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Optimizing participation of military service members with chronic symptoms after mild traumatic brain injury

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Optimizing participation of military service members with chronic symptoms after mild traumatic brain injury

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OPTIMIZING PARTICIPATION OF MILITARY SERVICE MEMBERS WITH CHRONIC
SYMPTOMS AFTER MILD TRAUMATIC BRAIN INJURY

by
Alison M. Cogan

______________________________________________________________________________

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(OCCUPATIONAL SCIENCE)

May, 2017

ii

Table of Contents
List of Tables ................................................................................................................................ iii
List of Figures ............................................................................................................................... iv
Abbreviations ................................................................................................................................ v
Acknowledgments ....................................................................................................................... vii
Abstract ......................................................................................................................................... ix
Chapter 1: Introduction ............................................................................................................... 1
Significance .............................................................................................................................................. 1
Innovation ................................................................................................................................................. 4
Background ............................................................................................................................................... 8
Specific Aims ......................................................................................................................................... 19
Chapter 2: Methods .................................................................................................................... 21
Study One: Conceptual Framework of Participation .............................................................................. 21
Study Two: Mapping the Treatment Model ........................................................................................... 24
Chapter 3: Deciphering participation: An interpretive synthesis of its meaning and
application in rehabilitation ....................................................................................................... 33
Abstract ................................................................................................................................................... 33
Methods .................................................................................................................................................. 36
Results .................................................................................................................................................... 38
Discussion ............................................................................................................................................... 49
Conclusion .............................................................................................................................................. 56
Chapter 4: “I don’t do anything anymore”: Occupational changes and challenges following
mild traumatic brain injury in active duty military service members .................................. 58
Abstract ................................................................................................................................................... 58
Methods .................................................................................................................................................. 60
Results .................................................................................................................................................... 62
Discussion ............................................................................................................................................... 70
Conclusions ............................................................................................................................................ 75
Chapter 5: A treatment model of occupational therapy intervention for optimizing
participation of service members with chronic symptoms after mTBI ................................. 76
Abstract ................................................................................................................................................... 76
Methods .................................................................................................................................................. 79
Results .................................................................................................................................................... 81
Discussion ............................................................................................................................................... 98
Conclusions .......................................................................................................................................... 103
Appendix: Focus Group Guiding Questions ......................................................................................... 104
Chapter 6: Divergent perspectives of chronic symptoms attributed to mTBI among patients
and healthcare providers .......................................................................................................... 108
Abstract ................................................................................................................................................. 108
Introduction .......................................................................................................................................... 110
Materials and Methods ......................................................................................................................... 112
Results .................................................................................................................................................. 114
Discussion ............................................................................................................................................. 121
Conclusions .......................................................................................................................................... 126
Chapter 7: Conclusions, Reflections, and Next Steps ............................................................ 127
Summary of Key Findings .................................................................................................................... 127
Reflections on the Research Experience ............................................................................................... 132
Possible Next Steps .............................................................................................................................. 134
References .................................................................................................................................. 137
iii

List of Tables
Table 2.1: Adaptations of Intervention Mapping Steps 25
Table 3.1: Characteristics of Interventional and Community-based Participation and their
Facilitative Relationship 41
Table 4.1: Participant Demographics 63
Table 4.2: Occupational Changes 65
Table 4.3: Wanting Others to Understand 71
Table 5.1: Provider Background Variables 82
Table 5.2: Service Member Demographics 82
Table 5.3: Matrix of Treatment Targets 89
Table 6.1: Provider Background Variables 115
Table 6.2: Service Member Demographics 116

iv

List of Figures
Figure 1.1: Commonly Reported Post-concussion Symptoms 1
Figure 1.2: Model of How Dissertation Studies and OT for TBI Study Fit Together 3
Figure 1.3: ICF Model (from WHO, 2002) 9
Figure 3.1: Conceptual Framework of Participation 46
Figure 5.1: Conceptual Model of Occupational Therapy Treatment for Service Members with
Chronic mTBI Symptoms 84

v

Abbreviations
AOTA American Occupational Therapy Association
CT Computed tomography
DoD Department of Defense
DTI Diffusion tensor imaging
DVBIC Defense and Veterans Brain Injury Center
FA Fractional anisotropy
ICF International Classification of Functioning, Disability and Health Framework
IED Improvised explosive device
IRB Institutional review board
MBSR Mindfulness-based stress reduction
MRI Magnetic resonance imaging
mTBI Mild traumatic brain injury
NMSCD Naval Medical Center San Diego
NHCP Naval Hospital Camp Pendleton
OSU-TBI-ID Ohio State University Traumatic Brain Injury Identification interview
OTPF Occupational Therapy Practice Framework
PCS Post-concussion symptoms
PTSD Post-traumatic stress disorder
RPG Rocket propelled grenade
USC University of Southern California
VA Department of Veterans Affairs
WHO World Health Organization
vi

WWB Wounded Warrior Battalion

vii

Acknowledgments
So many people have helped me along this journey. First, my committee members have
been an invaluable source of guidance and support. Mike Carlson, thank you for steering and
encouraging me through study one of this dissertation and helping me to become a better writer.
Margaret Ryan, I never would have found my way into or through Navy Medicine without you.
Mary Lawlor and Beth Pyatak, thank you for your excellent insights and feedback. Florence
Clark, you have been an amazing mentor and have had faith in my abilities even when I doubted
myself. It has been the opportunity of a lifetime to work with and learn from you. From the
bottom of my heart, I thank you all.
I am grateful for the many individuals at Naval Hospital Camp Pendleton and Naval
Medical Center San Diego who helped to make study two of this dissertation, as well as the pilot
study, happen. In particular, Maria Devore has embodied her title as “research facilitator” by
helping me to navigate the institutional review board process and making sure all of my
administrative requirements were current. Other important contributors were LCDR Eric
Harmon, CDR Paul Sargent, LT Christine Haines, CDR Karla Lepore, Mariliz Versoza-
Mendoza, the leadership at NHCP, and members of the IRB. Thank you all for your support.
This work would not have been possible without all of the participants, both occupational
therapy providers and Marines, who were generous with their time and knowledge. Thank you
for sharing your experiences, and for trusting me to understand and communicate them
effectively.
Several of my colleagues helped me by reading drafts of works in progress, providing
feedback and suggestions, and reminding me to take note of my accomplishments along the way.
Thank you all for your contributions and encouragement. I am also grateful to the many faculty
viii

and staff members at the USC Mrs. T. H. Chan Division of Occupational Science and
Occupational Therapy, many of who have become good friends, for all that they do every day.
Lastly, I would not be here if not for the infinite love and support of my husband and
partner, Patrick Carroll. You have cheered me on through all of the victories and obstacles and
helped me find balance. Thank you for going on this ride with me.

Disclaimer: The views expressed in this dissertation are those of the author and do not
necessarily reflect the official policy or position of the Department of the Navy, Department of
Defense, or the United States Government.

ix

Abstract
Chronic symptoms attributed to mild traumatic brain injury (mTBI) among military
services members can disrupt engagement in important activities and life roles. In addition,
service members with persistent sequelae after mTBI typically have comorbidities such as
mental health diagnoses and chronic pain. Occupational therapy intervention for this population
is not well described nor is there substantive evidence to support particular treatment strategies.
The general goal of an occupational therapy intervention for military service members with
mTBI is to improve their participation in daily life. Although participation is frequently
described as an important outcome of rehabilitation interventions, it is not consistently defined or
operationalized in practice.
This dissertation consists of two main studies. The purpose of the first study was to
define a conceptual framework of participation for rehabilitation. The second study was aimed at
developing a treatment model of occupational therapy intervention for military service members
with chronic symptoms after mTBI. Prior to beginning these two dissertation studies, I
conducted a pilot study, OT for TBI, in which I investigated the occupational needs of service
members who receive occupational therapy services for chronic mTBI symptoms. The results of
the two dissertation studies and a portion of the results from the pilot study are presented in the
form of four manuscripts (Chapters 3, 4, 5, and 6), each of which is tailored to the audiences and
formats of the targeted journals.
Chapter 3 (under review at Disability and Rehabilitation, co-authored with Dr. Mike
Carlson) conveys the findings of the first study, which is an interpretive synthesis of the
literature describing participation and related constructs as they relate to rehabilitation. Our
analysis identified that participation consists of three essential dimensions, which we labeled (1)
x

performance, (2) subjective experience, and (3) interpersonal connection. Furthermore, we found
that although participation usually referred to community engagement, it was sometimes used to
describe what patients do in the treatment setting. We characterized these two distinct contexts in
which participation occurs as community-based and interventional. In both settings, participation
is predicated by choice from among available opportunities. We created a conceptual framework
to incorporate all of these elements and postulate relationships among them. A key finding of this
study was that participation is not necessarily a positive or health promoting endeavor; its effects
are individualized and context specific. This conceptual framework has several implications for
rehabilitation practice, including the need for deeper investigation of clinicians’ and institutions’
roles in creating opportunities and choice within the interventional context.
Chapter 4 (under review at the American Journal of Occupational Therapy, co-authored
with Christine E. Haines, Maria Devore, Karla Lepore, and Margaret Ryan) presents the results
of the pilot study, OT for TBI, from the patient perspective. The findings are based on interviews
with 12 military service members who had received occupational therapy services for chronic
symptoms following mTBI. Service members identified needs in all areas of occupation, with a
particular emphasis on sleep. Other important themes were also identified, including the
significance of military culture in seeking healthcare and how individuals planned for the future
outside of the military. The results demonstrate the need for comprehensive occupational therapy
assessment and treatment in this patient population.
Chapter 5 (to be submitted to the American Journal of Occupational Therapy)
summarizes the main findings of the second study, which aimed to establish a treatment model
for occupational therapy intervention to optimize participation for military service members with
chronic mTBI. This qualitative study employed a serial focus group model, in which a group of
xi

occupational therapy professionals (n=5) and a group of service member patients with mTBI
(n=6) which met four times each to describe their experiences as providers and recipients of
occupational therapy services, respectively. The resulting model is organized into treatment
targets, active ingredients, and hypothesized mechanisms of action. This study establishes the
groundwork for the development of a manualized intervention to be tested in a future efficacy
study.
Chapter 6 (to be submitted to Military Medicine) imparts the unexpected findings that
arose from the OT for TBI pilot study and the second dissertation study described above. The
pilot study included clinicians from a variety of disciplines (n=14) and the dissertation study
included only occupational therapy professionals (n=5). In discussing intervention approaches,
clinicians across the two studies expressed differing views of the underlying causes of persistent
symptoms that are attributed to mTBI. Specifically, some health professionals believed that
symptoms resulted from a combination of structural brain damage from the injury event as well
as trauma and related psychological causes. In contrast, others thought that all symptoms were
attributable to mental health factors alone and that attributing them to structural injury
perpetuated patient complaints. Some providers of both positions raised concerns about
exaggerated or false symptom reporting for secondary gains, such as access to disability benefits.
On the other hand, most of the patients who participated in the pilot study (n=12) and focus
groups (n=6) did not attribute their ongoing symptoms to an earlier injury event until after they
sought treatment, which was usually many months or years after problems had arisen. These
findings raise numerous questions about the relationships between provider beliefs, patient
expectations, and health-related outcomes.
xii

The results of these studies have implications along two particular lines of research. First,
the proposed conceptual framework of participation combines fundamental concepts from across
the immense body of literature as it relates to rehabilitation. This framework may be a resource
for both clinicians and researchers to improve patient care, satisfaction, and quality of life.
Framing interventional participation as a distinct context has the potential to drive new research
into clinician-patient interactions and their relationship to treatment outcomes. More work is
needed to confirm the relationships in the model and ensure its completeness.
Second, the results of the focus group study provide solid foundation for future research
and outcome measurement to support active duty military service members with chronic
sequelae after mTBI. Additional work will be necessary to as well as to develop a comprehensive
manualized occupational therapy intervention for service members with mTBI. Moreover, the
conceptual framework of participation can be used jointly with the treatment model to ensure
that all elements of participation are addressed in the intervention protocol. In the interim, the
findings reported in this dissertation may prove useful to clinicians to guide patient goal setting
and treatment planning.

1

Chapter 1: Introduction
Significance
From 2000 through 2016, over 350,000 brain injuries have been reported among active
duty United States military service members. Over 80% of these injuries were classified as mild
(Defense and Veterans Brain Injury Center [DVBIC], 2016b). These mild traumatic brain
injuries (mTBI) are characterized in the Department of Veterans Affairs (VA) and Department of
Defense (DoD) guidelines by loss of consciousness for less than 30 minutes or alteration of
consciousness, post-traumatic amnesia for fewer than 24 hours, and absence of observable
damage on structural imaging (Management of Concussion-mild Traumatic Brain Injury
Working Group, 2016). Initial symptoms following mTBI may include headaches, dizziness, and
irritability. Although the majority of people who experience an mTBI can expect a complete
cessation of acute symptoms within three months, a minority continues to experience ongoing
problems (Carroll et al., 2014; Carroll et al., 2004). This consequence has been documented in
both civilian populations (Carroll et al., 2014; Rohling, Larrabee, & Millis, 2012; Williams,
Potter, & Ryland, 2010) and military personnel (Brenner et al., 2010; K. J. Miller, Ivins, &
Schwab, 2013). Persistent symptoms can consist of physical, cognitive, and emotional sequelae,
collectively known as post-concussion symptoms (PCS; see Figure 1.1).
Figure 1.1: Commonly Reported Post-concussion Symptoms

Physical
•Headaches
•Dizziness
•Nausea
•Fatigue
•Sleep problems
Cognitive
•Memory problems
•Difficulty
concentrating
Emotional
•Anxiety
•Irritability
•Depression
2

Persistent PCS can dramatically affect one’s ability to engage in daily occupations,
including fulfillment of military work duties and participation in home and community life. Yet,
there is little research in occupational science or occupational therapy that has addressed mTBI
in either civilian or military populations (Cogan, 2014). Difficulties with sleep (Macera, Aralis,
Rauh, & MacGregor, 2013), driving (Classen et al., 2011), relationships, school, and self-care
(Plach & Sells, 2013) have all been documented among service members and veterans with
histories of mTBI; however, further detail about the specific types of problems encountered in
each of these areas and how the injury impacts participation in daily life is not known. Patient
referrals for occupational therapy services have driven clinicians to identify a need for evidence
about the most effective intervention strategies for facilitating service members’ return to full
participation, either in military contexts or in the civilian community (C. Haines, personal
communication, May 8, 2013).
In fact, the meaning of the term participation itself is not altogether clear. It has been
defined in multiple ways, most of which involve social role performance, and is operationalized
differently in various measurement tools (Brown et al., 2004; Eyssen, Steultjens, Dekker, &
Terwee, 2011; Heinemann et al., 2010; Whiteneck & Dijkers, 2009). For example, a high score
is earned on the Community Integration Questionnaire by reporting greater frequency of
performing a set of predetermined activities (Willer, Rosenthal, Kreutzer, Gordon, & Rempel,
1993). Another tool, the Craig Handicap Assessment Reporting Technique, prioritizes the ability
to perform activities without assistance (Walker, Mellick, Brooks, & Whiteneck, 2003). A
thorough analysis of how participation has been used and how it applies in rehabilitation is
warranted.
3

Therefore, I have completed two separate but interrelated studies for my dissertation. The
first study is an interpretive review of the construct of participation. The second is a qualitative
study to document current occupational therapy practice with military service members with
chronic symptoms after mTBI. This latter study employed a methodology called intervention
mapping and serves as a first step in building a treatment model. The second study builds on a
pilot study, OT for TBI, which was a needs assessment for the same population. The two studies
are reported in Chapters 3 and 5 of this dissertation. Chapter 4 presents findings about the
occupational needs of service members that were identified through the OT for TBI study.
Chapter 6 is an analysis of an unexpected finding that emerged in the pilot study and was
supported by data from the second dissertation study. A model showing how the dissertation
studies and the OT for TBI study fit together is presented in Figure 1.2.
Figure 1.2: Model of How Dissertation Studies and OT for TBI Study Fit Together

4

Innovation
Overview
My dissertation involved three key innovations. First, the focus of both dissertation
studies on participation is novel, especially in the context of service members with mTBI.
Second, my pilot study is innovative because I am investigating the occupational needs of active
duty service members with mTBI, which has not previously been done. Third, the application of
the intervention mapping methodology to the design of a rehabilitation intervention is
innovative, as the approach was originally intended for health promotion interventions.
Focus on Participation
Participation is often described as a primary outcome of rehabilitation treatments
(Whiteneck & Dijkers, 2009), yet it lacks a clear, widely accepted definition (Heinemann et al.,
2010). There are numerous tools that attempt to measure participation, but most emphasize
observed performance and do not consider the perspective of the person being evaluated. This
oversight is problematic because subjective experience is likely related to one’s satisfaction with
life. Preferences about what a person needs and wants to do are very individualized and context-
specific. Therefore, attainment of a given score on an objective measure of participation may not
provide useful information about a what a person needs to do, wants to do, or is able to do
(Eyssen et al., 2011; Whiteneck & Dijkers, 2009). Given the ambiguity of the concept of
participation, a thorough exploration taking multidisciplinary perspectives into account is
worthwhile.
Pilot study: OT for TBI
OT for TBI was designed as a needs assessment with the primary objective of identifying
the participation challenges of active duty military service members with lingering PCS
5

following mTBI and who have been referred for occupational therapy services. Although
physical, cognitive, and emotional symptoms are well documented in service members with
mTBI (e.g., Brenner et al., 2010; K. J. Miller et al., 2013; Vanderploeg et al., 2012), very little is
known about how they impact participation in daily life. Hence, the aim of the OT for TBI study
was to begin to fill this gap in the literature. Four categories of participants were enrolled in the
study: service members with mTBI and PCS, their spouses, military personnel who have
supervised individuals with mTBI, and healthcare providers who treat service members with this
diagnosis. The OT for TBI study received institutional approval from both the Naval Medical
Center San Diego (NMCSD) and the University of Southern California (USC) and was
conducted at Naval Hospital Camp Pendleton (NHCP). Below is a summary of the key findings.
Areas of occupation affected by symptoms. Service members (n=12) reported deficits
across all areas of occupation: basic and instrumental activities of daily living, education, play
and leisure, rest and sleep, social participation, and work. Sleep was the most pervasive issue and
all study participants reported that they were unable to get sufficient sleep at night, in spite of
having been prescribed various medications and other trying other approaches such as counseling
with a health psychologist. In addition, service member participants characterized pain as a
chronic and difficult problem to manage. Two service members in the study hoped to recover
sufficiently to resume their military careers. The remaining 10 service members were planning to
separate from active service; however, most did not have distinct plans for what they would do in
civilian life. The role of military culture in the process of seeking and obtaining care was
complex, with almost all participants holding the belief that obtaining medical care for any
reason would put their military careers in jeopardy. Findings drawn from interviews with service
members are detailed in Chapter 4.
6

