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.

Blasts or explosions are the most common mechanisms of injury in modern warfare. Traumatic brain injury (TBI) is a frequent consequence of exposure to such attacks. Although the management of orthopedic, integumentary, neurocognitive, and neurobehavioral sequelae in survivors of blasts has been described in the literature, less attention has been paid to the physical therapist examination and care of people with dizziness and blast-induced TBI (BITBI). Dizziness is a common clinical finding in people with BITBI; however, many US military service members who have been exposed to blasts and who are returning from Iraq and Afghanistan also complain of vertigo, gaze instability, motion intolerance, and other symptoms consistent with peripheral vestibular pathology. To date, few studies have addressed such "vestibular" complaints in service members injured by blasts. Given the demonstrated efficacy of treating the signs and symptoms associated with vestibular pathology, vestibular rehabilitation may have important implications for the successful care of service members who have been injured by blasts and who are complaining of vertigo or other symptoms consistent with vestibular pathology. In addition, there is a great need to build consensus on the clinical best practices for the assessment and management of BITBI and blast-related dizziness. The purpose of this review is to summarize the findings of clinicians and scientists conducting research on the effects of blasts with the aims of defining the scope of the problem, describing and characterizing the effects of blasts, reviewing relevant patients' characteristics and sensorimotor deficits associated with BITBI, and suggesting clinical best practices for the rehabilitation of BITBI and blast-related dizziness.

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.