipated challenges such as the frequent movement of military personnel, selection of appropriate design and measures, study implementation at multiple sites, and involvement of multiple service branches (Army, Navy, and Marine Corps). We conclude by emphasizing the need to consider contemporary approaches for evaluating the effectiveness of clinical guidance.