Skip to main content

Military Health System

Test of Sitewide Banner

This is a test of the sitewide banner capability. In the case of an emergency, site visitors would be able to visit the news page for addition information.

NICoE, NHRC Team Up To Make CAREN Technology Portable

Image of A person walks in front of a large virtual reality screen. The Computer Assisted Rehabilitation Environment (CAREN) at the National Intrepid Center of Excellence (NICoE) offers clinicians a VR-based tool to assess and treat patients with TBI and PTSD. (Photo by Linsey Pizzulo, National Intrepid Center of Excellence)

Since the National Intrepid Center of Excellence opened in 2010, Biomedical Engineer Sarah Kruger has operated the center’s Computer Assisted Rehabilitation Environment (CAREN).

The CAREN is a large-scale virtual-reality system used to evaluate and treat NICoE patients with traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD).

Now, her team is collaborating with researchers at the Naval Health Research Center (NHRC) to scale the technology down to a mobile system, with the long-term goal of making the novel therapy more attainable throughout both the Military Health System and the Defense Intrepid Network for TBI and Brain Health.

“Head-mounted display technology has become more affordable and accessible over the past couple of years,” said Kruger. “It’s also portable. So we want to leverage what we’ve learned about the [CAREN] system and see if we can make it possible to use similar treatments without committing the space or funding to a CAREN.”

In the CAREN, the patient stands or walks on a treadmill in the middle of a circular platform while interacting with virtual environments projected in front of them onto a 9-foot-tall, 180-degree screen. The platform can tilt in all directions to mimic a rocking boat, an uphill climb, or other scenarios as a ring of motion-capture cameras track movement, allowing for real-time modifications to the environment.

Monitoring the patient’s behavior, physical therapists can assess and treat conditions such as vestibular dysfunction - one of the most common complaints following a TBI - and PTSD.

In initial discussions about using head-mounted displays for treatment, NICoE physical therapists expressed concern that the devices might be too heavy for their many patients with neck pain. So the NICoE and NHRC teams evaluated several different headsets and, after positive feedback from clinicians, chose an augmented-reality (AR) based head-mounted display which has a lightweight visor that allows digital content to be layered over the existing real-world environment.

A person wearing a virtual reality headset
Researchers at the National Intrepid Center of Excellence (NICoE) and the Naval Health Research Center (NHRC) are using their CARENs to test similar technology on an AR headset, which would be more accessible and less costly for military medical treatment facilities than a CAREN. (Photo by Sarah Kruger, National Intrepid Center of Excellence)

Application developers then worked to transition some of the CAREN’s most frequently utilized virtual environments over to a cross-platform game engine that allows for improved graphics, physics, and user control. The new environments are compatible on both the CAREN and AR headset.

These systems are currently being evaluated in two IRB-approved research protocols for a multisite vestibular physical therapy project, where data is being collected at both NICoE and NHRC.

Last month, the research team provided an overview of the development process in a symposium presentation at the International Conference on Virtual Rehabilitation. Kruger, physical therapist Kathleen Delpy, and research scientist Kerry Rosen represented the NICoE; with NHRC physical therapist Dawn Bodell and biomedical engineers Pinata Sessoms, Vrajeshri Ordek, and Jacob Van Dehy. 

While there are some clear differences between the CAREN and the head-mounted display - for instance, the CAREN makes it easier for patients to find real-world anchors and use their peripheral vision - Kruger does not consider them to be dealbreakers.

“There are obviously limitations to using [the mobile system],” she said, “but if I can get a 75% solution that clinicians will use, I’ll take it.”

The key to this health innovation is that the head-mounted displays are portable and can potentially be used at multiple locations without requiring a full-size CAREN. There are pros and cons to the new technology, but in the end, they may help make TBI and PTSD care more accessible to MHS patients.

You also may be interested in...

Acute Concussion Care Pathway: MACE 2 and PRA Training

Publication
5/12/2023

The Traumatic Brain Injury Center of Excellence is hosting a combined Military Acute Concussion Evaluation 2 and Progressive Return to Activity clinical recommendation virtual training.

Anomalous Health Incident Acute Assessment Training

Publication
4/17/2023

This virtual training, hosted by the Traumatic Brain Injury Center of Excellence, will introduce MHS health care providers to Anomalous Health Incidents and review assessment and treatment strategies. Detailed guidance on how to complete a medical evaluation using Anomalous Health Incident (AHI) Acute Assessment (DHA Form 244), will be provided.

2023 TBICoE Quarterly Education Series Schedule

Publication
4/14/2023

The Traumatic Brain Injury Center of Excellence's Quarterly Education Series is an enterprise-wide learning opportunity for Military Health System stakeholders. Since inception, the QES provides trainings and events that are relevant to the MHS, discussing specialty topics and current research related to TBI.