Provider challenges. Most healthcare providers who participated in the study (n=14)
described the management of multiple comorbidities as a challenge in their practice. Many
patients with mTBI and chronic symptoms have concurrent mental health diagnoses, such as
posttraumatic stress disorder (PTSD), major depressive disorder, or an anxiety disorder.
Providers emphasized different comorbidities based on discipline. For example, physicians and
physical therapists identified chronic pain as an important issue. Erectile dysfunction was noted
only by a nurse practitioner who was a primary care provider in the Concussion Care Clinic.
Furthermore, healthcare providers did not share a common understanding of the nature of
chronic symptoms after mTBI. Namely, some characterized persistent symptoms as attributable
to a combination of physical and psychological causes, whereas others believed that all problems
were of psychological origin. This latter finding, further supported by data from the second
dissertation study, is expounded upon in Chapter 6 of this dissertation.
Perspectives of military spouses. Despite recruitment efforts, only two spouses of
service members (both women) participated in the OT for TBI study. Nonetheless, their
interviews resulted in contrasting narratives of how mTBI affects families. In comparison to the
each service member’s description of their challenges in daily life, both women described their
husbands’ problems as being more extensive. The severity of their husbands’ injuries was not
necessarily analogous to their own satisfaction with their marriages. To illustrate, Julia’s
*

husband had been injured in an explosion in Iraq and, by the time he sought medical treatment
several years later, was struggling with suicidal ideation and was diagnosed with major
depressive disorder and PTSD in addition to his brain injury. However, she explained how her
family had made adjustments to help support him and that, after a difficult year in which both
she and her children also entered psychotherapy, her family was emotionally closer than they had

*
Pseudonym
7

previously been and was looking forward to the future. On the other hand, Lacy’s
*
husband had a
history of concussions but was able to continue working in his military job as a mechanic,
attended evening classes at a community college, and described himself as a “happy go lucky
guy.” Yet, she described their relationship as strained because of his uncommunicativeness at
home and their resulting difficulty in having meaningful conversations. A manuscript that
explores the narrative arcs of these two marriages in the context of mTBI is in progress.
Supervisor perspectives. Of the eight supervisors who participated in the study, five
were stationed in the Wounded Warrior Battalion (WWB), which is a non-deploying unit where
service members may be assigned while recovering from severe injuries. Outside of the WWB,
supervisors reported to have little if any knowledge about mTBI or any significant role in
facilitating treatment, although they had the power to order an individual who was under their
command to be medically evaluated. Within the WWB, supervisors were responsible for
overseeing their Marines’ progress toward whatever goals had been set (usually with healthcare
providers or other support staff), ensuring that Marines attended medical appointments,
facilitating engagement in adaptive sports or other activities offered through the WWB, and
preparing for transition out of the military. Interviews with supervisors yielded insights about the
operations of the WWB, but did not substantively help to address the goals of the OT for TBI
study. At present, no publications using data from supervisor interviews are underway. However,
this data may be useful for the design of future studies to investigate the transition from military
to civilian life, as most individuals who were assigned to WWB were unable to return to duty.
Mapping the Treatment Model
I employed a specific methodology called intervention mapping to develop the treatment
model for the second study (Bartholomew, Parcel, Kok, Gottlieb, & Fernandez, 2011).
8

Intervention mapping is an innovative, rigorous methodology for designing treatment protocols.
It emphasizes the use of theoretically informed treatment activities and outcomes, which are
connected back to the aims of the intervention and the needs of the population of interest
(Bartholomew et al., 2011). The methodology was used to guide the focus group discussion
questions as well as organize the study findings. However, the methodology was developed for
health promotion interventions, which are typically much narrower in scope than rehabilitation
interventions. Therefore, its adaptation for rehabilitation in my dissertation work is an
innovation.
Background
Understanding Participation
In the field of rehabilitation, participation is widely referred to in the context of the
International Classification of Functioning, Disability and Health Framework (ICF), developed
by the World Health Organization (WHO). Within the ICF model, participation is defined as
“involvement in a life situation” and participation restrictions as “problems with involvement in
a life situation” (WHO, 2002). The construct of participation appears in the middle level of the
ICF model of disability, alongside activity and body structures and functions (Figure 1.3). Within
the model, these three areas are influenced by both health conditions and contextual factors.
Contextual factors are classified as either environmental (e.g., architecture, public attitudes
toward disability, policies) or personal (e.g., gender, socioeconomic status, cultural group; WHO,
2002). Participation is further described by the qualifiers “performance”, what one does in one’s
environment, and “capacity”, an individual’s ability to execute a task (WHO, 2002).

9

Figure 1.3: ICF Model (from WHO, 2002)

The ICF definition is so broad as to be unhelpful, as nearly everything anyone does could
be construed as being embedded in a “life situation” (Whiteneck & Dijkers, 2009). Activities are
explained as individual tasks or actions, such as walking or speaking, and participation is a set of
activities that are associated with a social role, such as attending school (WHO, 2013; Whiteneck
& Dijkers, 2009). However, in practice, the distinction between activities and participation is less
clear. Within the ICF model, the constructs of activity and participation share a set of domains of
action (e.g., mobility, interpersonal relationships), which are additionally divided into categories
(e.g., organizing a daily routine, managing stress). Four options for implementation are
suggested (WHO, 2013): (a) designate each domain as either activity or participation with no
overlap allowed, (b) divide as in the first option with some overlap allowed, (c) designate broad
categories as participation and detailed categories as activities, and (d) designate all domains as
both participation and activities with complete overlap allowed (WHO, 2013). By offering so
10

many options, the ICF obfuscates the true meaning and intentions underlying these components,
and makes them difficult to operationalize in a useful way. As Whiteneck and Dijkers (2009)
noted, activity and participation are not necessarily hierarchical; one could have limitations in
certain activities but still be able to participate in desired social roles.
Baum (2011) challenged the ICF idea that activities and participation were dependent on
health conditions and argued that increasing one’s experience of participation need not wait for
recovery in the context of rehabilitation. Rather, the therapist and patient should work together to
enable the patient to do the things he or she wants or needs to do during the recovery process.
“Participation itself, may foster this recovery because it brings focus to motivation, competency,
and self-efficacy, all of which are psychological concepts that are known to support growth and
thus, plasticity” (Baum, 2011, p. 170). Although participation may look different after injury or
illness, personally acceptable, meaningful participation can be achieved when individual,
environmental, and task factors are appropriately organized.
Because the ICF model emphasizes observable performance in the fulfillment of social
roles, it has been criticized as failing to account for the subjective experience of participation
(Brown et al., 2004; Hemmingsson & Jonsson, 2005; WHO, 2002). This omission is a serious
deficit because understanding the experiences of clients and patients is a critical component of
the philosophy of client-centered practice that underpins the rehabilitation professions, and
occupational therapy in particular (Baum, 2011; Brown, 2010; Hammell, 2013; Hemmingsson &
Jonsson, 2005; Mallinson & Hammel, 2010). Measures of participation that are based on the ICF
are frequently lacking in components that assess the patient perspective (Eyssen et al., 2011).
Furthermore, most measurement tools reward higher levels of observed performance in a finite
11

set of activities, which may devalue an individual’s experience of engagement in his or her
world.
Additionally, although environmental barriers to activity or role performance are often
discussed in the context of participation, not all individuals, regardless of disability status, have
access or opportunity to all of the activities they may like to be involved in due to socioeconomic
status, government policies, social biases, and other systemic factors. These barriers are
technically part of the environmental component of the ICF and are sometimes mentioned in the
literature. Nevertheless, it is difficult to characterize how they affect engagement in activity or
roles and they are generally neglected in the development of measurement tools (Noreau &
Boschen, 2010). When describing a person’s participation in daily life, environmental influences
need to be identified and documented.
There are at least two problematic assumptions about participation that pervade the
rehabilitation literature. First, there is often an implicit assumption that activities and social roles
are positive, health promoting, desirable outcomes for the patients with whom a practitioner may
come in contact. However, this “more is better” belief about participation is unsupported. For
example, in a population with spinal cord injury, too much activity requiring extended time
sitting in a wheelchair can result in the development of pressure ulcers, a serious health issue that
can quickly worsen and result in additional medical complications and lengthy hospitalizations
(F. A. Clark et al., 2006). Second, discussions about measurement of participation typically
ignore the possibility that engagement in some activities or life roles is detrimental to one’s
heath. For instance, an injured gang member may desire to return to the activities of selling and
using illicit drugs after an injury, yet it is unlikely that a rehabilitation professional would
promote or support engagement in these activities. When a person’s preferred activities and roles
12

are detrimental to his or her health or illegal, reduced participation may be viewed as a positive
change, with the goal of shifting toward more healthful activities over time.
The descriptions of participation that have been used in rehabilitation, then, are
insufficient to describe the full range of human experience and engagement in the social world
and could therefore benefit from an exploration of the construct that draws from a broad variety
of literature. Existing definitions do not allow for personalization, account for undesirable
pursuits, or identify optimal amounts of participation. My conceptual framework of participation,
based on an extensive interpretive review of the literature, is presented in Chapter 3.
mTBI in the Military. mTBI has been labeled the “signature injury” of the wars in Iraq
and Afghanistan (Tanielian & Jaycox, 2008). Since 2000, over 350,000 traumatic brain injuries
have been reported across all military branches, and more than 80% are classified as mild
(DVBIC, 2016b). Only about 20% of these mild injuries occur during combat deployments; the
vast majority occurs in the continental United States (Cameron, Marshall, Sturdivant, & Lincoln,
2012). During the wars in Iraq and Afghanistan, prevalence of mTBI among deployed service
members has been estimated to be between 15% and 20% (Hoge et al., 2008; Tanielian &
Jaycox, 2008), and approximately half of these injuries were related to blasts (Benzinger et al.,
2009). Blast injuries are exceptionally rare in the civilian population (Faul, Xu, Wald, Coronado,
& Dellinger, 2010) and differ from brain injury via other mechanisms because the overpressure
of the blast wave can cause systemic injury, in addition to impact from projectiles or from the
body being thrown into objects (Finkel, 2006; R. R. Hicks, Fertig, Desrocher, Koroshetz, &
Pancrazio, 2010).
Official diagnostic criteria for mTBI in military populations include loss of consciousness
for less than 30 minutes, post-traumatic amnesia for less than 24 hours, and alteration of
13

consciousness, which is described as “seeing stars or having one’s bell rung.” Additionally, for
an injury to be classified as mild, structural damage cannot be visible in brain imaging studies,
such as computerized tomography (CT) or magnetic resonance imaging (MRI; Management of
Concussion-mild Traumatic Brain Injury Working Group, 2016). In the civilian population, a
Glasgow Coma Scale score of 13 to 15 in the immediate post-injury period is often used (Carroll
et al., 2004); however, since military service members often do not seek care immediately,
clinicians must frequently rely on self-report about loss of consciousness, post-traumatic
amnesia, and alteration of consciousness criteria (Brenner, Vanderploeg, & Terrio, 2009).
Notably, mTBI can be diagnosed even in the absence of loss of consciousness and post-traumatic
amnesia if a service member reports alteration of consciousness in the context of an event in
which mTBI could have occurred, such as a motor vehicle accident or exposure to blast from an
improvised explosive device (IED; Iverson, 2010).
There is a clear gap in the literature to support effective occupational therapy intervention
approaches for military service members with chronic symptoms attributed to mTBI. However,
because they do currently receive occupational therapy services, a logical first step in planning
an intervention study is to describe patient needs and current practice approaches. Thus, building
on my pilot needs assessment study, OT for TBI, the purpose of my dissertation study was to
characterize current occupational therapy practice with active duty service members with mTBI
and persistent symptoms to create a treatment model. This study is envisioned as a step toward
development of a manualized intervention for a future efficacy study. Partial results of the OT for
TBI study are presented in Chapter 4. Chapter 5 represents the findings of my second dissertation
study in the form of a treatment model. In Chapter 6, I present an analysis of data from both OT
14

for TBI and my second dissertation study related to attribution of chronic symptoms after mTBI,
which emerged as a potentially important problem.
Persistent symptoms following mTBI. The symptoms that are typically attributed to
mTBI are common to many other conditions and are often reported by adults with no injury
history or medical diagnosis (Iverson, Lange, Brooks, & Rennison, 2010; Williams et al., 2010).
Many studies have been conducted to attempt to understand the relationship of these symptoms
to an mTBI event, but a clear linkage has not been established (e.g., Brenner et al., 2010;
Brenner et al., 2009; Lange, Iverson, & Rose, 2010; O'Neil et al., 2014). Further complicating
matters, many service members with mTBI have concurrent diagnoses of sleep, anxiety,
depressive, and other disorders, including PTSD, (Bahraini et al., 2014; Brenner et al., 2010;
Brenner et al., 2009; Carlson et al., 2011; N. W. Nelson et al., 2012; Yeh et al., 2014), making it
unrealistic to unambiguously connect the presence of a symptom with any single diagnosis.
Investigators are recognizing that attempting to attribute particular symptoms to a precise
diagnosis is not useful in these cases. As one research team pointed out,
Examining the variance in PCS associated with mild TBI while controlling for PTSD
symptoms is arbitrary and obscures other potential explanations. PTSD and depression
are both health outcomes, and both are associated with a variety of symptoms that
overlap with PCS. (Vanderploeg et al., 2012, p. 1893)

Notably, PCS have been documented among active duty service members during peacetime in
the absence of combat deployment (K. J. Miller et al., 2013). This finding suggests that some
symptoms are related to the brain injury event and cannot be solely attributed to PTSD or
combat-related stress. Stein et al. have recently reported that several factors predict PCS,
including prior head injuries, stress levels, and loss of consciousness at time of injury (Stein et
al., 2016).
15

Vanderploeg and colleagues (2012) conducted an online cross-sectional cohort study of
Florida National Guard members and compared those who had deployed to Iraq or Afghanistan
to others who had not. Among the deployed group, significant associations were found between
mTBI and depression, anxiety, PTSD, and PCS. Deployed Guard members who had been
exposed to blasts also reported symptoms related to barotrauma, such as hearing loss and pain on
deep breathing (Vanderploeg et al., 2012).
Another study involved a retrospective medical records review of U.S. Army Special
Operations members to assess comorbidities associated with mTBI (Kontos et al., 2013).
Compared with soldiers who had no history of mTBI, those with mTBI had significantly greater
risk for PTSD symptoms and performed worse on tests of visual memory and reaction time.
Individuals with injury events that involved both blast and blunt forces had higher risk of
residual mTBI and PTSD symptoms. Greater exposure to injury was also positively correlated
with the number of reported symptoms. Other research has supported an association between
PCS and memory impairment (Larson, Zollman, Kondiles, & Starr, 2013). There is some
evidence that lower premorbid cognitive ability, based on Wechsler Test of Adult Reading,
increases risk for PCS after mTBI (Larson et al., 2013).
A case-control study of visual symptoms after mTBI identified deficits in reading,
saccades, pursuits, and vergence, as well as photosensitivity (Capo-Aponte, Urosevich, Temme,
Tarbett, & Sanghera, 2012). The authors suggested that screening for these visual problems be
included during assessment of service members with a history of mTBI. Though this study was
not conducted by occupational therapists, vision rehabilitation falls within the occupational
therapy scope of practice (American Occupational Therapy Association [AOTA], 2014) and
should be considered by occupational therapists treating military mTBI patients. A more recent
16

study demonstrated that the prevalence of visual impairments after mTBI does not appear to
differ based on mechanism of injury (Capo-Aponte et al., 2017).
Several studies have identified sleep disorders among service members with mTBI.
Problems with sleep likely exacerbate other symptoms, making participation in daily life even
more challenging (Ishak et al., 2012). Mysliwiec and colleagues (2013) observed high rates of
obstructive sleep apnea, insomnia, or diagnosis of both in a sample of previously deployed
military personnel who reported sleep problems. Most of the service members who were
diagnosed with a sleep disorder also had a diagnosis of PTSD, mTBI, depression, or pain.
Although this study did not address mTBI exclusively, results suggest the need to conduct formal
sleep studies for all patients with brain injury who report sleep problems (Mysliwiec et al.,
2013). Another study of 116 service members who sustained a traumatic brain injury in combat
(84.5% designated as mild) reported high frequencies of insomnia, sleep apnea, hypersomnia,
and daytime somnolence (Collen, Orr, Lettieri, Carter, & Holley, 2012). Co-occurring
psychiatric disorders and the use of numerous prescription drugs complicated sleep problems in
this sample. Bryan (2013) reported a positive correlation between rates of insomnia and exposure
to multiple mTBI events in a cross-sectional study of patients in a brain injury clinic in Iraq. He
also pointed out that the environment during deployment, in which sleep is frequently
interrupted, influenced sleep hygiene and may cause insomnia (Bryan, 2013). A recent study
found that sleep quality was predictive of cognitive function independent of mTBI or PTSD
diagnoses (Martindale, Morissette, Rowland, & Dolan, 2017).
In summary, service members with a history of mTBI and persistent PCS frequently
experience co-occurring diagnoses that are associated with similar symptoms (see Figure 1.1).
Because mTBI occurs in the context of a traumatic event regardless whether it or not is in
17

