Therapy Is Geared Toward Military Duties
| Checklist of military activities of daily living (M-ADL). | |
|---|---|
| 1. Military paper work completed on time | 2. Showing up to place of duty/formation on time |
| 3. Adequate attention/concentration for work tasks | 4. Operation/maintenance of equipment/tools |
| 5. Communication with subordinates and superiors | 6. Military appearance/bearing |
| 7. Supply ordering | 8. Uniform (appropriate wear, location of code) |
| 9. Reading technical manuals/procedural guides | 10. Weapon use |
| 11. Military Training (online/in person) | 12. Endurance for work assignments |
| 13. Perform MOS/NEC specific job tasks | 14. Complete military PT tests with passing score |
| 15. Military duty (charge of quarters/staff duty) | 16. Decision making |
| 17. Remembering to complete assignments | 18. Ability to stay organized during complex tasks |
CAMP PENDLETON, CA — In the immediate aftermath of the Iranian missile attack on Al Asad Air Base in Iraq in January 2020, reports indicated no servicemembers sustained injuries. By late February, 110 of those in the area had received a diagnosis of mild traumatic brain injuries from the attack.
Most people recover from a mild traumatic brain injury (mTBI) or concussion within seven to 10 days, according to the Defense and Veterans Brain Injury Center (DVBIC). For some, however, the effects can linger, impairing cognitive function and delaying return to work.
Seven weeks after the assault at Al Asad, for instance, 25 of those with mTBIs had been sent back to the United States for treatment, and another six were still undergoing testing. Altogether, nearly a third of the injured had not recovered or resumed their duties.
Because most people expect to recover quickly after a concussion, they might not seek out testing or report symptoms immediately. “[I]t’s quite common that we’ll have folks who will say, ‘I just was blasted. Of course, I’m not going to feel quite right. I’m going to ride this out for a few days.’ Or ‘I’m going to wait and see if this gets better.’ And then they come in several days or weeks after the fact,” explained Air Force Brig. Gen. Paul Friedrichs, MD, joint staff surgeon at the Pentagon.
Ultimately, persistent physical and cognitive issues typically cause individuals who suffer extended effects from a mild TBI to seek help. Those often include ongoing headaches and dizziness or problems with concentration and recall.
Traditional cognitive rehabilitation approaches focus on developing compensatory techniques such as using mnemonics to help remember names or a sequence of activities. These strategies fail to address the more subtle deficits induced by mild traumatic brain injury and frequently leave servicemembers who have mTBI-related cognitive deficits unable to adequately perform their work and support their unit, according to researchers at DVBIC and Camp Pendleton.
First author Ida Babakhanyan, MD, a neuropsychologist at the Naval Hospital Camp Pendleton Concussion Care Clinic and DVBIC in Silver Spring, MD, and her colleagues sought to develop an approach more suitable to the military environment.
Military personnel “must be able to translate training into novel environments, adapt to new technological capabilities, and make split-second potentially life-threatening decisions,” they wrote in the December issue of Contemporary Clinical Trials Communications. “Thus the goal of treatment in military medicine is not necessarily remediation of cognitive deficits but to obtain an acceptable level of cognitive performance required for operation in wartime environments.” 1 Yet, a 2017 study by DVBIC and VA researchers showed that traditional cognitive rehabilitation did little to improve cognitive function in service members with mTBIs.2
“A scientifically driven approach to evaluating current treatment methods and including innovations from civilian practices is necessary to ensure that we are providing the most effective care possible in all rehabilitation domains including cognition,” wrote Babakhanyan and her co-authors. “In fact, this is particularly necessary given the heightened awareness of the impact of concussions and repetitive blast exposures and the occupational demand placing the military population at risk.”
The team proposed a study comparing Strategic Memory Advanced Reasoning Training (SMART) to traditional clinician-directed cognitive rehabilitation. The study received funding from the Congressionally Directed Medical Research Program (CDMRP) Office.
SMART targets the cognitive domains critical to cognitive readiness and has demonstrated success in improving executive function, mental agility, strategic learning, problem-solving, focus and psychological well-being. Previous studies have found it achieved greater improvement in cognition, psychological health, and outcomes in daily life than the same duration and dose of traditional treatment.
Military Occupation
In their article, the researchers outline the study’s methodology. Designed to measure cognitive performance and ability to meet the demands of the patients’ specific military occupation, the study also takes into consideration the use of healthcare resources following treatment.
The study will be a prospective randomized clinical trial. The control arm will use clinician-directed cognitive rehabilitation developed for the Study of Cognitive Rehabilitation Effectiveness (SCORE) trial for 10 hours per week for six weeks for a total of 60 hours. Each week, treatment will include five one-hour sessions divided between compensatory and restorative strategies plus two one-hour weekly group therapy sessions and three hours of Attention Process Training-3 work on a computer. All time will be supervised by clinic staff.
Participants in the SMART arm will receive a total of 20 hours of therapy. In the first week, participants will receive training in strategic attention, integrated reasoning and innovation in five one-hour sessions. During Weeks 2 through 4, the participants will practice integrating the three core strategies into their military responsibilities and personal lives during three one-hour group sessions and two one-hour individual sessions each week. A therapist trained in SMART intervention will provide feedback on complex cognitive activities and applied activities.
Response to therapy will be measured with a variety of tools that test attention, executive functioning, processing speed, learning, and verbal memory as well as the Global Deficit Score. The study will evaluate change in symptoms using self-reported measures of health, sleep, key behaviors and other symptoms. Healthcare utilization, specifically of mental health and rehabilitation resources, will be compared for the period three months prior to treatment and three months after. Occupational performance will be assessed by a direct supervisor using a modified version of the Checklist of Military Activities of Daily Living.
To return to full unrestricted duty status, servicemembers who have suffered mTBI must exhibit cognitive readiness to perform and respond quickly to complex and dynamic situations. That requires keen situational awareness, problem-solving, metacognition, decision-making, adaptability and creative thinking, Babakhanyan and her colleagues noted.
“The success of this study can aid in returning a warfighter back to duty status more quickly as well as overall improving the cognitive capacity of all service members even if no deficits are present,” the authors concluded. “If successful, this study has the potential to set a pathway to new treatment interventions for our service members which is an important facet of treatment and care.”
- Babakhanyan I, Jensen M, Remigio-Baker RA, Sargent P, Bailie JM. Use of a randomized clinical trial design to study cognitive rehabilitation approaches to enhance warfighter performance. Contemp Clin Trials Commun. 2020 Oct 6;20:100660. doi: 10.1016/j.conctc.2020.100660.
- Cooper DB, Bowles AO, Kennedy JE, Curtiss G, French LM, Tate DF, Vanderploeg RD. Cognitive Rehabilitation for Military Service Members With Mild Traumatic Brain Injury: A Randomized Clinical Trial. J Head Trauma Rehabil. 2017 May/Jun;32(3):E1-E15. doi: 10.1097/HTR.0000000000000254.