Most experts recommend the early provision of verbal and written educational information about MTBI symptoms (headache, difficulties with memory and/or attention, etc), as well as reassurance that symptoms are likely to recover over a period of weeks or a few months.27–30 Because military members may not identify MTBI symptoms until days to weeks to months after onset, physical therapists should be aware of the important reassuring effect of education about typical sequelae of MTBI and the time course (typically <3 months) of recovery. The PR&R has created a series of downloadable/printable MTBI-related patient education handouts that are available at their Web site (http://www.armymedicine.army.mil/prr/edtraining.html).
A slow progression for return to duty is recommended, similar to guidelines for return to play following sports concussion.12 Rest is encouraged until symptom free and then a daily stepwise progression is followed. Intensity of activity should be decreased with any symptom return. Studies in rats suggest that exercise in the first 7 days after concussion is detrimental to the formation of neurotrophic factors and other molecules that enhance brain plasticity and improve cognitive status following brain injury.36 Metabolic and physiologic changes in the brain postconcussion may worsen during physical or cognitive exertion, with alterations in cerebral blood flow.37 Exercise in the short-term postconcussive period may increase brain metabolic requirements at the specific time when brain metabolism is compromised. Certainly, the activity requirements of full combat duty can be of high intensity, given the heavy physical loads of rucksacks and safety equipment. Consideration should also be given to slowly progress exertion in general fitness programs or “working out” as may be undertaken by a Service member in-theater. Exercise programs provided by therapists for Service members with musculoskeletal injuries may require modification if MTBI is also identified.
Two types of vestibular dysfunction that can occur following a MTBI, benign paroxysmal positional vertigo of the posterior canal or lateral canal and unilateral vestibular hypofunction, were identified by the OT/PT workgroup and expert consultants as deficits that can be assessed and treated by a general practice PT in a war zone or stateside medical facility.10,13 Episodic dizziness that is associated with migraine headache was also considered an appropriate diagnosis for intervention by a general practice therapist when circumstances require it. Service members who do not respond to initial treatment or those with other more complex etiologies such as perilymphatic fistula, bilateral vestibular hypofunction, and Ménière's disease, or other etiologies for dizziness complaints, should be referred for further specialty evaluation (an ear, nose, and throat physician or a neurologist who specializes in this area) and for treatment by therapists with specialized vestibular training.
Impaired balance following concussion in sport is one of the signs used to restrict return to play for athletes12 and has been recommended for use as a restrictive sign for return to duty for soldiers.8 Persons with concussion or MTBI may complain of imbalance (postural instability) or unsteadiness during walking. Complaints of dizziness, vertigo, and blurred vision are common following damage to the peripheral vestibular system.13 In this context, blurred vision can be caused by reduced gaze stability during head or body movement.
Multiple measures, both subjective and objective, of balance or postural instability are recommended for persons with dizziness and balance issues following MTBI.13,41,42 Assessments of high-level mobility important for “participation” in leisure, sporting, and social activities18 as well as a standardized measure of gait abilities43–45 and gross strength46 are recommended.
Patients with MTBI often complain of balance impairment and feelings of postural instability even when there is no evidence of a neurological deficit on a standard clinical examination. In such cases, computerized dynamic posturography may reveal abnormalities in postural responses to changing sensory conditions and perturbations that are not easily detected on clinical examination.47 Given that the symptoms of imbalance or postural instability can strongly influence a person's quality of life, a measure of confidence in balance, and its impact on a person's life, is also important.45,48–51
Balance retraining programs improve symptoms in military personnel with dizziness associated with TBI.50,52 Balance retraining programs should include progressively more challenging tasks and environments42 including sports and martial arts activities to make them relevant for Service members. In addition, posturography platforms can be used in treatment situations to provide practice in adjusting to altered platform stability and sensory conditions.52
Furthermore, high-level balance dysfunction may be more evident after the Service member has been stressed by exercise or intense work. Therapists should be aware of the need to increase task challenges progressively and monitor perception of exertion accordingly.
While the type and quality of headache may be different for a Service member exposed to blast injury, a consistent means to assess level of pain and the functional impact of headache is recommended. Clinicians are encouraged to use a standardized approach for a musculoskeletal evaluation including that of the cervical spine. Neck pain, TMDs, and shoulder pain are common complaints reported in conjunction with MTBI, all of which contribute to PTH. Headache assessment includes both general measures of the frequency, severity, and limitations caused by headache pain and condition-specific measures that are used to determine the disability and its severity related to the neck, jaw, and headache.55–58
Pharmacologic treatment is common for headache, as is its use preventatively. This type of treatment is not typically within the scope of civilian PT practice but may be in the purview or responsibility of the military physical therapist. Physical therapy interventions with the strongest evidence in the treatment of PTH include a multimodal approach of specific training in exercise and postural retraining, stretching and ergonomic education, and manipulation and/or mobilization in combination with exercise.14,59 Patient education regarding PTH and appropriate exercise program handouts are effective intervention techniques. Unique to headache is the inclusion of education regarding environmental triggers for headache.60
Temporomandibular disorders as well as neck and shoulder pain complaints are commonly seen in conjunction with MTBI and may be contributing to the headaches.61 Common symptoms of TMD can include ear pain and stuffiness, tinnitus, dizziness, neck pain, and headache. Common impairments found in persons with TMD include joint mobility restrictions, muscle length limitations, as well as postural limitations and neuromuscular deficits. These TMD complaints are also seen in the general population, so they may be a preexisting condition in Service members with MTBI. The prevalence of at least 1 sign of TMD is reported in 40% to 75% of adults in the United States.62 While up to 40% of those who experience signs/symptoms of TMD show spontaneous resolution of their symptoms,62 patients with posttraumatic TMD may differ to a small extent from those with nontraumatic disorders on reaction time testing, neuropsychological testing, and clinical testing of TMD.63 A physical assessment of the temporomandibular joint and surrounding musculature as well as a measure of functional limitation brought on by TMD is recommended.64–66
No studies specifically address intervention for TMDs that occur as a result of MTBI. Systematic reviews suggest symptom management of TMD is best applied by a multimodal approach.62,67–69 The majority of those with TMD respond to symptom management techniques and education, but for those who experience chronic pain, referral and collaboration with dentists and/or a multidisciplinary chronic pain center may be needed.
Persons with MTBI frequently complain of imbalance and unsteady or slow walking, which may become even more pronounced when they attempt to do more than 1 task at a time.70,71 They may also report a problem with speed and/or accuracy when simultaneous tasks are attempted. These deficits may be particularly devastating for a deployed Service member in a war zone. Clinical measures that assess dual-task costs72 involving relevant tasks are recommended. Intervention strategies should involve functional skills for balance, gait, and cognitive tasks73,74 trained in progressively more challenging dual-task conditions.
To reiterate, with the exception of patient/client education, our work group found very little specific evidence for PT assessment and intervention for persons with MTBI, especially given the complexities of injury sustained in a war zone. We have summarized guidelines for the assessment of specific impairments that follow MTBI. Many of the recommendations for intervention are at best based on existing practice conventions, highlighting the need for extensive research. We hope this document can be an impetus for the enhancement of evidence-based practice for our deserving Service members. Further expansion of this work is in progress in the development of an OT/PT MTBI toolkit to summarize available evidence including the instructions for use of specific measurement tools and intervention techniques.
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