combat, these findings are not surprising. Complex interactions among the psychological and
physical symptoms are likely. The studies described in this section are consistent with the
findings from my pilot study, in which service members with chronic symptoms reported
concurrent mental health diagnoses and disruption to all areas of occupation with particular
emphasis on sleep.
Neuroscience evidence in mTBI. Individuals with mTBI typically show no evidence of
damage on CT and MRI scans (Bazarian et al., 2007). However, studies that employ other
imaging techniques such as diffuse tensor imaging (DTI) and fractional anisotropy (FA) have
reported white matter damage after mTBI, which is evidence of diffuse axonal injury (Aoki,
Inokuchi, Gunshin, Yahagi, & Suwa, 2012; Cogan, 2016; Davenport, Lim, Armstrong, &
Sponheim, 2012; Jorge et al., 2012). The implications of axonal injuries are congruent with many
of the reported symptoms. For instance, white matter integrity is associated with cognitive
processing speed (Turken et al., 2008) and working memory (Burzynska et al., 2011). White
matter damage in military and veteran populations with histories of mTBI has been found to
correlate with both cognitive deficits (Matthews et al., 2011) and physical symptoms (D. R.
Miller, Hayes, Lafleche, Salat, & Verfaellie, 2016). Ware et al. found that returning to work
post-deployment was associated with white matter integrity, whereas the average number of
medical visits per year was correlated to white matter damage in the splenium of the corpus
callosum (Ware et al., 2016). Moreover, Shively and colleagues identified a pattern of astroglial
scarring that was unique to brain injury via blast exposure in a postmortem tissue analysis
(Shively et al., 2016). DTI and FA are not yet widely available for clinical use and current
methods cannot confirm a diagnosis of mTBI; nor is postmortem evaluation helpful for living
patients. Nevertheless, the recent neuroimaging studies support a physiological component
18

underlying PCS. Therefore, intervention approaches that specifically target neuroplasticity may
be useful.
Interventions for mTBI and PCS. Many interventions targeting people with mTBI have
been tested with civilians in the immediate post-injury period; therefore, they do not directly
address chronic PCS (Borg et al., 2004; Nygren-de Boussard et al., 2014). In two systematic
reviews conducted a decade apart, task forces from the World Health Organization (WHO)
concluded that there was some evidence to suggest that early education about the positive
prognosis for most individuals with mTBI reduces the likelihood that persistent symptoms will
develop (Borg et al., 2004; Nygren-de Boussard et al., 2014), a finding also supported in a
randomized controlled trial (Matuseviciene, Borg, Stalnacke, Ulfarsson, & de Boussard, 2013).
Nygren-de Boussard et al. additionally concluded that extensive bed rest in the acute post-injury
period did not reduce the risk of PCS (Nygren-de Boussard et al., 2014). Nonetheless, the
authors noted a dearth of scientifically rigorous studies to find effective treatments for either
children or adults with PCS after mTBI (Nygren-de Boussard et al., 2014).
This evidence may not be particularly relevant for military service members with mTBI.
There is often a delay in identifying mTBI in service members (Iverson, 2010). Once symptoms
become chronic, there is limited support for effective interventions. A pilot study of an internet-
based psychoeducational intervention found a reduction in self-reported symptoms in
participants with both acute and chronic mTBI (E. G. King et al., 2013). Nonetheless, it is not
clear how symptoms impacted participation and whether symptom reduction was associated with
any changes in daily life. Another pilot study demonstrated improvements in perceived quality of
life and self-efficacy in adults with chronic mTBI and PCS after a 10-week mindfulness-based
stress reduction (MBSR) program (Azulay, Smart, Mott, & Cicerone, 2013). On the other hand,
19

the MBSR intervention had no effect on working memory or attention regulation outcomes
(Azulay et al., 2013). As in the King et al. study (2013), the relationship between PCS and
participation in daily activities was not reported. There remains a need to study and describe the
relationship between PCS and participation.
To date, there are no effectiveness studies of occupational therapy intervention for mTBI
and PCS (Cogan, 2014). Clinical guidelines for occupational therapy intervention for service
members with mTBI exist; however, they have not been empirically evaluated (Radomski,
Davidson, Voydetich, & Erickson, 2009). A small study of a multidisciplinary residential
program for veterans with PTSD and a history of traumatic brain injury (all levels of severity)
that included weekly individual occupational therapy sessions found improvements in
occupational performance, as well as PTSD and depression symptoms (Speicher, Walter, &
Chard, 2014). The intensity of a residential program, however, may not be required for all
individuals, nor may it be practical for active duty personnel. A scoping study of the
occupational science and occupational therapy literature on the needs and intervention strategies
for service members with mTBI and PCS found that there were only three papers that addressed
military service members or veterans specifically and few studies of mTBI and PCS among any
population in the occupational therapy literature (Cogan, 2014). A recent study of a
multidisciplinary outpatient program that included occupational therapy was demonstrated to
reduce both concussion and PTSD-related symptoms, yet did not investigate whether these
findings translated to changes in participation (Janak et al., 2017).
Specific Aims
The overall goals of my proposed dissertation studies were to (a) develop a sophisticated
understanding and description of the construct of participation and (b) identify and document a
20

theoretically-grounded treatment model to improve participation of military service members
who suffer from PCS following mTBI.
 Aim 1: Develop a conceptual framework of participation based on a review, comparison,
and critique of multidisciplinary literature about this construct.
 Aim 2: Utilize intervention mapping methodology to conceptualize a treatment model for
optimizing participation in daily life of military service members with mTBI and PCS
that includes treatment targets, mechanisms of action, and hypothesized active
ingredients.

21

Chapter 2: Methods
As described above, my proposed dissertation is composed of two separate but
interrelated studies. Below, I detail the methods used for each, as well as any changes from the
originally proposed approaches.
Study One: Conceptual Framework of Participation
The first study consisted of developing a conceptual framework of participation. As
explained earlier, the ICF framework is problematic in describing participation because of its
ambiguity, emphasis on observable performance, omission of the patient perspective, and narrow
focus on culturally normative roles. This study fills a need for a thorough analysis of
participation literature to better characterize its conceptualization in the context of rehabilitation.
Data Collection and Analysis
My original plan had been to use an adaptation of the qualitative synthesis methodology
that was delineated by Thomas and Harden (2008). They described a three-stage analytical
process that includes line-by-line coding of included studies, identification of descriptive themes,
and identification of analytical themes. I had intended to draw literature from a variety of fields,
including philosophy, sociology, anthropology, and education.
As I began the literature search, the original plan and methodology soon proved to be
inadequate for the task. First, an issue that arose was the disparate ways participation is used
across different fields, resulting in a struggle to glean a meaningful synthesis of literature that
would prove useful for rehabilitation. In consultation with Dr. Mike Carlson, who is a co-author
on the manuscript reporting the results of this study, I adjusted my approach and focused my
attention on rehabilitation and healthcare literature. Findings from other areas were still included
where relevant, but were not emphasized in the literature search. Second, the synthesis process as
22

described by Thomas and Harden (2008) was too restrictive and linear. I undertook an
investigation of other approaches for synthesizing the literature and, after considering different
options, selected a methodology called interpretive synthesis to achieve this aim (Dixon-Woods,
Agarwal, Jones, Yong, & Sutton, 2005; Suri & Clarke, 2009).
The reasons for choosing an interpretive synthesis approach were multiple. First, this
methodology enables inclusion of diverse methodologies, including quantitative, qualitative, and
theoretical literature, which was consistent with the original plan (Suri & Clarke, 2009;
Whittemore & Knafl, 2005). Second, the aim of an interpretive synthesis is not merely to
summarize existing literature, as is the purpose of many other review styles, but to create new
knowledge by uncovering novel meanings and connections among previous articles (Suri &
Clarke, 2009). As I intended to create an original conceptual framework, this purpose also fit my
aim. Third, interpretive synthesis emphasizes theory generation and a recursive, flexible method
of analysis (Dixon-Woods, Bonas, et al., 2006; Dixon-Woods, Cavers, et al., 2006; Heaton,
Corden, & Parker, 2012). This iterative approach allowed me to continue to return to the
literature to explore concepts more deeply as they arose in my analysis, which was not possible
using the more linear process of Thomas and Harden’s method. For these reasons, interpretive
synthesis was deemed the best method for achieving the aims of the paper. The results are not
intended to be replicable, per se, as different authors may come up with different results using
the same resources (Dixon-Woods, Bonas, et al., 2006; Heaton et al., 2012). Therefore, the
results presented herein are reflective of the literature as well as the authors’ ideas and points of
view.
The literature search began by querying the terms participation and rehabilitation jointly
in the PubMed and Web of Science databases. The volume of resulting citations was
23

overwhelming – more than 13,000 in PubMed and nearly 6,000 in Web of Science. Therefore, a
purposeful, opportunistic sampling technique was employed to identify important articles related
to participation in the rehabilitation literature (Patton, 2002; Suri, 2011). Papers were retained if
they addressed aspects of participation that were relevant to rehabilitation or healthcare. Other
related terms identified in the literature such as engagement, involvement, and community
reintegration were also investigated. Bibliographies of selected articles were scanned for further
applicable citations. Articles that used participation in idiosyncratic ways, such as those
pertaining to involvement in research studies, were excluded.
Analysis of the literature was inductive and based on the constant comparative method,
which is a process of systematically appraising new data against evolving categories and themes
(Patton, 2002). As I read through articles, I regularly conferred with Dr. Carlson. We looked for
common concepts across the literature even if differing terminology was used. Articles were
sorted into groups based on possible themes that focused on the uses and characteristics of
participation. After we identified initial categories and considered possible interpretations, we
returned to the literature using a theoretical sampling strategy to locate additional content to fine-
tune and validate concepts and meanings (Dixon-Woods et al., 2005; Patton, 2002; Suri, 2011).
Themes and categories were clarified, collapsed, reorganized, and occasionally discarded during
this process. This iterative procedure continued until additional literature no longer introduced
new concepts and was consistent with our identified themes and categories. At the conclusion of
this recursive analysis, 76 articles formed the foundation of the results. These findings of this
interpretive synthesis and the resulting conceptual model of participation are presented in
Chapter 3.

24

Study Two: Mapping the Treatment Model
I used intervention mapping methodology to construct a preliminary treatment model for
occupational therapy intervention to optimize participation for service members with mTBI and
chronic symptoms (Bartholomew et al., 2011). I utilized Whyte et al.’s (2014) definition of
treatment theory to identify the necessary components of the model, which includes treatment
targets, active ingredients, and mechanisms of action. Treatment targets are the things about a
person that are expected to change as a direct result of the intervention (Whyte et al., 2014).
Examples of treatment targets are knowledge, skills, and attitudes (Bartholomew et al., 2011).
Active ingredients are the actions that healthcare providers execute to facilitate change toward
attainment of the treatment targets. Mechanisms of action explain how the change is expected to
occur in the patient (Whyte et al., 2014). I began with from the findings of the OT for TBI pilot
study and conducted two series of focus groups—one with patients and another with
occupational therapy professionals.
The goal of intervention mapping is to clearly define the objectives of a program or
intervention at the outset of its development and to systematically match those objectives to
supporting theories and intervention activities (Bartholomew et al., 2011). During this process,
there should be regular communication with program stakeholders to maximize the
appropriateness and acceptability of the intervention for the targeted population and context
(Bartholomew & Mullen, 2011; Bartholomew et al., 2011). Initially conceived for narrowly
focused health promotion interventions such as smoking cessation, the objectives and processes
are congruent with those necessary to develop complex protocols targeting multiple treatment
objectives. As such, a subset of the steps in the intervention mapping methodology were adapted
to guide data collection and analysis (Bartholomew et al., 2011). The adapted steps are
25

Table 2.1: Adaptations of Intervention Mapping Steps
Intervention mapping step
(from Bartholomew et al., 2011)
Adapted step
Needs assessment Needs assessment
 Establish and maintain a planning group that
includes program stakeholders
 Analyze health and quality of life problems
and their causes
 Balance needs assessment with assessment of
community capacity
 Link the needs assessment to program and
evaluation planning by specifying desired
program goals

 Establish stakeholder involvement by
recruiting and conducting focus groups with
patients and occupational therapists
 Analyze data from OT for TBI study to
identify needs of service members with mTBI
and PCS
 Identify occupational therapy treatment
targets relevant to optimizing participation for
service members with mTBI and PCS
Prepare matrix of change objectives Prepare matrix of treatment targets
 State expected program outcomes for health
behaviors and environmental conditions to
improve health and quality of life
 Subdivide behavioral and environmental
outcomes into performance objectives
 Select important and changeable determinants
of the health behavioral and environmental
outcomes
 Create a matrix of change objectives for each
level of intervention planning (individual,
interpersonal, organizational, community, and
societal) by crossing performance objectives
with determinants and writing change
objectives

 Describe the type and direction of expected
changes in each treatment target
 Identify which active ingredients are
associated with each treatment target
 Identify hypothetical mechanisms of action by
which each treatment target might change
 Create a matrix that links, targets, active,
ingredients, and mechanisms of action.

summarized in Table 2.1. The outcome of this approach is a matrix that connects the treatment
targets, active ingredients, and hypothesized mechanisms of action. Bartholomew et al. (2011)
specify additional steps for protocol development, implementation, and evaluation; however,
these steps are beyond the scope of the present study.
Permission to conduct this study was obtained from the institutional review boards of
both NMCSD and USC. No protected health information was collected. Confidentiality of
participant information was maintained through the use of identification numbers in study
records and transcripts, and pseudonyms in the manuscripts. Consent forms were stored
separately from other study data in a locked cabinet in a restricted office at NHCP.
26

Rationale for Focus Group Approach
Focus groups are a special kind of group interview designed to solicit peoples’ thoughts
and feelings about a particular topic (Kreuger & Casey, 2015). Participants in a focus group have
a certain set of characteristics in common in relation to the topic of discussion, which varies from
study to study. The intention of a focus group is not to gain consensus on an issue; rather, the
goal is to obtain a range of opinions and ideas about the topic and generate discussion between
participants about it (Kreuger & Casey, 2015; Patton, 2002). Focus groups are also appropriate
for gathering expert opinions about a subject, which is how they were employed in my research
(Kreuger & Casey, 2015).
Moreover, focus group research is appropriate for service and program development
(Jayasekara, 2012; Kreuger & Casey, 2015). The DoD has identified patient involvement as
being key to improved care in future research and program evaluation (Johnson, 2014). Kreuger
and Casey (2015) suggested three stages at which focus groups are most useful in this capacity.
First, focus groups are useful for understanding the perspectives of stakeholders and service
providers about the problem or issue. Second, focus groups can provide feedback on prototypes
of the program to describe what the group members like or do not like about the program,
identify potential barriers to implementation, and suggest changes that would enhance usability.
Third, focus groups are helpful for evaluation of programs after they have been implemented. In
the present study, my emphasis was on the first purpose and I approached patients as experts in
their own needs and experiences. Occupational therapy providers were considered experts on
their practice area. These perspectives were integral to the resulting treatment model and
thematic analysis.
27

The fluidity of the military context was also part of the reason for using focus groups
instead of a more traditional stakeholder planning group, like those that have been employed in
previous intervention mapping endeavors (Bartholomew et al., 2011). Active duty service
members, which include patients as well as some healthcare providers, serve at each duty station
for a limited time period and are usually transferred to another location within three years. The
service members who were eligible for this study were often nearing the end of their active
military service and it was possible that some would be unable to participate for the duration of
the research. My protocol allowed for new participants to be recruited if original participants left
the area and discontinued participation in the study; however, no service members withdrew and
the only occupational therapist who withdrew did so prior to the first meeting. As a result, I had a
stable group of participants for the duration of the study.
A frequent criticism of focus group research is that group interaction, supposedly one of
the critical features of the approach, is generally overlooked in data analysis (Belzile & Öberg,
2012; Parker & Tritter, 2006; Smithson, 2000). Instead, most researchers present only the
content of the group discussion and frequently present quotes as if they were from individual
interviews, without the context of the group discussion (Smithson, 2000). Belzile and Öberg
(2012) argue that the degree of emphasis on group interactions in the data analysis should be
determined by the purpose of the study. For example, if the purpose of a focus group is to obtain
feedback about a particular product, group interactions are probably not crucial to data analysis.
On the other hand, if the topic is more abstract, group interactions may be more likely to
influence the substance of discussion and would therefore be essential to the analysis (Belzile &
Öberg, 2012).
28