2022 TBICoE Publication Catalog

Publication
4/7/2023

TBICoE publication citations and summaries are organized by category, or overarching research topic. The purpose of this document is to (1) summarize key findings and potential clinical implications of calendar year 2022 TBICoE publications, (2) increase awareness, and (3) assist in planning of future efforts.

TBI—The Female Experience

Publication
4/6/2023

Join the Traumatic Brain Injury Center of Excellence for an exploration of the unique ways in which brain injury manifests in the female population at the next Quarterly Education Series virtual event. Etiology, symptomatology, and diagnosis can be nuanced and have long gone unstudied in women. Experts will discuss a new wave of research, clinical support, and barriers for females with TBI. TBICoE's QES is an enterprise-wide learning opportunity for Military Health System stakeholders.

TBICoE Research Review: Chronic Traumatic Encephalopathy

Publication
3/17/2023

The purpose of this Research Review is to summarize current peer-reviewed scientific literature and expert assessment regarding the pathology, genetic pre-disposition, causes, clinical manifestations, and neuroimaging of chronic traumatic encephalopathy.

Back to School: A Guide to Academic Success After Traumatic Brain Injury

Publication
3/16/2023

Back to School: A Guide to Academic Success After Traumatic Brain Injury is a free resource, developed by the Traumatic Brain Injury Center of Excellence that is tailored to help service members and veterans who have sustained a TBI and are pursuing higher education. Those who have sustained a TBI may face unique challenges, and this guide provides information and resources on how to navigate higher education while still prioritizing brain health care.

INFORMATION PAPER: The Impact of Mild Traumatic Brain Injury on the Autonomic Nervous System

Publication
3/15/2023

The purpose of this information paper by TBICoE is to provide a general overview of the current evidence related to the impact of concussion/mild traumatic brain injury (mTBI) on the autonomic nervous system (ANS). This paper will focus on heart rate variability (HRV), pupillary light reflex (PLR), and hyperhidrosis within the military and civilian populations.

Intrepid Voices Newsletter March 2023

Publication
3/1/2023

Intrepid Voices Newsletter, March 2023 is a product of the Defense Intrepid Network for TBI and Brain Injury.

FEB 2023 TBICoE Quarterly Education Series Flyer

Publication
2/8/2023

TBICoE Quarterly Education Series: TBI Across the Lifespan. Join TBICoE at this virtual event to explore clinical best practices for prevention, assessment, and treatment of mild TBI, also known as concussion, for military dependents. Download the flyer for details.

Progressive Return to Activity: Primary Care for Acute Concussion Management

Publication
1/23/2023

The Progressive Return to Activity (PRA): Primary Care for Acute Concussion Management clinical recommendation is an evidence-based return to activity protocol for primary care managers and concussion/traumatic brain injury (TBI) clinic providers. The PRA is a six-step approach that begins after the provider performs the Military Acute Concussion Evaluation 2 (MACE 2) and diagnoses the patient with a concussion/TBI. The PRA stages start with relative rest and allow service members to gradually increase activities until they receive clearance for return to full duty or activity. In each stage, it offers general and military specific activities and options to help providers manage their patients’ primary symptom clusters. The PRA also offers recommendations on specialty referrals and handouts are available for providers to give patients and leadership.

DOD TBI Worldwide Numbers At-A-Glance

Publication
8/24/2022

TBICoE is the Defense Department’s office of responsibility for tracking traumatic brain injury data in the U.S. military. The "DOD TBI Numbers At-A-Glance" provide a high level overview of TBI's sustained since 2000 and also show the data by severity and service branch.

Neuroimaging Following Mild TBI Clinical Recommendation

Publication
5/16/2022

This TBICoE clinical recommendation allows primary care managers to make an informed, evidenced-based decision regarding whether or not imaging is indicated following a concussion/mild TBI.

2021 Traumatic Brain Injury Center of Excellence Annual Report

Publication
4/26/2022

The 2021 Traumatic Brain Injury Center of Excellence (TBICoE) Annual Report provides a look at accomplishments and activities from calendar year 2021.

References and Acknowledgements: Neuroimaging Following Concussion Clinical Recommendation

Publication
4/6/2022

This document acknowledges those who participated in the expert working group with the Traumatic Brain Injury Center of Excellence and provides the resources and references used to develop the Neuroimaging Following Concussion/Mild Traumatic Brain Injury: Guidance for the Primary Care Manager.

Page 1 of 6 , showing items 1 - 15
First < 1 2 3 4 5  ... > Last 
Refine your search
Last Updated: September 01, 2022
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on Twitter Follow us on YouTube Sign up on GovDelivery