Within the last decade, more than 220,000 service members have sustained traumatic brain injury (TBI) in support of military operations in Iraq and Afghanistan. Mild TBI may result in subtle cognitive and sensorimotor deficits that adversely affect warfighter performance, creating significant challenges for service members, commanders, and clinicians. In recent conflicts, physical therapists and occupational therapists have played an important role in evaluating service member readiness to return to duty (RTD), incorporating research and best practices from the sports concussion literature. Because premorbid (baseline) performance metrics are not typically available for deployed service members as for athletes, clinicians commonly determine duty readiness based upon the absence of postconcussive symptoms and return to "normal" performance on clinical assessments not yet validated in the military population. Although practices described in the sports concussion literature guide "return-to-play" determinations, resolution of symptoms or improvement of isolated impairments may be inadequate to predict readiness in a military operational environment. Existing clinical metrics informing RTD decision making are limited because they fail to emphasize functional, warrior task demands and they lack versatility to assess the effects of comorbid deficits. Recently, a number of complex task-oriented RTD approaches have emerged from Department of Defense laboratory and clinical settings to address this gap. Immersive virtual reality environments, field-based scenario-driven assessment programs, and militarized dual-task and multitask-based approaches have all been proposed for the evaluation of sensorimotor and cognitive function following TBI. There remains a need for clinically feasible assessment methods that can be used to verify functional performance and operational competence in a variety of practice settings. Complex and ecologically valid assessment techniques incorporating dual-task and multitask methods may prove useful in validating return-to-activity requirements in civilian and military populations.

Study design Clinical trial. Objective To demonstrate that a 12-week exoskeleton-based robotic gait training regimen can lead to a clinically meaningful improvement in independent gait speed, in community-dwelling participants with chronic incomplete spinal cord injury (iSCI). Setting Outpatient rehabilitation or research institute. Methods Multi-site (United States), randomized, controlled trial, comparing exoskeleton gait training (12 weeks, 36 sessions) with standard gait training or no gait training (2:2:1 randomization) in chronic iSCI (>1 year post injury, AIS-C, and D), with residual stepping ability. The primary outcome measure was change in robot-independent gait speed (10-meter walk test, 10MWT) post 12-week intervention. Secondary outcomes included: Timed-Up-and-Go (TUG), 6-min walk test (6MWT), Walking Index for Spinal Cord Injury (WISCI-II) (assistance and devices), and treating therapist NASA-Task Load Index. Results Twenty-five participants completed the assessments and training as assigned (9 Ekso, 10 Active Control, 6 Passive Control). Mean change in gait speed at the primary endpoint was not statistically significant. The proportion of participants with improvement in clinical ambulation category from home to community speed post-intervention was greatest in the Ekso group (>1/2 Ekso, 1/3 Active Control, 0 Passive Control, p < 0.05). Improvements in secondary outcome measures were not significant. Conclusions Twelve weeks of exoskeleton robotic training in chronic SCI participants with independent stepping ability at baseline can improve clinical ambulatory status. Improvements in raw gait speed were not statistically significant at the group level, which may guide future trials for participant inclusion criteria. While generally safe and tolerable, larger gains in ambulation might be associated with higher risk for non-serious adverse events.

Mild traumatic brain injury (mTBI), a principal injury of the wars in Iraq and Afghanistan, can result in significant morbidity. To make accurate return-to-duty decisions for soldiers with mTBI, military medical personnel require sensitive, objective, and duty-relevant data to characterize subtle cognitive and sensorimotor injury sequelae. A military-civilian research team reviewed existing literature and obtained input from stakeholders, end users, and experts to specify the concept and develop a preliminary assessment protocol to address this need. Results of the literature review suggested the potential utility of a test based on dual-task and multitask assessment methods. Thirty-three individuals representing a variety of military and civilian stakeholders/experts participated in interviews. Interview data suggested that reliability/validity, clinical feasibility, usability across treatment facilities, military face validity, and capacity to challenge mission-critical mTBI vulnerabilities were important to ultimate adoption. The research team developed the Assessment of Military Multitasking Performance, a tool composed of eight dual and multitasking test-tasks. A concept test session with 10 subjects indicated preliminary face validity and informed modifications to scoring and design. Further validation is needed. The Assessment of Military Multitasking Performance may fill a gap identified by stakeholders for complex cognitive/motor testing to assist return-to-duty decisions for service members with mTBI.

Mild traumatic brain injuries (MTBIs) are of increasing concern in both the military and civilian populations as the potential long-term effects and costs of such injuries are being further recognized. Injuries from conflicts in Afghanistan and Iraq have increased public awareness and concern for TBI. The Proponency Office for Rehabilitation and Reintegration, Office of the Surgeon General, US Army tasked a team of physical and occupational therapists to assemble evidence-informed guidelines for assessment and intervention specific to MTBI. Given the paucity of specific guidelines for physical therapy related to MTBI, we focused on literature that dealt with the specific problem area or complaint of the Service member following MTBI. Recommendations, characterized as practice standards or practice options based on strength of evidence, are provided relative to patient/client education, activity intolerance, vestibular dysfunction, high-level balance dysfunction, posttraumatic headache, temporomandibular disorder, attention and dual-task performance deficits, and participation in exercise. While highlighting the need for additional research, this work can be considered a starting point and impetus for the development of evidence-based practice in physical therapy for our deserving Service members.