During data collection and analysis, I attended to both discussion content and group
interactions, with particular attention to power dynamics within each group. While focus group
meetings were in progress, I made sure that each person in the group had an opportunity to speak
and sometimes directed questions toward quieter participants. In the patient group, service
members were of similar rank (E-5 to E-7), which helped with the balance of power. The
therapist group included occupational therapists and certified occupational therapy assistants;
thus, there was potential power imbalance. Nevertheless, I observed that group members were
respectful of each person’s knowledge and all contributed approximately equally, with some
variation between meetings.
Setting
NHCP is a Naval hospital located on Marine Corps Base Camp Pendleton in Oceanside,
CA. The main hospital building is houses a variety of inpatient and outpatient medical services
for military service members and their families, along with administrative offices including the
Clinical Investigation Program, with which I coordinated to obtain institutional approval to
conduct the study. There are conference rooms throughout the building, many of which are
located in restricted areas within the various clinics. For the present study, I was able to reserve a
conference room for patient meetings on the first floor of the building that is accessible from the
main lobby and does not require passage through any restricted spaces.
In addition to the main building, smaller clinics are located throughout the base. One of
these is the Concussion Care Clinic, which is a multidisciplinary treatment facility that
specializes in treating service members with chronic symptoms attributed to mTBI. Because the
majority of the participating occupational therapy professionals worked in the Concussion Care
Clinic, we used the occupational therapy clinic space to hold focus group meetings after work
29

hours when there were no patients remaining in the clinic. NHCP refers to the main hospital as
well as all of the associated clinics on base.
Participants
Two categories of participants were recruited: (a) service members with mTBI and PCS
who have received care at the NHCP Concussion Care Clinic (n=6), and (b) occupational therapy
professionals who have treated service members with mTBI and PCS in a military medical
facility (n=6). LCDR Eric Harmon, OTR/L, CHT, the original Navy principal investigator, made
initial contact with potential service member participants. He provided fliers, explained the
purpose of the study, and referred interested individuals to me to complete the enrollment
process. In order to be eligible, service members had to (a) have received occupational therapy
services for symptoms attributed to mTBI and (b) meet the criteria for mTBI as defined in the
VA/DoD guidelines (Management of Concussion-mild Traumatic Brain Injury Working Group,
2016). Potential participants were excluded if they were diagnosed with a DSM-V personality
disorder or if they were currently enrolled in a substance abuse treatment program.
LCDR Harmon recruited occupational therapy professionals from NHCP and other
centers via personal contacts. Recruitment strategies included the distribution of fliers, email
communications to clinic staff, and identification of key informants within the clinics who could
identify potential participants. Professionals were eligible if they were occupational therapists or
certified occupational therapy assistants who had experience treating patients with chronic
symptoms after mTBI in a military medical facility for at least six months. Of the 11
occupational therapy providers who were recruited and initially demonstrated interest in the
study, six completed the informed consent process and one subsequently withdrew before
completing a demographic interview, therefore the final sample included five occupational
30

therapy participants. Reasons for refusal to enroll in the study were lack of time (n=1), perceived
conflict of interest with their employer (n=2), or no reason given (n=2).
Data Collection
All participants in both groups completed an informed consent process upon enrollment
in the study. After completion of informed consent, I conducted brief demographic interviews
with each participant. The Ohio State University Traumatic Brain Injury Identification (OSU-
TBI-ID) interview was used to establish head injury history for patients (Bogner & Corrigan,
2009).
Meetings with each group were scheduled approximately one to two weeks apart and each lasted
one hour. All patient meetings took place at NHCP in a conference room that is accessible to the
public. Occupational therapy provider meetings were held at the Concussion Care Clinic, which
is part of NHCP but located in a different part of the base from the main hospital. Most attendees
participated in-person for all focus groups, with the exception of an occupational therapist who
worked at a facility on the east coast and joined by teleconference. Meetings with occupational
therapy providers were held after work hours. The patient group requested an earlier time of day,
so meetings were scheduled in the early afternoon. All meetings were audio-recorded and
transcribed verbatim. On some occasions, a flip chart was used to facilitate discussion. Any data
recorded on the flip chart was also transcribed and included in the analysis. After each focus
group meeting, I maintained a reflective journal where I recorded my thoughts about the group
process, anything that surprised me, and questions or ideas I had as a result of the discussion.
My original plan for conducting the focus groups was to provide an agenda and related
information for review in advance of the meetings and focus specifically on the elements of the
treatment theory – treatment targets, active ingredients, and mechanisms of action. By the end of
31

the first focus group with the occupational therapy professionals, it became apparent that the
introduction of this methodological language and direction from me as the moderator would not
be effective for soliciting the kind of feedback I sought. In response to this situation, I adjusted
my approach for all subsequent meetings to use more open-ended questions and avoid confusing
jargon. I did continue to provide the main topics for each meeting to participants in advance.
Discussion topics and guiding questions for each focus group meeting are listed at the end of
Chapter 5.
Data Analysis
Data analysis occurred concurrently with data collection. Initial review of each meeting
transcript was completed prior to the next focus group. As treatment targets, active ingredients,
and mechanisms emerged, they were verified through member checking in subsequent meetings.
The Occupational Therapy Practice Framework (OTPF) domain was used to categorize treatment
targets (AOTA, 2014). Data that did not fit the parameters of the treatment model were coded
thematically.
The results of the OT for TBI study were shared with patient and therapist focus groups to
facilitate the initial discussion of treatment targets. The list of identified targets was revised and
prioritized based on focus group discussions. The resulting matrix of treatment targets maps the
intersection of each treatment target, active ingredient, and hypothesized mechanism of action.
The matrix “represents the pathways for the most immediate changes in motivation and
capability to influence health behavior and actions taken by environmental agents. Thus, each
element of the matrix is interrelated, and collectively the elements are a logic model for the
change process” (Bartholomew et al., 2011, p. 275). A complete matrix of treatment targets
signifies the completion of the second aim of my dissertation.
32

The main results of study two are reported in Chapter 5. Chapter 6 represents an analysis
of an unanticipated finding about disparate beliefs among healthcare providers and patients about
the underlying causes of persistent symptoms that are attributed to mTBI. Data in this latter
analysis are drawn from both this study and the pilot, OT for TBI.

33

Chapter 3: Deciphering participation: An interpretive synthesis of its meaning and
application in rehabilitation
(Co-authored with Dr. Mike Carlson; under review at Disability and Rehabilitation)
Abstract
Purpose: Participation is widely recognized as an important outcome for rehabilitation.
However, it lacks a universally accepted definition. The purpose of this review is to synthesize
the literature about participation in rehabilitation in order to clarify the term and increase its
usefulness for rehabilitation providers and researchers.
Methods: We undertook an interpretive synthesis of the literature, drawing from a broad and
varied selection of the vast number of publications on the subject of participation. The search and
analysis was iterative and continued until saturation of themes was achieved.
Results: We argue that three essential dimensions – performance, subjective experience, and
interpersonal connection – constitute participation. We further divide participation into
community-based and interventional contexts. Interventional participation is circumscribed by
the treatment setting, whereas community-based encompasses all other areas. Participation in
either interventional or community-based contexts is largely determined by the available
opportunities from which a person can choose, with such opportunities affected by conditions
that are either internal or external to the individual. As defined in this framework, participation is
not inherently good or bad; rather, its effect is determined by a person’s unique life
circumstances. We posit this model as a resource for future research as well as clinical reasoning.
Keywords: Participation; community integration; engagement; healthcare; clinical practice;
patient participation; rehabilitation

34

People receive rehabilitation treatment when they become injured or ill and,
consequently, are unable to do the basic things they are accustomed to doing. Because
rehabilitation draws on the holistic biopsychosocial model (Wade, 2015), it is not surprising that
returning to a viable daily activity routine is a key intervention priority. Participation, therefore,
is often described as a primary outcome of rehabilitation treatment (Whiteneck & Dijkers, 2009),
yet the term lacks any clear, widely accepted definition (Heinemann et al., 2010). In this regard,
the word participation has been used to describe anything from a patient completing activities
during a treatment session (Kortte, Falk, Castillo, Johnson-Greene, & Wegener, 2007; Lenze et
al., 2004) to the same individual fulfilling personally meaningful social roles in the community
(Hammel et al., 2008; Law, 2002). Additionally, although many scholars emphasize the
subjective experience of the individual in participation (Brown et al., 2004; Hemmingsson &
Jonsson, 2005; Piskur et al., 2014), the construct is often operationalized using objective
observations and measures (Eyssen et al., 2011). Such conceptual inconsistencies reduce the
utility of the term for important purposes such as professional communication, outcome
measurement, scientific study, and application of research findings to practice. Furthermore, the
body of related literature is unwieldy and in need of organizational clarity. Accordingly, the goal
of this paper is to provide an overarching synthesis of the literature about participation, so as to
promote the term’s interpretability and practical usefulness for rehabilitation providers and
researchers.
In addition to participation not having a universally accepted definition, the term is often
used interchangeably with engagement (Bright, Kayes, Worrall, & McPherson, 2015),
involvement (Williamson, 2014), or community reintegration (Dijkers, 2010). Meanings for these
terms vary according to context and share substantial overlap. This terminological divergence
35

leads to confusion in research and clinical applications because findings or treatment aims,
respectively, may not be straightforwardly comparable.
Tools developed to measure participation frequently have several drawbacks. First,
responses are often limited to a set of predetermined questions that fail to capture the full range
of personally relevant life domains (Chang, Coster, & Helfrich, 2013; Resnik & Plow, 2009).
Second, most measurement tools do not assess the subjective experience of participation for the
individual being evaluated (Eyssen et al., 2011; Whiteneck & Dijkers, 2009). Moreover, existing
measures are frequently scored based on the idea that “more is better,” a strategy that is not
necessarily accurate because the value placed on each activity by an individual is not considered
(Piskur et al., 2014).
The World Health Organization (WHO) International Classification of Functioning,
Disability and Health Framework (ICF) defines participation as “involvement in a life situation”
(WHO, 2002). However, this characterization has at least three important drawbacks. First, it is
so broad as to be unhelpful, as nearly all human action could be construed as being embedded in
a life situation (Whiteneck & Dijkers, 2009). Second, although participation appears in the ICF
model at the same level as activities, it is also characterized as a set of activities that are
associated with a social role (WHO, 2002, 2013), which impairs the practicality of the
framework for classification purposes (Badley, 2008). Third, participation is operationalized as
observable performance of social roles (WHO, 2002, 2013), which fails to account for the
subjective experience of the individual (Brown, 2010; Hemmingsson & Jonsson, 2005). This
emphasis on overt observation does not fully take into account the philosophy of patient-centered
practice that underpins the rehabilitation professions (Baum, 2011; Brown, 2010; Hammell,
36

2013; Hemmingsson & Jonsson, 2005; Mallinson & Hammel, 2010). For these reasons, we will
not adopt the ICF definition in this review.
In this paper, we begin by defining participation broadly as consciously doing an activity,
and will subsequently expand and refine this definition based on a synthesis of relevant
literature. In this context, we conceptualize activity as an integrated, culturally labeled personal
action that is done for a particular purpose, such as preparing a family meal. Consciousness is a
requirement because there is an element of choice in the activities one pursues. We have found
that the body of literature related to participation is massive, challenging to organize, and
difficult to translate into recommendations for practice. In response to these problems, the
purpose of this paper is to go beyond the initial definition we propose by providing a synthesis
and clearer conceptualization of participation that can guide providers toward implementation of
patient-centered care and suggest avenues for future research.
Methods
An interpretive synthesis of the literature on participation was completed (Dixon-Woods
et al., 2005). This approach was chosen in part because it enables inclusion of information that
stems from diverse methodologies, including quantitative, qualitative, and theoretical literature
(Suri & Clarke, 2009; Whittemore & Knafl, 2005). The aim of an interpretive synthesis is not
merely to summarize existing literature, as is the purpose of many other review styles, but to
create new knowledge by uncovering fresh meanings and connections that stem from previous
work (Suri & Clarke, 2009). Interpretive synthesis emphasizes theory generation and a recursive,
flexible approach to analysis (Dixon-Woods, Bonas, et al., 2006; Dixon-Woods, Cavers, et al.,
2006; Heaton et al., 2012). Therefore, the results presented herein reflect both the literature and
the authors’ ideas and points of view.
37

The first author (AMC) began by conducting a literature search using variations of the
terms for participation and rehabilitation jointly in the PubMed and Web of Science databases.
The volume of resulting citations was overwhelming – more than 13,000 results in PubMed and
nearly 6,000 in Web of Science. Therefore, a purposeful, opportunistic sampling approach
(Patton, 2002; Suri, 2011) was employed to identify important articles related to participation in
the rehabilitation literature. Initially, known references were reviewed and additional articles
were selected from their bibliographies. Titles of electronic search results were scanned for
relevance. Papers were retained if they addressed aspects of participation that were relevant to
rehabilitation or healthcare. Other related terms identified in the literature such as engagement,
involvement, and community reintegration were investigated. Bibliographies of selected articles
were scanned for further applicable citations. Articles that used participation in idiosyncratic
ways, such as those pertaining to involvement in research studies, were excluded.
Analysis of the literature was inductive and based on the constant comparative method
(Patton, 2002), which is a process of systematically appraising new data against evolving
categories and themes. The first author (AMC) read the articles and regularly consulted with the
second author (MC) throughout this process. Additional electronic searches were conducted as
new ideas were considered. We looked for common concepts across the literature, even when
differing terminology was used. Articles were sorted into groups based on possible themes,
focusing on the uses and characteristics of participation. After we identified initial categories and
considered possible interpretations, we returned to the literature using a theoretical sampling
strategy to locate additional content to fine-tune and validate concepts and meanings (Dixon-
Woods et al., 2005; Patton, 2002; Suri, 2011). Themes and categories were clarified, collapsed,
reorganized, and occasionally discarded during this process. Even after themes were fairly stable,
38

literature was searched to find additional supportive or contradictory articles. This iterative
procedure continued until we achieved saturation among the categories and themes. At the
conclusion of this recursive analysis, 76 articles formed the foundation of our results. The
included articles contain ideas that recur prominently in the literature; however, they do not
represent an exhaustive search of all literature in each theme and category.
Results
The interpretive review process led us to theorize the essential dimensions of
participation, different contexts of relevance to rehabilitation, and antecedents of participation.
Essential Dimensions of Participation
Based on our review of the literature, we conceptualized participation as being composed
of three essential dimensions: performance, subjective experience, and interpersonal connection.
Each is a separate construct, but they are closely intertwined.
Performance. In order to participate, one has to do something. Performance describes
the overt execution of activities and actions in a person’s life context (Badley, 2008). Referring
back to our earlier broad definition, to participate a person must be conscious and engaged in one
or more activities. Researchers in occupational science have identified performance as distinct
from the form, or general description, of the activity itself (Crabtree, 2003; Hocking, 2009; D. L.
Nelson, 1988). D. L. Nelson (1988) noted that performance is usually observable, although
cognitive processing is also included and cannot be directly viewed.
Subjective experience. Subjective experience signifies the individual’s perception of
participation and has been identified as an essential element by many scholars (Brown, 2010;
Hemmingsson & Jonsson, 2005). Experience is variable and contextual; repeated instances of the
same activity may have different meanings for an individual (Reed, Hocking, & Smythe, 2010).
39

Likewise, two people could undertake the same activity, but have different motivations, levels of
difficulty, and personal meanings. Subjective experience is often covert, but there may be
outward expressions such as smiling, frowning, or laughing (Reed et al., 2010). This aspect of
participation may be the least explored in research, although its importance is widely
acknowledged (F. A. Clark et al., 1991; Doble & Caron Santha, 2008; Reed et al., 2011).
Interpersonal connection. Interpersonal connection refers to the process of connection
with others and how such connections relate to activities and actions. Even for activities
performed in the absence of others, scholars argue that participation is always social because
activities are culturally defined and are associated with social roles (Levasseur, Richard, Gauvin,
& Raymond, 2010; Piskur et al., 2014). The salience of the social aspect of a given activity is
variable. Levasseur et al. (2010) proposed a taxonomy of social involvement in activities along a
continuum beginning with “doing an activity in preparation for connecting with others” and
ending with “contributing to society.” A sense of belonging in a social context has been
identified as a significant contributor to the experience of participation (Erikson, Park, & Tham,
2010; Hammell, 2014).
Contexts of Relevance to Rehabilitation
In the literature, participation is typically used to connote community involvement
(Baum, 2011; Hammel et al., 2008; Law, 2002; Magasi, Hammel, Heinemann, Whiteneck, &
Bogner, 2009; Piskur et al., 2014), but in fact is sometimes employed to refer to what a patient
does within the treatment context (Kjellberg, Kahlin, Haglund, & Taylor, 2012; Kortte et al.,
2007; Lenze et al., 2004; Rettke, Geschwindner, & van den Heuvel, 2015; Skidmore et al.,
2010). We characterize the former as community-based participation and the latter as
interventional participation. The settings of studies imply which meaning is intended, but such a
40

dichotomy has not previously been explicit in the literature we reviewed. This partition between
contexts is important for rehabilitation because, although rehabilitation clinicians are concerned
with both how patients participate in treatment and in the outside world, they only directly
influence the interventional milieu. The chief characteristics of community-based and
interventional participation and their relationship to the three essential dimensions of
participation are described below and summarized in Table 3.1 below.
Community-based participation. Community-based participation is an action or set of
actions in which a patient engages within naturalistic life settings outside of a treatment
encounter. It is determined by an individual’s unique configuration of roles, personal goals, and
life circumstances. Typically, there is no built-in time constraint. Examples of community-based
participation include attending school, hosting a social engagement, and creating art.
Community-based participation can be described in terms of the three dimensions of
participation described above. People perform activities to support their positions in society and
personal projects or goals (Hammel et al., 2008; Little, 1983), which entails overt action. Goals
and life roles are foundational to living an engaged, purposeful life (Law, 2002; Wilcock, 1993).
Experience and meaning are central to community-based participation, as perceived participation
in activities of one’s choice is more important to life satisfaction than the quantity of activities or
performance of a predetermined set of activities (Dalemans, de Witte, Wade, & van den Heuvel,
2010; Hemmingsson & Jonsson, 2005). Finding meaning in activities is associated with overall
well-being (Eakman, Carlson, & Clark, 2010; Fry, 2000). Regarding interpersonal connection,
social inclusion and access to social support have been identified as important components of
community-based participation (Hammel et al., 2008; Hammell, 2014; Lund, Nordlund, Nygard,
Lexell, & Bemspang, 2005). For example, in a study of people with aphasia, Dalemans et al.
41

