Page 66 - Journal of Special Operations Medicine - Summer 2015

Figure 1 Reprinted with permission from Hack (2013). 5

literature has provided a valuable starting point from to determine relevant biomarkers and other potential
which to evaluate, treat, and conduct return-to-duty as- prognostic indicators are also underway. There is also
sessment procedures following mTBI in both deployed ongoing research to better hone return-to-duty clinical
and nondeployed clinical practice settings for the mili- pathways and return-to-duty assessment strategies us-
tary. 1,18–20,27,36–47 Based on current evidence, which now ing virtual reality environments and dual-task processing
includes years of relevant military research on the assessments. 2,5,25–27,42,50,51
subject, the Defense and Veterans Brain Injury Center
(DVBIC) has developed a set of clinical practice guide- What Is Needed
lines, which are included in the 2013 Department of
Defense Instruction 6490.11 for the acute and subacute Though a clear return-to-activity guideline has been es-
management of mTBI. 4,5,7,8,10,12,26,33,34,48–52 tablished, there is significant need for objective screen-
ing and diagnostic methods that can reliably diagnose
Those guidelines aid providers in diagnosis and early and quantify concussion, and that can capture improve-
treatment of patients, with gradual return to normal ments as the brain regains normal functioning. The
activity as soon as safely possible, using a progressive research involving exploration of eye-tracking technol-
activity protocol. Clear guidance on a progressive return ogy shows promise in the area of diagnosis and corre-
to activity following mTBI after the mandatory recovery lating observed functional improvement with healing.
period is well described for primary care and rehabili- However, it lacks the ability to quantify performance,
tative care providers. These clinical recommendations because that technology cannot factor in confounding
for the progressive return to preinjury activity promote variables such as the attentional and spatial cognitive
standardization of care following mTBI in the Military processes that vision and oculomotor control affect and
and Veterans Health Systems. 2 are affected by. There should be a line of research to de-
termine if differences in cognitive processing, visual and
Continuing lines of research within both DoD and visual-psycho-motor skills, and reaction time exist be-
sports include studies developing valid measures for as- tween subpopulations such as elite SOF units versus reg-
sessment both in clinical and field/deployment setting. ular infantry and noncombat Soldiers (subelite) as has
Additionally, studies on detecting, treating, and reha- been done and is ongoing in sports research. 12,25–27,42,53–64
bilitating comorbidities associated with mTBI, such as
disordered sleep, cognition, vision and vestibulo-ocular Current primary indicators of readiness in RTD deci-
function, visual tracking, vestibular function, substance sions are the same as that in sport: subjective symptom
abuse, and psychological disorders are ongoing. Studies resolution at rest and after exertion, in conjunction with

56 Journal of Special Operations Medicine Volume 15, Edition 2/Summer 2015