Introduction The objective of this study was to determine the utility of the Community Balance and Mobility scale (CB&M) among service members presenting with mild traumatic brain injury (mTBI), to compare the results against well-established balance assessments, and to find a new military-specific CB&M cut score to help differentiate those with and without mTBI. Materials and Methods The setting was a 4-week, intensive-outpatient, interdisciplinary program for active duty service members with mTBI. This was a nonrandomized, cross-sectional design that compared multiple measures between two groups: active duty service members with (n = 45) and without (n = 45) mTBI. The assessments, including the Activities-Specific Balance Confidence Scale, gait speed (comfortable and fast), the Functional Gait Assessment, and the CB&M, were provided to both sample groups. Results The mTBI group performed significantly worse (P ≤ 0.01) across all measures. A higher cut score for the CB&M of 81.5 is suggested. The CB&M demonstrated the best sensitivity (78%) and specificity (91%) ratio, as well as the largest effect size and area under the curve(0.92). Conclusion All objective measures distinguish participants with mTBI from controls, ranging from fair to excellent. The recommended CB&M cut score of 81.5 allows for good variance, standard deviation, and reduced risk of ceiling or floor effects. Further examination of the recommended CB&M cut score is warranted for use in the mTBI civilian populations.

The National Intrepid Center of Excellence (NICoE), on the campus of Walter Reed National Military Medical Center, was developed to help improve the lives of active duty service members (SMs) with traumatic brain injury (TBI) and comorbid behavioral health (BH) conditions. During the NICoE intensive outpatient program, SM who have all been identified as having some degree of TBI, undergo extensive interdisciplinary evaluations, including comprehensive vestibular assessment. These SMs sometimes present with vestibular symptoms ranging from lightheadedness to vertigo associated with the dual TBI/BH diagnoses, and vestibular testing results reported elsewhere have varied among this population. The study's purpose was to collate the vestibular test results obtained from a sample of the NICoE patients to determine if specific tests have a tendency to be abnormal in these SMs. Results indicate that oculomotor tests, particularly pursuit and saccade, were most often abnormal. The vertical subtests of the pursuit and saccade tests were abnormal more frequently than the horizontal subtests, suggesting that the vertical subtests should be utilized when evaluating the TBI population. Overall, oculomotor tests of vertical pursuit and saccades, as well as tests of central vestibular function, appear useful for detecting neurologic changes in active duty SMs with chronic symptoms after TBI.

The CB&M appears to have higher sensitivity and specificity than other measures of balance in SMs with mTBI/PH. A higher cut score for the CB&M is needed for this population.

The objective of this study was to determine whether physical performance during virtual environment (VE) tasks in the Computer-Assisted Rehabilitation Environment (CAREN) could differentiate between service members (SMs) with a history of traumatic brain injury (TBI) with and without comorbid post-traumatic stress disorder (PTSD). Data were obtained by independent review of clinical notes, objective outcomes, and validated questionnaires from 214 SMs (208 males) with a history of TBI assessed in the CAREN from 2010 to 2015. Three preliminary VEs acclimatized patients to the CAREN: Balance Balls, weight shifting on a static platform (timed); Balance Cubes, step shifting with and without platform motion (timed); and Continuous Road, flat ambulation (self-selected speed). Multiple regression analyses revealed that patients with comorbid TBI-PTSD were significantly slower in completing the VE tasks than patients without PTSD. Logistic regression showed that the Balance Cubes VE without platform motion significantly predicted diagnostic category (i.e., no PTSD vs. comorbid PTSD). In conclusion, in SMs with a history of TBI, physical performance on the CAREN effectively distinguished those with comorbid PTSD, as their performance was significantly slower than SMs without PTSD. These results portray the potential of the CAREN as a novel assessment tool in SMs with a history of TBI.

Introduction Mild traumatic brain injury (mTBI) is associated with significant financial cost and reduced military readiness and impacts quality of life for active duty service members (SMs). Post-concussive symptoms can include vestibular impairments, such as chronic dizziness and postural instability, which can be compounded by psychological comorbidities like PTSD. Comprehensive vestibular evaluations are required to assess symptoms and guide clinical decision-making. At the National Intrepid Center of Excellence (NICoE), in addition to traditional vestibular assessments, clinicians can also leverage virtual environments (VEs) in the Computer-Assisted Rehabilitation Environment (CAREN) to further evaluate balance. The objective of this study was to examine the relationship between conventional outcomes and VE performance on immersive balance tasks in the CAREN, determine whether VE performance could predict conventional outcomes, and explore the impact of PTSD. Materials and Methods This retrospective analysis included 112 SMs from the NICoE Intensive Outpatient Program who provided informed consent for their clinical data to be used for research purposes. All had a history of mTBI, underwent vestibular evaluations, and completed immersive balance tasks on the CAREN. Conventional outcomes included the Sensory Organization Test (SOT), Functional Gait Assessment (FGA), Activities Balance Confidence (ABC) Scale, and Dizziness Handicap Inventory (DHI). The PTSD Checklist—Military Version was added to account for behavioral symptoms. Computer-Assisted Rehabilitation Environment outcomes included total time to complete the Balance Cubes VE, with the platform static (BC-Static) and with random platform motion (BC-PM) as well as composite scores for the Shark Hunt VE, with (SH-Recall) and without a recall task (SH-Standard). Statistical analyses included independent t-tests to determine group differences, Pearson’s correlations to examine relationships between conventional outcomes and VE performance, and binary logistic regressions to determine if VE performance predicted conventional outcomes based on clinically relevant cutoffs. Results SMs who took less time to complete BC-Static had better overall balance, indicated by higher ABC, SOT, and FGA scores (P <.001). Those with greater self-reported dizziness, higher DHI scores, took longer to complete BC-Static (P < .05). FGA and SOT, objective gait and balance, were similarly correlated to BC-PM performance (P <.001). SMs with higher SOT scores, better balance, also tended to have higher SH-Standard scores (P <.1). SMs, who were above normative SOT, FGA, and ABC cutoffs, completed BC-Static significantly faster than those below (P <.05). This remained true for BC-PM but was only significant for SOT (P = .004). Performance on BC-Static, BC-PM, and SH-Standard was significant predictors of SOT score. For SMs with comorbid mTBI and PTSD, increased functional disability was observed in conventional outcomes and diminished VE performance was noted. Conclusion Objective balance and gait, SOT and FGA, demonstrated the strongest relationships to immersive VE performance in the CAREN. Our findings suggest that these immersive balance tasks may be effective as an adjunct assessment to examine balance. Future work will focus on moving these VEs from the CAREN to a portable system, which could be more readily utilized in a variety of clinical settings, increasing accessibility.