Table 3.1: Characteristics of Interventional and Community-based Participation and their Facilitative Relationship
Interventional participation Facilitative relationship Community-based participation
Performance
Performance of activities of therapy/treatment
session
 Rehabilitation entails limited set of activities
that vary by discipline (Beaulieu et al., 2015;
DeJong et al., 2009; Ozelie et al., 2009)
 There is an expectation that patients perform
treatment activities during treatment sessions
(Kortte et al., 2007; Lenze et al., 2004)
Activities of treatment sessions relate to life
roles and projects/goals
 Rehabilitation serves as bridge between
medical and social worlds (Baum, 2011)
 Occupation as part of treatment can (re)create
real life after onset of disability (F. A. Clark,
1993)

Performance of life roles and projects/goals
 Involvement in activities of everyday living
is vital for human life (Law, 2002; Wilcock,
1993)
 Participation is a responsibility to self,
family, society (Hammel et al., 2008)
 Personal projects characterize role-related,
personally chosen goals (Little, 1983)
Subjective Experience
Patient perception of intervention process
 Patient perspective is essential to develop
treatment goals relevant to life goals (Brown,
2010; Crepeau, 2016; Doig et al., 2009)
 Perceived self-efficacy for coping is
important to recovery process (Bosmans et
al., 2015)
 Provider communication style mediates
patient subjective experience (Ridgway et
al., 2016; Zachariae et al., 2003)
Patient experience of intervention relates to
outcomes
 Positive patient experience correlates with
clinical safety and outcomes (Doyle et al.,
2013)
 Patient-centered communication is associated
with patient satisfaction and improved health
(Charlton et al., 2008)

Patient perception of community life
 Important for patient to define life goals on
own terms (Dalemans et al., 2010; Hammel
et al., 2008; Law, 2002)
 Subjective experience of meaning and
autonomy are critical to participation
(Hemmingsson & Jonsson, 2005)
 Personal meaning in activities is associated
with well-being (Eakman et al., 2010; Fry,
2000)
Interpersonal Connection
Rapport and communication between patient
and provider
 Engagement is a co-constructed process
between provider and patient (Bright et al.,
2015)
 Power differential exists between provider
and patient and can influence communication
and care process (Schoeb & Burge, 2012)
 Communication challenges due to illness or
language differences can occur and may
require involvement of others (Berg et al.,
2016; Fiscella et al., 2002; Schyve, 2007)
Therapeutic rapport facilitates treatment
planning that reflects patients’ social context
and aligns with community-based participation
goals
 Appropriate provider-patient communication
and information are associated with better
quality of life (Vogel et al., 2009)
 Elements of purposeful therapeutic
communication can be linked to both
interventional and community-based
participation goals (de Haes & Bensing,
2009; Street et al., 2009)

Social connectedness within communities
relevant to the patient
 Societal inclusion and community
membership are central to participation
(Erikson et al., 2010; Hammel et al., 2008;
Hammell, 2014; Lund et al., 2005)
 All activities fall on continuum of social
involvement with others (Levasseur et al.,
2010)
 Participation refers to performance of
socially and culturally defined roles (Piskur
et al., 2014)

42

(2010) found that feelings of inclusion and engagement were more important to participants than
simply being present in social settings. As mentioned above, even activities that are not overtly
social are based on socially and culturally defined roles (Levasseur et al., 2010; Piskur et al.,
2014).
Interventional participation. Interventional participation is an action or set of actions in
which a patient engages in the immediate context of a treatment setting, which potentially
includes a community setting. It is bounded by the duration of treatment and the scope of
practice of the provider with whom the patient is working. An example of interventional
participation occurs when a patient who is recovering from a stroke works toward dressing
independently with an occupational therapist during a treatment session in a clinic or in the
client’s home.
As in the community-based context, interventional participation also reflects the three
essential dimensions. First, with respect to performance, a patient engages in overt treatment
activities such as therapeutic exercise, activities of daily living, or swallowing (Beaulieu et al.,
2015; DeJong et al., 2009; Kortte et al., 2007; Lenze et al., 2004; Ozelie et al., 2009). Second,
myriad factors affect the subjective experience including perceived self-efficacy (Bosmans,
Hofland, De Jong, & Van Loey, 2015; Marszalek, Price, Harvey, Driban, & Wang, 2016),
emotions (Turner-Cobb, Michalaki, & Osborn, 2015), and feelings surrounding the therapeutic
relationship (Bright et al., 2015; Crepeau, 2016; Doig, Fleming, Cornwell, & Kuipers, 2009).
Third, interventional participation requires a connection between provider and patient (Bright et
al., 2015). For example, the provider-patient relationship is marked by a power differential and
therefore clinicians’ communication approaches have a significant impact (Schoeb & Burge,
2012). Patients’ subjective experiences are mediated by providers’ communication styles and
43

strategies (Ridgway et al., 2016; Zachariae et al., 2003). Communication challenges, such as
aphasia or language differences between a patient and provider, impair effective communication
(Fiscella, Franks, Doescher, & Saver, 2002; Schyve, 2007) and may necessitate inclusion of
family members and/or caregivers in treatment (Berg, Rise, Balandin, Armstrong, & Askim,
2016).
We recognize that characterizing engagement in a treatment setting as a unique domain
of participation has not been explicit in previous literature. Identifying interventional
participation as a separate domain does not in any way detract from community-based
participation. Rather, it is a limited area of participation that is of great importance in the
rehabilitation process. As demonstrated in the table, the community-based and interventional
domains share similar underlying principles. Furthermore, parsing participation into these two
contexts helps to highlight the links between them.
Facilitative relationship between interventional and community-based participation.
The purpose of interventional participation is to enable community-based participation and
relationships between the two contexts exist along each of the three dimensions described above.
Within performance, interventional participation may include doing preparatory activities or
replicating community-based activities within the treatment (Baum, 2011; F. A. Clark, 1993). As
for subjective experience, patients’ positive thoughts and feelings about intervention have been
linked to improved health outcomes (Doyle, Lennox, & Bell, 2013). Moreover, patients report
greater satisfaction with treatment when providers use a patient-centered approach to
communication (Charlton, Dearing, Berry, & Johnson, 2008). Interpersonal connection during
intervention, operationalized as effective communication and provision of information, is
associated with better quality of life for patients after discharge (Vogel, Leonhart, & Helmes,
44

2009). This facilitative relationship between interventional and community-based participation is
mediated through changes that occur internally to the patient as a result of the intervention as
well as by external factors that act as barriers or facilitators to community-based participation.
Although rehabilitation interventions may take place in community settings, according to our
definition treatment sessions would still be classified as interventional rather than community-
based participation. However, such interventions may be particularly conducive to optimizing a
patient’s participation in the community (F. A. Clark, 1993).
Antecedents to Participation: Opportunity and Choice
The concepts of opportunity and choice are distinct from participation but are significant
in determining the activities in which people are able to take part. They materialize differently in
community-based and interventional contexts. Opportunity refers to the set of circumstances that
makes it possible to do something. Choice is the act of making a decision from among two or
more possibilities.
Opportunity and choice in the community. Participation in the community requires the
opportunity to do something in the context of a specific configuration of internal and external
factors and the subsequent decision to do it (Mallinson & Hammel, 2010). Therefore, reliance on
objective performance alone results in an incomplete understanding of community-based
participation. Rather, it must be considered in light of available opportunities from which a
person can choose (Baumgartner & Burns, 2013; Hendricks & Hatch, 2011; Nordenfelt, 2006),
including both physical and social access (Hammel et al., 2008). Choices from among available
opportunities are based on a wide variety of factors (Galvaan, 2012; Hammell, 2004) such as life
roles and objectives (Magasi et al., 2009), perceived self-efficacy (Bandura, 1977), and cognitive
function (Erez, Rothschild, Katz, Tuchner, & Hartman-Maeir, 2009).
45

Opportunity and choice in interventional participation. Opportunity and choice are
also significant factors within interventional participation. However, they arise from different
sources than they do in the community. Social, cultural, and institutional structures create a
situation in which, traditionally, providers and third party payers have much greater control over
the treatment domain than does the patient (Carman et al., 2013; Faber, Grande, Wollersheim,
Hermens, & Elwyn, 2014; Joseph-Williams, Edwards, & Elwyn, 2014). Because of this power
imbalance, providers and institutions are largely responsible for creating opportunities for patient
participation. Opportunity creation incorporates providers’ expectations of patient involvement
(Schoeb & Burge, 2012) as well as recognition of patients’ knowledge and perspective (Eldh,
Ekman, & Ehnfors, 2006). Provider knowledge of what Brown referred to as the “insider”
perspective (Brown, 2010), or the patient’s point of view, enables better collaboration on
decisions about the care process, which is valued by rehabilitation providers (Kjellberg et al.,
2012).
Given adequate conditions, patients can make choices in all aspects of intervention,
including setting goals, selecting treatment activities, and electing courses of treatment
(Kjellberg et al., 2012; Schoeb & Burge, 2012). When opportunities for shared-decision making
exist, a patient’s ability to choose may be influenced by his or her beliefs about the proper role of
patients (Frosch, May, Rendle, Tietbohl, & Elwyn, 2012), knowledge of the options and possible
outcomes (Eldh et al., 2006), or level of cognitive functioning (Skidmore et al., 2010). Choice
also includes delegation to a provider, family member, or other surrogate for important decisions
(Roberts, 2002; A. G. H. Thompson, 2007). Ethical concerns can arise when there is a difference
between provider advice and patient decisions, an area that requires further research to better
46

understand how providers can effectively respond to such situations (E. Hicks, Sims-Gould,
Byrne, Khan, & Stolee, 2012; Muhlbacher & Juhnke, 2013).
Conceptual Framework
Figure 3.1 below presents an integrative synthesis of the key components identified in the
literature review. Within the figure, we identify the relationships between interventional and
community-based participation and factors that shape them in the context of rehabilitation.
Figure 3.1: Conceptual Framework of Participation

Disabling event/condition. Because rehabilitation is a process of restoring health after
injury or illness, a disabling event or condition must precipitate the rehabilitation process.
Common disabling events and conditions for which people receive rehabilitation services include
47

brain injury, spinal cord injury, stroke, neurodegenerative diseases, cancer, and orthopedic
injuries (American Academy of Physical Medicine and Rehabilitation, 2016).
Internal/external barriers and facilitators. There are numerous factors, both internal
and external to the patient, which can act as either barriers or facilitators to interventional or
community-based participation. Internal factors are qualities or conditions that occur within the
patient. Prominent internal factors include self-efficacy, motivation, subjective well-being, pain,
fatigue, and ability to communicate (G. King et al., 2003; Magasi et al., 2009; Sherer et al.,
2014). External factors occur in the environment outside of the individual and include the built
environment, access to information technology, social systems and policies, economic resources,
and societal attitudes (Hammel et al., 2015; Jellema et al., 2016; Magasi et al., 2009; Rimmer,
Riley, Wang, Rauworth, & Jurkowski, 2004; Verdonschot, de Witte, Reichrath, Buntinx, &
Curfs, 2009). Family situation, geographic location, and even weather are external factors.
Different people may have different experiences of the same factors, such as the physical
environment (Van'T Leven & Jonsson, 2002). Moreover, a single factor could act as both a
facilitator and a barrier in different circumstances.
Feedback loops in the model. As noted above, a disabling event or condition precedes
interventional participation. The severity of impairment generally determines treatment goals, the
length of time a person is engaged in rehabilitation, whether treatment occurs in an inpatient or
outpatient setting, and what kinds of services are required. The event or condition also causes
changes that are internal or external to the person, which can subsequently result in the
emergence of new or changed internal or external barriers and facilitators.
Internal and external factors combine to create the opportunities that are available for
participation in an individual’s life context in both community-based and interventional domains.
48

Some external factors are specific to the circumscribed context of healthcare delivery and are
relevant for interventional participation but not for community-based participation. For instance,
access to healthcare services is a prerequisite for interventional participation (Buntin, 2007).
Furthermore, institutional environments and payer systems can support or hinder patient choice
through mechanisms such as accessibility of information, reimbursement schemes, and adequacy
of staffing (Bernabeo & Holmboe, 2013; Joseph-Williams, Elwyn, & Edwards, 2014). Such
external factors also affect providers’ perceptions of how much they attention they can give to
community-based participation goals as compared to injury or illness remediation, thereby
limiting the choices they offer to their patients (Magasi et al., 2009). Internal factors may be
similar across both interventional and community-based contexts, such as a patient’s cognitive
level, whereas others like perceived self-efficacy may vary based on the situation.
On the other hand, interventional participation can alter internal and external factors. For
example, a person’s physical deficits may be remediated which then increases the accessibility of
the built environment. Internal and external factors can also be modified by the choices one
makes about community-based participation. For instance, participation in an education program
can result in a new degree or credential, which then enables access to different employment
opportunities. Community-based participation determines life outcomes.
The relationship between interventional and community-based participation is mediated
by internal and external factors. For example, interventional participation may remediate
physical dysfunction (internal factor) which changes a person’s access to the built environment
(external factor) in his or her community. Community-based participation in an advocacy
initiative could increase self-efficacy (internal factor) and may also affect policy change
(external factor). In both of these examples, the result of the changes is positive. On the other
49

hand, these feedback loops could also have neutral or negative effects. For instance, community-
based participation in illicit activities that result in criminal charges and incarceration would
change the external barriers and facilitators to participation, yielding a greatly diminished set of
opportunities from which to choose.
Discussion
The proposed conceptual framework of participation draws from a broad, diverse sample
of existing literature and organizes the findings into a comprehensive model with hypothesized
interrelationships. Below, we discuss potential meanings of this model for how participation is
theorized in rehabilitation, implications for practice, and avenues for future research.
Participation is Neither Positive or Negative
In contrast to much prior work that tacitly endorses participation as positive, desirable, or
health-promoting (Eyssen et al., 2011; Willer et al., 1993), the proposed framework is predicated
on the idea that participation is neither inherently good nor bad. Its relationship to health and
wellness is dependent on context. Life outcomes related to participation can be positive,
negative, or neither. This aspect of the model can capture a full spectrum of possibilities and is
important because context is fundamental in gauging participation’s relationship to health. For
instance, exercising outdoors is generally accepted as a healthful activity. Yet, in areas with poor
air quality, it could cause breathing difficulty and possibly long-term illness, especially among
people with existing respiratory conditions (Bernstein et al., 2004). Furthermore, prior research
has demonstrated that some activities can simultaneously be both helpful and harmful, and such
activities also fit into the proposed framework. For example, Guptill (2013) investigated the
experiences of professional musicians who had playing-related injuries and struggled to balance
their desire to play their instrument with maintenance of health. In a study of adults with spinal
50

cord injury, Jackson and colleagues (2010) described lifestyle trade-off, a tension between full
participation in life and prevention of pressure ulcers, which represent a dangerous secondary
health problem after spinal cord injury that may require extended periods of rest. Other chronic
health conditions also create dilemmas between participation in desired social roles and self-
management of conditions (Townsend, Wyke, & Hunt, 2006). These findings highlight the
importance of considering individual cases in terms of their unique circumstances.
Implications for Clinical Care
The framework has several implications for how participation is conceptualized both
within the rehabilitation process and as an outcome of treatment. Below, we focus on
applications in (a) assessment, goal setting, and outcome measurement, (b) therapeutic
communication, (c) systemic and structural issues in healthcare settings, and (d) patient-specific
internal and external conditions. We recognize that some of these recommendations may be
difficult to implement with certain groups of rehabilitation patients, such as those with severe
cognitive impairment or disorders of consciousness.
Providers should attend to all areas of the model during assessment and connect
interventional participation with community-based goals. Although providers are not directly
involved in community-based participation with their patients, they have a vested interest in
learning patients’ perspectives and understanding how interventions are relevant to their lives
(Brown, 2010). In this vein, consistent use of clinical tools that align intervention and
community-based goals could facilitate patient-centered care and health-promoting participation.
A simple checklist could be developed to ensure that each area within the conceptual framework
is addressed. A few extra minutes spent during assessment to better understand the patient’s full
life context may result in more efficient treatment planning and delivery. Goal attainment scaling
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(Turner-Stokes, 2009) and the Canadian Occupational Performance Measure (Law et al., 1990)
are examples of approaches that attempt to match treatment goals with real-life needs. A
challenge with emphasizing community-based participation in practice is that payers tend to
prioritize productive work over other areas of participation for persons with disabilities (Magasi
et al., 2009). Providers have also reported that patients adjusting to a new disability are more
focused on functional recovery and may not be prepared to address community-based
participation (Magasi et al., 2009). In these kinds of cases, it may be necessary to first focus on
remediation of disability until patients are ready to consider community goals. Thus, clinical
judgment and flexibility are necessary even for providers who are committed to addressing
community-based goals.
Providers must actively focus on patient participation in the intervention process
and how they help or hinder engagement. Over the last 50 years, there has been a shift in the
roles of both patients and healthcare providers towards greater collaboration. In the current era,
healthcare is envisioned as a shared endeavor between a provider and patient in which treatment
is responsive to patients’ individual goals and life situations (Hoving, Visser, Mullen, & van den
Borne, 2010). In accordance with this change, rehabilitation providers reportedly value patient
participation in treatment encounters (Kjellberg et al., 2012; Lenze et al., 2004). This kind of
participation is sometimes called patient engagement or patient activation, which is defined as
“actions individuals must take to obtain the greatest benefit from the healthcare services
available to them” (Center for Advancing Health, 2010, p. 2).
Consistent with a review by Bright et al. (2015), the proposed framework redistributes
some of the responsibility for patient participation to the provider, who must create opportunities
for patient choice within an intervention. This conceptualization of shared responsibility for
52

interventional participation could reframe how patient participation is evaluated by assessing, in
addition to what the patient actually does, the degree of opportunity and choice available.
Additionally, there is evidence that activation or engagement can be enhanced by provider
behaviors such as collaborating on goals (Allen et al., 2015) and facilitating patients’ confidence
in their knowledge (Rieckmann et al., 2015). Several authors have suggested strategies for
enhanced therapeutic communication (Jesus & Silva, 2016) and alignment of communication
strategies with interventional and community-based goals (de Haes & Bensing, 2009; Street,
Makoul, Arora, & Epstein, 2009). Further, there is evidence that provider reinforcement of
autonomy supports positive patient experiences of rehabilitation (Cardol, De Jong, & Ward,
2002; Chan, Lonsdale, Ho, Yung, & Chan, 2009; Wain, Kneebone, & Billings, 2008). Therefore,
a greater awareness of the provider’s role in creating opportunities for patient interventional
participation and use of the related communication strategies has the potential to optimize patient
engagement.
Providers should be explicit about how patient involvement is valued and identify
local barriers and supports to shared decision-making. Cultural and systemic structures,
however, have not necessarily evolved as quickly as patient and provider roles and may present
barriers to clinicians’ abilities to support patient choice (Bernabeo & Holmboe, 2013). For
instance, even though most providers support the idea of sharing decision-making responsibility
with their patients, they also report barriers such as insufficient time for answering questions,
discomfort with the possibility of conflict, and a belief that sharing responsibility may not be
appropriate for all patients (Zeuner, Frosch, Kuzemchak, & Politi, 2015). On the other hand,
many care recipients hold beliefs about what it means to be a “good patient” based on previous
experiences and therefore avoid questioning the provider’s authority (Frosch et al., 2012).
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Presentation of available options can also be influenced by institutional concerns and provider
beliefs about what is realistic for a particular patient (E. Hicks et al., 2012). Bernabeo and
Holmboe (2013) suggest several strategies, such as employment of shared decision-making tools,
to support structural and cultural changes that will encourage greater interventional participation
for patients. On an individual basis, providers can be clear in their communications with patients
about expectations and preferences for involvement. Identification by providers of local barriers
and facilitators to patient interventional participation is a starting point for finding resources for
support or advocating for change within the healthcare organization.
Providers should bear in mind patient-specific internal and external factors when
considering community-based participation. Assessment and treatment of internal patient
factors is a primary focus of rehabilitation. Consequently, they are generally accounted for in
intervention planning and delivery. There are, however, a vast number of external factors that
determine community-based participation and that are outside the scope of practice of clinicians
and are unlikely to be directly influenced through rehabilitation (Magasi et al., 2009). Hammel
and colleagues (2015) identified the built environment, transportation, social attitudes, public
policy, and socioeconomic factors among the environmental barriers and supports to
participation in daily life for people with disabilities. Although they generally do not create new
community-based opportunities or services that could enhance participation, rehabilitation
interventions can connect individuals with community-based resources.
Implications for Future Research
The proposed framework leads to several suggestions for future research. First, research
on therapeutic processes and outcomes should seek to identify strategies to promote desired
outcomes along each of the three essential dimensions (i.e., performance, subjective experience,
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interpersonal connection) for both interventional and community-based participation. As
described in this framework, interventional participation is not limited to a patient’s performance
of rehabilitation activities as expected or instructed. If clinicians share responsibility with
patients for creating opportunities for interventional choice, it is necessary to consider the full
intervention context and clinicians’ actions as well. Previous research has assessed the kinds of
activities that are performed in therapy sessions (Beaulieu et al., 2015; DeJong et al., 2009;
Ozelie et al., 2009), patient experience or satisfaction with treatment (Manary, Boulding, Staelin,
& Glickman, 2013), and the provider-patient relationship (Mazzi et al., 2013; Palmadottir, 2006),
although the number of studies in each category varies widely across rehabilitation professions
and diagnostic groups. Future research could incorporate all three dimensions to better
understand how they relate to one another. Furthermore, clear differentiation between
interventional and community-based participation in research is necessary, as well as exploration
of the relationship between them.
Second, research on how to best facilitate patient opportunity and choice in healthcare
settings is necessary. In this regard, Bernabeo and Holmboe (2013) suggest patient, provider, and
institutional competencies to support shared decision-making. Future research in this area could
focus on which methods are most effective at each level, such as patient education, clinician
training, care delivery models, and reimbursement schemes.
Third, research is needed on how neutral or potentially harmful activities influence the
rehabilitation process and how providers can best respond. There is a conspicuous gap in
research on patients’ participation in activities that are neutral or potentially harmful and
especially how they relate to provider-patient interventional interactions. Patient motivation to
engage in dangerous or illicit activities may stem from economic factors (Ehrlich, 1973), limited
55

community-based opportunities (Saegert & Winkel, 2004), or thrill-seeking (Brymer &
Schweitzer, 2013; Partington, Partington, & Olivier, 2009), among other possibilities, and any
expressed desire to participate in these kinds of activities could present ethical dilemmas for
rehabilitation providers. It is likely that oftentimes patients avoid disclosing dangerous or illicit
activities to healthcare providers because they perceive sharing to be unacceptable or irrelevant
in a treatment context (Pyatak et al., 2013). Scenarios such as the earlier example of professional
musicians who incurred playing-related injuries but wanted to continue playing their instruments
(Guptill, 2013) could also be difficult for a provider to navigate. A provider may judge an
activity to be hazardous to a patient’s health, yet may also want to support the patient’s
autonomy and engagement in meaningful activities. Most research about practice-related ethical
issues has focused on problems for providers emerging from role balance, institutional
constraints, and policies (Austin, Rankel, Kagan, Bergum, & Lemermeyer, 2005; Hartley &
Cartwright, 2016; Houston et al., 2013). Although such studies are important, they do not
address situations in which the provider faces an ethical challenge because of a patient request or
need. This topic warrants further investigation.
Limitations
This interpretive synthesis does not represent an exhaustive search of all literature related
to participation across all disciplines relevant to rehabilitation. Further, our conceptual
framework is not intended to oversimplify a complex construct or problem. Rather, we suggest a
novel approach to considering the meaning of participation in rehabilitation, which, we hope,
will encourage patient-centered research and care, and ultimately better health outcomes. Neither
do we offer a comprehensive review of all internal and external factors that could impede or
facilitate interventional or community-based participation. In the methodological approach we
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chose, interpretive synthesis, the included literature is intermingled with the voices of the review
authors and is therefore not intended to be strictly replicable (Dixon-Woods, Bonas, et al., 2006;
Heaton et al., 2012).
There are other useful ways to organize the literature. For example, participation could be
arranged by the types of activities in which people engage (e.g., social, work/productivity) as
Chang and Coster (2014) suggested in their model. Our framework complements their work and
other classifications by elucidating the underlying construct and dimensions of participation that
will be of practical utility for all rehabilitation providers. The proposed classification therefore
aligns with our intent to synthesize the literature in a way that is consistent with existing
literature as well as useful and applicable to rehabilitation practice.
Conclusion
Without consistent definition and operationalization, employing participation as an
important outcome of rehabilitation will continue to limit measurement approaches and tools,
hinder synthesis of research results, and produce confusing patient outcomes. The proposed
conceptual framework of participation unifies the key ideas from the vast and eclectic body of
literature as it relates to rehabilitation. In the current era of healthcare reform, in which patient
satisfaction is valued alongside traditional functional outcomes, this comprehensive framework
may serve as a tool for both clinicians and researchers to enrich patient care in a way that
improves satisfaction and quality of life outcomes. By embedding opportunity and choice within
both interventional and community-based contexts, future clinical work and research based on
this framework may help to explicate how these elements interact with participation in both
clinical and community contexts. A common understanding and application of participation will
strengthen outcome reporting in both research and clinical practice.
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Implications for Rehab:
 The often tacit assumption that increasing participation is a desirable outcome needs to be
challenged and considered in each patient’s life situation.
 Treatment settings constitute a unique context in which patients participate.
 Intervention goals should be clearly connected with patients’ personal goals for
community-based participation.

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Chapter 4: “I don’t do anything anymore”: Occupational changes and challenges
following mild traumatic brain injury in active duty military service members
(Co-authored with Christine E. Haines, Maria D. Devore, Karla Lepore, and Margaret Ryan;
under review at the American Journal of Occupational Therapy)

Abstract
Objective: Approximately 15-20% of military service members with a diagnosed mild traumatic
brain injury (mTBI) experience chronic physical, emotional, and cognitive symptoms that
interfere with daily life. The purpose of this study is to identify their needs that fall within the
scope of occupational therapy practice.
Methods: In this qualitative descriptive study, service members with a history of mTBI (N=12)
participated in semi-structured interviews about their injury history, symptoms, daily routines,
challenges, and plans for the future.
Results: Needs were identified across all domains described in the Occupational Therapy
Practice Framework, with sleep disruption being the most pervasive problem. Military culture
was significantly intertwined with the process of seeking medical care. Plans for the future were
often nebulous and not well defined.
Conclusions: Occupational therapists who work with service members or veterans with histories
of mTBI events should consider all areas of occupation, especially sleep, in the context of
military culture during assessment and treatment planning.
Keywords (MeSH): Mild Traumatic Brain Injury; Occupational Therapy; Military Personnel;
Community Integration; Return to Work
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Mild traumatic brain injuries (mTBI), or concussions, account for more than 80% of the
nearly 350,000 brain injuries reported among active duty military service members from 2000
through the first quarter of 2016 (DVBIC, 2016b). The Department of Defense (DoD)
characterizes mTBI as an injury that results in loss of consciousness for less than 30 minutes or
alteration of consciousness, less than 24 hours of post-traumatic amnesia, or Glasgow Coma
Scale score of 13-15 in the first 24 hours after injury (Department of Veterans Affairs & DoD,
2009). Most people who experience mTBI, whether in a civilian or military population, can
expect a complete recovery within three months, if not much sooner (Carroll et al., 2014; Carroll
et al., 2004). However, persistent cognitive, emotional, and physical impairment occurs in
approximately 15-20% of people who experience mTBI (Carroll et al., 2014; Williams et al.,
2010).
Within the military, a screening tool has been in place since 2008 to identify acute mTBI
in the combat environment (French, McCrea, & Baggett, 2008; Iverson, 2010) and guidelines to
facilitate return to duty after injury as symptoms resolve were released in 2014 (McCulloch et
al., 2015). These procedures are designed to promote timely diagnosis and treatment in the
immediate aftermath of an injury event. Nonetheless, many military service members were
injured during the wars in Afghanistan and Iraq, as well as in training exercises and more typical
accidents (e.g., motor vehicle accidents), prior to the installation of these protocols (Iverson,
Langlois, McCrea, & Kelly, 2009) and may not have sought immediate care. Diagnosis of
mTBI, in fact, may not occur for months or even years after the injury event and the usefulness
of such a retrospective diagnosis has yet to be established (Davenport, 2016). Moreover, among
military personnel, mTBI is frequently coupled with psychological trauma. In the moments after
the injury event, personnel often must focus on avoiding further danger, responding to
60

commands, or directing others rather than seeking assistance for their own symptoms. The
conditions of this high-stress environment may also contribute to the later appearance of
symptoms, and delayed seeking of diagnosis and treatment (Davenport, 2016; Rigg & Mooney,
2011).
Although there is a body of research describing the symptoms that service members with
mTBI report, connection between symptoms and disruption in daily life has not been established,
particularly among the active duty population. Much of the recent occupational therapy research
with veterans of the Afghanistan and Iraq wars has been with those who were already separated
from active service (Eakman, Schelly, & Henry, 2016; Plach & Sells, 2013; Tomar & Stoffel,
2014) or focused on mental health diagnoses (Rogers, Mallinson, & Peppers, 2014). Only rarely
have such studies included only a combat veteran population with mTBI (Classen et al., 2011).
Classen and colleagues have tested driving interventions for combat veterans with polytrauma
including mTBI (Classen, Cormack, et al., 2014; Classen, Monahan, Canonizado, & Winter,
2014). There remains a need to investigate how chronic symptoms of mTBI affect daily living,
particularly among active duty service members, and potential areas for occupational therapy
intervention.
The purpose of this study is to identify the needs of military service members who have a
history of mTBI and chronic symptoms that fall within the scope of occupational therapy
intervention.
Methods
We conducted a qualitative study designed as a needs assessment to identify the
occupational challenges of active duty service members. The study took place at Naval Hospital
Camp Pendleton in Oceanside, California. This study was approved by the institutional review
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boards of Naval Medical Center San Diego and the University of Southern California. The
design was primarily descriptive in nature with an influence of phenomenology (Merriam &
Tisdell, 2016; Sandelowski, 2000), as we sought to learn about the essence of living with chronic
mTBI symptoms while still serving in the military.
Participants were recruited from a concussion care clinic. To be eligible, service members
had to have a history of mTBI and have been referred for occupational therapy services for
chronic symptoms. Service members who were concurrently receiving treatment for substance
abuse or who had a diagnosis of a DSM-V personality disorder were ineligible. Study fliers were
posted in the clinic and providers connected interested service members with the research team.
No member of the research team was involved in the clinical care of participants. We aimed for
maximum variation sampling and successfully recruited participants with a wide range of ages,
years of military service, and brain injury history. All participants completed an informed
consent process prior to being interviewed.
The first author (AMC) conducted a semi-structured interview with each study
participant. Interviews were conducted in a private office located in the Naval hospital during
regular business hours at times convenient to the participants and lasted an average of 67 minutes
(range: 41-87 minutes). Brain injury history was confirmed using the Ohio State University TBI
Identification (OSU-TBI-ID) structured interview (Bogner & Corrigan, 2009), which was
embedded into the semi-structured interview guide. Interviews were audio recorded and
transcribed verbatim. The interviewer also recorded field notes after each interview, as well as
personal reflections. These notes were used to provide context during the data analysis process
and identify researcher biases.
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As the study purpose was to identify needs that could be served by occupational therapy,
data analysis emphasized the content of the interview responses. The first author read through all
of the transcripts, recorded memos of reflections and possible themes, then began an iterative
coding process of the transcripts using NVivo software (QSR International, Inc.). Thematic
saturation was achieved after the ninth interview. We proceeded with the last three interviews for
confirmation. All co-authors reviewed and confirmed the themes. Names used below are
pseudonyms.
Results
Participants
Twelve male service members participated in the study. Demographic data are
summarized in Table 4.1. All participants were enlisted personnel on active duty status and 10
had plans to separate from military service at the time the interviews were conducted. Eleven
participants were Marines and one was a Navy medical corpsman. All Marines were high school
graduates, two had completed some college courses, and the Navy corpsman had a bachelor’s
degree. All service members reported several chronic symptoms, including memory loss,
headaches, and disrupted sleep. Ten out of the 12 reported a concurrent mental health diagnosis,
including PTSD, major depressive disorder, and generalized anxiety. One service member
reported previous treatment for substance abuse but was not being treated at the time of his study
participation. Ten participants also reported a history of orthopedic injuries and chronic pain. All
had at least one brain injury event. Of the 11 with a combat-related mTBI, all had at least one
blast-related injury and seven reported periods of frequent exposure to low-level blasts during
their military careers.

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Table 4.1: Participant Demographics
Service Members (n=12) Average (range)
Age 35.2 (22 – 49)
Years of Service 13.7 (3 – 28)
Number of combat deployments 2.4 (1 – 5)
Number of recalled lifetime head injuries 3.8 (1 – 10)
Time from last head injury (months,
approximate)
63 (12 – 132)
Marital Status Married: n=9
Unmarried: n=2
Separated: n=1
Children living at home 1.16 (0 – 2)
Ethnicity African American: n=2
Caucasian: n=6
Hispanic/Latino: n=3
Asian American: n=1
Military Operational Specialty Infantry: n=3
Logistics: n=3
Mechanic: n=3
Engineer: n=1
Reconnaissance: n=1
Corpsman: n=1
Duty Status Full Duty (still in prior work role): n=2
Limited Duty (assigned to prior unit but with reduced
responsibilities): n=4
Wounded Warrior Battalion (non-deploying unit with focus
on injury recovery): n=6

Due to the semi-structured nature of the interviews, multiple themes were identified that
went beyond the study purpose of identifying occupational needs. The four main themes were
occupational changes, plans for the future, interaction of military culture and healthcare, and
wanting others to understand.
Occupational Changes
Because of the descriptive nature of this analysis and the study purpose, the Occupational
Therapy Practice Framework (OTPF; AOTA, 2014) domains were used to organize data about
occupations. Service members reported challenges in all areas. Table 4.2 presents examples of
data to support each area of occupation.
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Activities of daily living (ADL)/Instrumental activities of daily living (IADL): When
asked how he spent his time, Drew replied, “I don’t do anything anymore.” Service members
reported difficulty with maintenance of basic household tasks and relying on spouses, children,
and assistive devices (e.g., smart phone, iPad) to help them manage basic and instrumental
activities of daily living. Eleven participants reported using a calendar, notebook, or other device
for reminders of tasks they needed to do or places they needed to be. For example, Maurice
described arriving at a grocery store and not remembering what he had intended to purchase.
Social participation: All participants described purposefully limiting their social
engagement in the community. Nearly all preferred to avoid crowds and events that would be
noisy, like fireworks. One exception, Drew, described his preferred weekend activities as
attending concerts in the area. In some cases, social isolation extended into family life, in which
they described a conflict between the desire to engage with their spouse and children and also
wanting to be alone. In one case, Ryan reported that his participation in family life had improved
because of his injury, as he had more free time to spend with his wife and children.
Education: Although several service members stated that they were interested in
attaining a degree after they left military service, only two of the 12 participants reported current
enrollment in college courses. Both currently enrolled participants, Jake and Rhett, reported
struggles with concentration and retention of material they had read, as well as increased
difficulty compared to school experiences prior to their head injuries.
Play/leisure: All participants described a loss of interest in previously enjoyable leisure
activities. In some cases, they had stopped doing activities entirely. Maurice reported that he was
unable to watch certain types of movies or television shows because they triggered his anxiety.

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Table 4.2: Occupational Changes
Theme Example Quote
ADL/IADL I can’t do the finances anymore at home. Um, my wife has to handle all that. Um, there’s a
lot that goes into it. Scheduling, stuff like that, everything has, has to be broken down almost,
almost on a daily basis to where it’s, it’s actually at a, at a child’s level scheduling. You
know, to where it’s actually put into a calendar every single day, what I’m doing and, it’s like
my homework every night, this is what you’re doing tomorrow, this is where you’ve got to
go. And still sometimes, that doesn’t even go right, you know. (Jason)
Social
Participation
So I sought help at the new command and you know, and then it started with my upper torso,
I think after the second deployment, was when I really knew I needed to get help because, my
wife was concerned that I was losing my temper with the kids over things that just didn’t
matter. And they were young then, so um, and I didn’t like that either when I realized, you
know, I was losing my temper, just clicking off safe, just, I didn’t want to do that to them. So
I sought help again after coming back from the second deployment. (Rhett)
And people kind of, they start giving you a bit of a wide berth. Which is fine by you because
you don’t want to socialize with them, you don’t want to go anywhere. Unless it’s the people
that you were there with, you don’t want to be around anybody. (Armand)
Education The problem is getting through it. Like as far as the actual reading part of it. So I’ll read a
sentence then I’ll realize that my mind is like, I’m not paying attention (A: Ok). Which is
weird to say about reading (A: I understand) but yeah, so, you know, have to go back and re-
read it and re-read it until I’m paying attention so, and I do have moments where, or like time
periods where like I’m really good at it, and you know I get through the stuff at a, at a pretty
decent pace, but then, all the sudden something will click again, and I’ll just be back to, god
dang it, it takes time, it’s an effort. (Jake)
Play/Leisure I used to go camping a lot, um, I used to go fishing a lot, go to the beach a lot. Now I just
stay around, like I go out, uh, I used to drink a lot, but that wasn’t, like I said, it wasn’t
kicking it for me. (Drew)
Um, certain movies I can’t watch anymore or certain songs I can’t hear anymore because it
just, giving me a flashback or a memory (SM 5) Um, certain movies I can’t watch anymore
or certain songs I can’t hear anymore because it just, giving me a flashback or a memory.
(Lorenzo)
Work So I pushed everything to the back of my mind, any problems I was having. I hit the ground,
wide open. And then over time, I started noticing it. I would be in the middle of sentences
and I would just completely forget what I was saying. And it would be, sometimes it would
be pretty important stuff. I was getting to where I, kind of like, nervous system problems,
tingling in my hands, I couldn’t feel stuff. As a mechanic, I had to be able to feel things and
do things. (Jeremy)
Sleep Yeah, it’s an improvement, so, uh, before I was getting this treatment, before I started
treatment I was only getting like 4 you know, hours of sleep a night. Um, I’m still jumping
up in the middle of the night, like 3, 4 times a night you know, um, that’s why my wife and I,
we do not um, you know, sleep together…She sleeps in a different room than I. And when
I’m asleep, whenever I’m asleep she’s awake to watch me in case, I’m, you know, kicking
the bed too much or something like that she can grab my foot. Now she knows, hey, you
gotta grab my foot, you know, and don’t grab anywhere up here [motions to upper body],
grab my foot and try to wake me up like that. So, if it’s too bad for me, so, she knows about
that and when I’m, when I wake up she goes to sleep. (Maurice)

Jake described that he was no longer able to play video games, which had previously been his
preferred leisure activity, because they caused migraine headaches.
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Work: Work was significantly impacted by chronic symptoms of mTBI. Several
participants were assigned to limited duty with a reduced workload or had been reassigned to an
administrative job within their unit. Others had been transferred to the Wounded Warrior
Battalion, a non-deploying unit in which their mission was to recover from their injuries. The
two that remained on full duty status reported significant support from their respective
commands that enabled them to balance their workload with attending medical appointments. In
both of these cases, they reported that their workloads had been reduced even though their duty
status had not changed. Being unable to continue in their previous work roles was a significant
source of distress for six of the participants.
Rest/sleep: Perhaps the most pervasive occupational change reported was a disruption of
sleep. All participants described an extended period (more than one year) of disrupted sleep that
had been only marginally or temporarily improved with pharmacological treatment. Most
reported difficulty with both falling and staying asleep and none reported sleeping more than
seven hours during the night, on average. In one case, a participant reported that he had slept
excessively prior to attending an intensive outpatient treatment program for PTSD, but that since
that intervention had been unable to sleep more than two to three hours a night. Gavin explained,
“Now I can’t sleep because…everything’s coming out”.
Plans for the future
Although a few participants intended to continue their military service, most had an
impending separation date. Their plans varied widely in terms of certainty and detail. Service
members identified supports, barriers, and fears about the future.
Plans: Two service members, Maurice and Jeremy, wanted to recover sufficiently to
return to their military jobs. Three others had concrete plans to complete school or seek a
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particular kind of employment, but most reported rather nebulous plans. Armand, who had been
a Navy corpsman, reported such diverse possible career trajectories as physician’s assistant,
attorney, and hospitality management. For those who had uncertain post-discharge plans, what to
do after leaving the military seemed to depend on a combination of their disability status upon
discharge and related compensation (none had received a decision at the time of the interview)
and jobs they perceived as being lucrative and attainable with their skill set and education.
Supports: Many of the supports identified were family members, particularly spouses.
Others noted transition support services and programs in which they had participated in
preparation for separation from military service. Some also reported the Veterans’ Affairs (VA)
infrastructure as a support, although this sentiment was not universal and one service member
(Drew) explicitly stated concern about the quality of VA care.
Barriers: Interestingly, several participants reported that they could not think of any
barriers that would prevent them from attaining their goals. One participant, Julio was explicit
about the loss of his identity as a significant barrier. A few mentioned the difference between
military and civilian cultures as being a challenge for them, such as behaviors the observed
among civilians that would not be acceptable in the Marine Corps. For example, Julio described
how “you hear all these people talking and they complain so much.” From his point of view, it
was not acceptable for a service member to complain about his or her work, and that he would
have to learn to not criticize individuals outside of the military for such behavior.
Fears: Fears characterized potential problems in the future that had not yet occurred, but
were of concern. They were not included with barriers because they were not perceived as a
current problem, but instead something that could happen in the future. Maurice was afraid that
he would not be able to find a job. “You know, they [other Marines] think… ‘I can get out and
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I’m going to go work this job’ and … next thing you know, a year down the road, they’re still
trying to find a job so, you know, … that could be me in the future and I don’t want that to
happen at all.” Another, Rhett, expressed that, given his current physical challenges, he was
concerned about how much worse he could get. “Especially knowing the issues I have now, well
what am I going to be, what kind of shape am I going to be in in 10 years? … From all the
service connected problems, you know? So yeah, there’s a lot of apprehension there that I have.”
Military culture interaction with health
Military culture figured significantly into how service members approached and engaged
in health care. The subthemes related to military culture include delay of care, commitment, and
service. The relationships between the subthemes are complex, with the same ideal leading to
different ends for different people.
Delay of care: Only two of the 12 participants in the study sought care immediately after
their head injury event. Drew’s command required him to get assessed after a combat injury
because he had non-combat related concussion earlier in the same year. The other, Jeremy, was
injured in an assault that occurred when he was on leave. In fact, several service members stated
that they did not know they had experienced a brain injury, even in cases in which they reported
a loss of consciousness at the time of the injury event. Generally, they described avoidance of
healthcare throughout their military careers. As Gavin explained, “…throughout my whole
career I haven’t really gone to BAS [battalion aid station], I don’t go to BAS, I guess it shows
weakness, you know, cause now it’s just like, you get labeled.” Rhett referred to this label as a
“sick bay commando,” someone who is avoiding his duties. In addition to the label, several
participants reported that they would not have been able to fulfill all of their work-related duties
and also attend regular medical appointments, and so avoided initiating any kind of medical care.
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Delay of care extended to orthopedic injuries as well. For example, Julio persevered with an
injured knee until he could no longer bear weight on it. “I wanted to deploy again so I didn’t
really say anything that my knee was bothering me, just getting back on the bird [helicopter]
with the pack of full gear just, it just gave out.”
Commitment: Commitment to one’s work role or unit was frequently a reason for not
seeking medical care, even after symptoms became apparent and were interfering with daily life.
Intertwined with this commitment was fear of losing their position. Maurice explained, “…if
there is a chance of me getting kicked out of the Marines or, you know, losing my job … I’d just
rather deal with it, you know?” Gavin stated that in the combat environment, he was
unconcerned with possible future problems and prioritized doing his job each day. “I just kind of
took it and yeah, kept going.” On the other hand, commitment was also expressed as a reason for
seeking care. If a Marine is aware of injury or illness that prevents him from fulfilling his work
duties in an optimal way, the unit as a whole is not as strong as it can be. Gavin recalled his
thoughts upon being diagnosed with PTSD. “Yeah, it’s like, knowing that hey, I’m sick, you
know, I’m not right in the head, and then I deploy and take a platoon is just, … that’s not really
right, not for me but for the Marines, you know?” Another aspect of commitment was feeling
that one’s command was committed to his well-being and supportive of attendance at regular
medical appointments.
Service: Several participants described a dedication to serving others. This manifested in
both seeking help for their injuries or symptoms as well as delaying care for themselves. Gavin
described that it was much easier for him to take care of others, but that “I don’t even know
where to start” when he finally entered treatment and had time to focus on himself. Others
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expressed that their reason for choosing to participate in the study was to help others. As Jeremy
described,
That’s one of the main reasons I wanted to do this [participate in the study] is because I
know what I did, I know what happened to me and I know what I did by pushing it to the
back of my mind and I didn’t seek help when I needed it at first. So it might have caused
me more problems, so if I can give advice and give my story, and maybe if somebody
else hears something like that, can understand that, hey, I’m going through these type of
things too, then, maybe that’ll make them change their mind and maybe seek help faster
and maybe they won’t have the amount of problems that I do.

Wanting Others to Understand
One of the questions in the interview was, “what do you want others to understand about
your experience with these injuries?” The responses varied among advice, observations, and
suggestions for systemic changes. Many encouraged other service members who experienced
symptoms to seek medical care. Others used the term “invisible injuries” as a way of expressing
the incongruity between their outward appearances and internal experiences. Another described
how he would like to be viewed by prospective employers as reliable and dependable rather than
as an injured veteran. Still others had suggestions for how screening processes and record
keeping could be changed to better track injury histories. Because of the range, we did not label
subthemes per se. Rather, we present several representative responses in Table 4.3.
Discussion
The study was contextualized with an occupational science lens. That is, the first author
held the view that engagement in occupation is intimately connected to health, and that
symptoms alone do not determine satisfaction with participation in occupation. To the best of our
knowledge, this is the first study to explore the occupational challenges related to the aftermath
of mTBI in an active duty military population. The findings suggest that service members with
chronic symptoms have needs across the full domain of occupational therapy practice while they
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Table 4.3: Wanting Others to Understand
Theme Example Quote
Take it seriously Trying to be mister tough guy. Ah, nothing is going to bother me, nothing hurts me.
Well, it will eventually show up and I wish that I would have done something about it
earlier so, that’s probably the most important thing I could say about it is take it
seriously. (Jeremy)
Getting help doesn’t
have to hurt career
(1 person)
I think the biggest thing is, you know, everyone talks about the stigma of you know,
people not wanting to hurt their career and all. You know, the good thing that I found
out, and I didn’t know this at the time, I just knew that if I didn’t get help, I would
probably be dead right now, and I love my family to death and they love me, and you
know, I would never want to do anything to hurt them, but you know, at the point that
I’ve been, it seems like the best solution at the time. But I would say uh, I found out
that it doesn’t have to hurt your career. (Ryan)
Invisible injuries (2
people)
You know, I was talking to an old vet, that’s funny too, not too long ago. He’s an old
Vietnam vet, Vietnam and Korea, and he said, you know, the hardest thing is you
don’t have the visible injuries. I think that probably is it. (Greg)
Still reliable (1 person) You know, I think probably if I look at it from an employment standpoint, you know,
with my, there’s certain training … you’re getting leadership. You’re getting
experience, you’re getting, you know when they hire a military member, you’re
getting someone that you know is committed and dedicated, obviously. You’re
getting some, you know, a dependable product. (Rhett)
Better screening and
education (2 people)
I do believe that a lot more research should be done, more, more finances and you
know, resources should be dedicated towards research. Especially in the initial stages
too. Like, say the 30 days post-deployment, it shouldn’t just be, well, you know
where the BAS [Battalion Aid Station] is, go if you need help. No. Or the FRO
[Family Resource Office], are you guys ok, the family is ok? We’re having this
picnic, this barbecue, No. You have someone sit down with each individual, and you
talk to them and see…Hard questions too, not the sugar coated, nice, no. The real
questions. (Armand)

continue their military service. Service members may also benefit from occupational therapy
throughout the transition process upon separation from the military and return to civilian life.
Occupational therapy services are included as part of rehabilitation in the military health
system (Woodson, 2011). In the experiences of one of the authors (CEH), the role of
occupational therapy within the treatment team varies among facilities. Furthermore, evidence to
support the efficacy of occupational therapy interventions in the population of active duty service
members with chronic symptoms after mTBI is still needed. Other healthcare providers likely
address some of the problems described in the results; however, occupational therapy is unique
in its emphasis on activities of daily living and this lens could complement other services such as
medicine, physical therapy, psychology, and speech-language therapy. We suggest that
occupational therapy have a broader, more consistent role in evaluating and treating service
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members from the acute to chronic stages of mTBI. Further, we recommend that occupational
therapists consider all areas with the domain of practice (AOTA, 2014).
Occupational therapy support may also be warranted to facilitate the process of transition
from military to civilian life. Participants reported learning about the resources available through
the DoD and VA during educational programs and information sessions that they had attended,
yet several had unclear pictures of how they wanted their lives to look once they were no longer
in the military. Occupational therapists could provide career transition support and help with
establishing new, health promoting daily routines as service members make the shift to the
civilian world and rebuild their identities. This kind of role for occupational therapy may be
better situated in a VA or civilian context so that care could continue following a service
member’s end of active service and throughout the transition period.
The unique situation of care delivery among the active duty population requires further
scrutiny. Our findings indicate that warrior culture permeates service members’ views of seeking
any kind of medical help. There is widespread awareness of the stigma around seeking mental
health care (DoD Task Force on Mental Health, 2007; Langston, Gould, & Greenberg, 2007) and
the DoD has undertaken initiatives to address these issues and encourage people to seek
treatment (Quartana et al., 2014). Yet, avoidance of treatment extended to physical injuries, such
as Julio’s report of not getting any treatment for an injured knee until he was no longer able to
walk on it. Even though most of the participants eschewed this belief in hindsight, it clearly
played an important role in their reasoning processes around getting care when they first
experienced difficulties. There seemed to be dichotomous thinking about this matter – that
“sucking it up” was a demonstration of fortitude and that going to BAS made one a “sick bay
commando.” This rationale is supported by prior research findings that engagement in health
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promoting behaviors is inconsistent with cultural ideals of masculinity (Abraham, Cheney, &
Curran, 2015; Courtenay, 2000). As the military is a predominantly male organization and often
used as a cultural exemplar of idealized masculinity, avoidance of health behaviors and increased
risk-taking is likely greater than in the general civilian population.
Participants viewed medical care as incompatible with the requirements of their military
jobs, stating that it would have interfered with their ability to engage in all of their required
training exercises and could therefore not only leave them unprepared, but also threaten unit
cohesion by removing themselves from the team even for a few hours. At the same time, they
understood that their units would benefit from each individual being in good health and that, if
one was not able to perform all of one’s duties, the unit would benefit by replacing that person
with another who could. There is not a simple or obvious answer to this challenge, which likely
goes beyond the active duty population with mTBI. Nonetheless, because the DoD encompasses
military work as well as healthcare, there may be opportunities for creative approaches to the
healthcare delivery model to facilitate acceptance of treatment in the future.
It is important to note that while all participants in this study had a history of mTBI and
reported symptoms that were consistent with this injury (headaches, memory loss), many had co-
occurring diagnoses such as PTSD and major depressive disorder. It is not possible to fully
disentangle the etiologies of the symptoms of mTBI from mental health diagnoses. Furthermore,
participants also reported sleep disorders, chronic pain, hearing impairment, and visual
impairment among other problems. Many of these issues create a feedback loop that increases
symptoms. For example, disrupted sleep may worsen persistent headaches and memory
problems. These multiple diagnoses and symptoms demand a holistic approach to care as is the
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foundation of occupational therapy. It is not simply a resolution of symptoms that is required to
allow for a return to meaningful activities, but learning to live well under these conditions.
Limitations
All of the interviews were conducted by the same researcher (AMC), who is a civilian.
Service member participants were integrated in a concussion care clinic and most had not
returned to full participation in their work roles. The study sample was limited to individuals
with chronic symptoms after mTBI, which is not representative of all service members with head
injury events. Because we did not review medical records, we were not able to verify that
structural MRI scans were negative in all cases, as is a criterion for mTBI.
A possible limitation to the study is the issue of secondary gains. Level of disability at the
conclusion of one’s military service determines the financial disability benefits a service member
receives. It is conceivable that some of the participants were motivated by the possibility of
monetary gain and this situation affected their interview responses, although participants were
assured of the confidentiality of their answers and none disclosed that he was exaggerating their
symptoms or disability. However, we acknowledge it as a potential risk.
Implications for Occupational Therapy Practice
Our findings indicate the following implications for practice:
 Occupational therapy evaluation should be thorough and assess the full domain of
functions, role identity, life goals, and satisfaction with occupational performance.
 When working with this population, special attention should be given to rest and sleep.
 Practitioners should be aware of the influences of military culture on healthcare
engagement. This factor is especially important for practitioners who are new to a
military treatment setting or who treat service members in a civilian healthcare context.
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Conclusions
The unique injury and symptom patterns among military service members with mTBI
deviate from those of civilians with mTBI (Bailie et al., 2016), therefore research to design
appropriate interventions for this population and test their efficacy is much needed. Meanwhile,
we suggest that occupational therapists who work with these service members and veterans
consider the full domain of their professional scope of practice during assessment and treatment.
This generation of veterans with chronic symptoms after mTBI will continue to be seen in VA
and civilian health care settings after they separate from the military, therefore investigation into
long-term strategies and solutions is justified.

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Chapter 5: A treatment model of occupational therapy intervention for optimizing
participation of service members with chronic symptoms after mTBI
Target Journal: American Journal of Occupational Therapy
Abstract
Objective: To develop a conceptual model for occupational therapy intervention to optimize
participation for military service members with chronic symptoms after mild traumatic brain
injury (mTBI).
Method: Qualitative descriptive study using an adaptation of the intervention mapping approach.
Focus groups were conducted with occupational therapy professionals (n=5) and service
members with chronic mTBI symptoms (n=6).
Results: Primary treatment targets were occupations, performance skills, performance patterns,
and client factors. Active ingredients included community-based and simulated occupations,
skills training, and patient education. The most commonly identified mechanism of change was
increased self-efficacy. Thematic analysis highlighted the importance of the therapeutic
relationship, the need to include family members, differences between combat and non-combat
head injuries, and the complex role of military culture.
Conclusion: Occupational therapy intervention for service members with mTBI and persistent
symptoms currently addresses a broad range of therapeutic concerns. There are opportunities for
more focused treatment of disordered sleep and chronic pain.

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Mild traumatic brain injury (mTBI) is the most commonly reported classification of brain
injury among all military service members, accounting for 80% of the more than 350,000
reported brain injuries since 2000 (DVBIC, 2016b). The Department of Defense (DoD) classifies
a traumatic brain injury as “mild” if the event results in loss of consciousness for less than 30
minutes or alteration of consciousness, less than 24 hours of post-traumatic amnesia, or a
Glasgow Coma Scale score of 13-15 in the first 24 hours after injury (Management of
Concussion-mild Traumatic Brain Injury Working Group, 2016). Following an mTBI event,
most people experience a complete cessation of acute symptoms within three months (Carroll et
al., 2014; Carroll et al., 2004). However, 15-20% experience persistent cognitive, emotional, or
physical impairment (Carroll et al., 2014; Williams et al., 2010). Common symptoms include
memory loss, irritability, headaches, and light sensitivity.
Active duty service members with chronic symptoms after mTBI are not represented in
the occupational therapy literature. Members of this patient population are unique because they
often are not diagnosed with mTBI until several months (or even years) after the injury,
frequently have comorbid mental health diagnoses, and are immersed in military culture, making
them quite different from most civilians with concussion injuries (Bahraini et al., 2014; Brenner
et al., 2009; Iverson et al., 2009). Some distinguishing features of military culture include blast
as a common mechanism of injury (Benzinger et al., 2009), strong commitment to one’s work
role within a unit (see Chapter 4), and stigma around seeking medical care (Quartana et al.,
2014). Studies of interventions that facilitate such individuals’ return to full participation in life,
either inside or outside of the military, have not been conducted (Cogan, 2014). Yet, these
service members are often referred for occupational therapy services as part of a comprehensive,
multidisciplinary rehabilitation program (Woodson, 2011).
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It is increasingly important for healthcare providers to justify the interventions they use
with patients, which is challenging in the absence of intervention efficacy studies. Establishment
of a theoretically supported treatment model, however, could help occupational therapists ensure
that their interventions are well designed and conceptually supported. A treatment model (or
theory) is an attempt to explicate an intervention’s associated clinical reasoning processes and
underlying assumptions, which are usually tacit (Whyte et al., 2014). According to the definition
put forth by Whyte and colleagues (2014), a treatment theory identifies targeted outcomes of an
intervention, providers’ actions to facilitate the desired outcomes (active ingredients), and how
those actions facilitate the outcome of interest (mechanisms of action). Rehabilitation
interventions frequently lack clearly defined theoretical foundations; however, by recording what
is being done in current practice along with the underlying rationale, it is possible to draw out the
main theories that guide clinical decisions, assess the evidence supporting treatment strategies,
and evaluate their validity
One approach to establishing a theoretically supported treatment protocol is intervention
mapping (Bartholomew et al., 2011). This approach requires identification of all program
objectives, actions taken to achieve the objectives, and theoretical supports; these three
components are analogous to the treatment targets, active ingredients, and mechanisms of action
as defined by Whyte et al. (2014). Use of such a process to describe current practice serves as a
useful starting point in the design of future interventions and may help to identify appropriate
outcome measures.
The purpose of this study was to develop a conceptual model, based on Whyte et al.’s
characterization of a treatment theory, for occupational therapy intervention to optimize
participation for military service members with chronic symptoms after mTBI. This study builds
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on the findings of a qualitative needs assessment that identified the areas of occupation in which
this patient population has the greatest challenges (see Chapter 4).
Methods
This qualitative study employed an adaptation of the intervention mapping approach
(Bartholomew et al., 2011). Intervention mapping is an innovative, rigorous methodology for
designing treatment protocols. As described above, it emphasizes the use of theoretically
informed treatment activities and outcomes, which are connected back to the aims of the
intervention and the needs of the population of interest (Bartholomew et al., 2011). Although the
methodology was originally developed for health promotion interventions, I have adapted it for
the purpose of modeling a rehabilitation intervention. Unlike the narrowly focused health
promotion interventions in which intervention mapping has been previously employed, such as
weight management (De Craemer et al., 2014; Verweij, Proper, Weel, Hulshof, & van Mechelen,
2009), rehabilitation interventions typically have a much broader scope and encompass diverse
treatment objectives relating to all aspects of daily life. The outcome of the mapping process is a
matrix that links treatment targets, active ingredients, and hypothesized mechanisms of action.
Bartholomew and colleagues described such a matrix as “a logic model for the change process”
(Bartholomew et al., 2011, p. 275).
Data Collection
Stakeholder engagement is critical during the intervention mapping process
(Bartholomew et al., 2011). Therefore, a focus group approach was used to collect data. Two
series of focus groups were conducted—one with occupational therapy professionals and one
with service members with a history of mTBI and chronic symptoms who had received
occupational therapy services. The study was conducted in collaboration with a multidisciplinary
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Concussion Care Clinic that is part of NHCP, which is located on Marine Corps Base Camp
Pendleton in Southern California. Occupational therapy professionals were recruited through the
primary research site and the professional networks of the research team members. To be study
eligible, they needed to have practiced in a military medical facility and treated an active duty
population with mTBI for at least six months. Patient participants were recruited by a member of
the research team who worked in the Concussion Care Clinic but was not directly involved in
their clinical care. Patients were excluded if they were concurrently being treated for substance
abuse or diagnosed with a personality disorder, as such individuals do not represent typical cases,
which were sought for the study. All patients and occupational therapy professionals completed
an informed consent process and brief demographic interview prior to the first focus group
meeting.
Focus groups were conducted between October and December of 2016. Each focus group
lasted approximately one hour, was held in a private conference room in a military medical
facility, was audio recorded, and was transcribed verbatim. Participants met in person with the
exception of one occupational therapist who joined via conference call from a remote location.
Meetings with occupational therapy professionals focused on describing current practice with
patients with chronic mTBI as well as identifying other areas or resources that would enhance
intervention efforts. Discussions with the patient group centered on their most significant
challenges, what worked best for them in occupational therapy, their priorities for care, and their
suggestions for how services could be improved. Focus group discussion questions are listed at
the end of Chapter 5.
Patient head injury history was documented using the Ohio State University Traumatic
Brain Injury Identification (OSU-TBI-ID) structured interview (Bogner & Corrigan, 2009). This
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interview captures all lifetime head and neck injury events via patient report. The institutional
review boards of NMSCD and USC approved this study.
Data Analysis
Data were coded using NVivo (QSR International, Inc.). The components described by
Whyte et al. (2014)—treatment targets, active ingredients, and mechanism of action—served as a
priori codes for the development of the treatment model. The Occupational Therapy Practice
Framework (OTPF) domain was used to label categories of treatment targets (AOTA, 2014).
Data that did not fit within the treatment model framework were coded thematically. I began
analysis during data collection (i.e., first round of coding was completed prior to the second
focus group meeting). Member checking was employed to increase trustworthiness of the
findings, particularly for treatment targets and active ingredients. Flip charts were used during
some of the meetings, which also provided an opportunity for participants to correct or confirm
any statements that I recorded. Hypothesized mechanisms of action were discerned through
occupational therapy practitioners’ descriptions of their clinical reasoning processes and, in some
cases, my interpretation of the active ingredients. Literature was used to inform the descriptions
of the mechanisms of action.
Results
Participants
Five occupational therapy professionals and six service members participated in the
study. One additional occupational therapist completed the consent process but withdrew from
the study before completing a demographic interview or participating in any focus group
meetings. Demographic and background data about occupational therapy providers and service
members are summarized in Tables 5.1 and 5.2, respectively. All participating occupational
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Table 5.1: Provider Background Variables
Role

Occupational therapist: n=3
Certified occupational therapy assistant: n=2
Practice Setting

Concussion care clinic: n=4
Neurorehabilitation occupational therapy clinic: n=1
Gender

Male: n=1
Female: n=4
Age 32.2 (29-40)
Ethnicity African American: n=1
Asian: n=2
Hispanic/Latino: n=1
White: n=1
Total years of practice 4.2 (2-7)
Years of practice with military
mTBI population
2.5 (1.5-5)
Specialty certifications Certified brain injury specialist: n=4
Stroke rehabilitation specialist: n=1
Vestibular rehabilitation: n=1
Continuous variables are represented as average (range)

Table 5.2: Service Member Demographics
Average (range)
Gender Male: n=6
Age (years) 36.5 (25 – 44)
Years of Service 15.6 (7 – 20)
Number of combat
deployments
2.7 (2 – 3)
Number of recalled lifetime
head injuries
9.0 (5 – 16)

History of blast exposure n=6
Marital Status Married: n=5
Separated: n=1
Ethnicity Caucasian: n=3
Hispanic/Latino: n=3
Military Rank Sergeant (E5): n=1
Staff Sergeant (E6): n=1
Gunnery Sergeant (E7): n=3
Master Sergeant (E8): n=1
Military Operational Specialty Infantry: n=3
Engineer: n=1
Ammunition & Explosive Ordinance Disposal: n=1
Communications: n=1
Duty Status Full Duty: n=1
Limited Duty: n=2
Wounded Warrior: n=3
Full Duty: still in prior work role; Limited Duty: assigned to prior unit but with reduced responsibilities; Wounded
Warrior Battalion: non-deploying unit with focus on injury recovery
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therapists (n=4) had attained master’s degrees and all certified occupational therapy assistants
(n=2) held bachelor’s degrees. All service members were male enlisted Marines (Sergeant,
Gunnery Sergeant, or Master Sergeant). Each occupational therapy professional attended an
average of 3.4 of four meetings (range: 3-4), whereas service member attendance was lower,
averaging 2.3 of four meetings (range: 1-4). When given by participants, notice of non-
attendance usually occurred shortly before a meeting started (e.g., visit to Social Security office
to apply for disability benefits taking longer than anticipated), therefore it was not possible to
reschedule in such cases.
During the focus group discussions, occupational therapy professionals and patients
characterized their experiences and priorities differently, even in response to identical questions.
As such, the conceptual model of occupational therapy treatment draws primarily from the
professional perspective whereas the subsequent thematic analysis is representative of the
patients’ points of view.
Conceptual Model of Occupational Therapy Treatment
A conceptual model of current occupational therapy intervention for military service
members with chronic symptoms after mTBI is represented in Figure 5.1. Treatment targets,
active ingredients, and hypothesized mechanisms were drawn from content analysis of focus
group data. Treatment targets were organized according to the domain areas of the OTPF
(AOTA, 2014). Hypothesized mechanisms of action were supplemented with descriptions from
the literature and are described below. Table 5.3 presents the underlying details of the conceptual
model as a matrix that maps treatment targets to the relevant active ingredients and hypothesized
mechanisms of action.
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Figure 5.1: Conceptual Model of Occupational Therapy Treatment for Service Members with
Chronic mTBI Symptoms

Active ingredients. Active ingredients, as described in the focus groups, were organized
into four categories: (a) community-based occupations; (b) simulated occupations; (c) skills
training; and (d) patient education. Referral to outside specialists was not characterized as an
active ingredient, but is listed in the matrix where relevant.
Community-based occupations. This category includes all treatment activities that were
conducted in community settings outside of the clinic. Examples of community-based activities
that were described in focus groups were an outing to a hardware store in which patients were
required to locate items on a list and a visit to a local museum that required a patient to navigate
using public transportation.
Active Ingredients
Mechanisms of Action Treatment Targets
Performance
Skills
Occupations
Client
Factors
Performance
Patterns
Arts/Creativity
Social Support
Self-Regulation
Habits
Health Beliefs
Motivation
Neuroplasticity
Self-Efficacy
Community-
based
Occupations
Patient
Education
Skills Training
Simulated
Occupations
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Simulated occupations. Simulated activities were conducted in the clinic setting and
attempted to replicate real-life tasks. For instance, patients gave PowerPoint presentations to
clinic staff to replicate a job responsibility of presenting to a group. Another example was the use
of different media tools (videos, podcasts) to practice attention skills relevant to classroom
learning amidst environmental distractions.
Skills training. Activities in this category were aimed at remediating deficits, teaching
compensatory strategies, or practicing components of occupations. One example of skills
training was the use of visual scanning exercises to address oculomotor irregularities. Other
activities that fall in this category were setting up calendars to manage appointments and
providing assistive technology such as an iPad.
Patient education. Education was used as an adjunct ingredient alongside almost all other
approaches. Patient education included verbal explanations of the rationale for certain treatment
activities as well as provision of printed handouts with information about the topic and general
recommendations. Patient education was typically employed in combination with other active
ingredients except in cases of treatment targets that the occupational therapy professionals did
not consider an important part of their practice. In these situations, education was used on its
own.
Hypothesized mechanisms of action. Neither providers nor patients explicitly named
the theories about why they expected particular active ingredients to be effective in reaching
treatment targets. Instead, the author interpreted them based on the explanations given during the
focus groups. Below, each identified mechanism listed in Table 5.3 is briefly summarized.
Arts/creativity: Creative arts and crafts have been part of occupational therapy practice
since its inception (Bissell & Mailloux, 1981). Although the use of creative activities in therapy
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is not tied to a specific theory, prior research has shown that engagement in the arts can enhance
one’s sense of control and sense of self, provide an outlet for self-expression, foster a sense of
purpose, and increase social support (Perruzza & Kinsella, 2010; M. Thompson & Blair, 1998).
Elements of arts/creativity may overlap with other mechanisms; however, the occupational
therapy professionals described the use of arts, crafts, and creative expression as a means of
addressing numerous treatment targets including cognition, emotional regulation, and leisure.
Due to its distinctive characteristics, I chose to conceptualize arts/creativity as its own
mechanism.
Habits: A habit is characterized as “routine repetition of past acts that is cued by stable
features of the environment” (Wood, Quinn, & Kashy, 2002, p. 1281). Stable environments are
conducive to habit performance and reduce the cognitive load of initiating a given behavior
(Wood et al., 2002). Active ingredients that encourage habit development include creating
environmental cues for desired action and repetition of the action in a natural setting. For
instance, treatment activities that relied on habits as the mechanism of change often incorporated
a combination of implementing behavioral cues (e.g., reminder alerts on a smart phone, alarms
for events on a calendar) and recommending environmental modifications to create cues in the
home setting (e.g., placement of wall calendar with schedules of family members). Home
programs were often recommended to continue habit development.
Health beliefs: Patient education strategies can have many different theoretical
foundations (Bellamy, 2004). In this setting, education was largely based on the health belief
model, which posits that if a person values an outcome and believes that a health behavior will
help them achieve that outcome, then he or she will engage in that health behavior (Green &
Murphy, 2014). This mechanism was usually employed as a complement to others.
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Motivation: In planning for life after military service, goal setting strategies were used to
encourage patients to consider their options for the future and make choices about what they
wanted to pursue. Such treatment activities or active ingredients are aimed at creating or
increasing motivation to act and are best aligned with the goal setting theory of motivation
(Locke & Latham, 2002). This theory postulates that goals direct performance through multiple
mechanisms. Therefore, through the process of considering options and selecting goals,
motivation to perform goal-connected actions increases.
Neuroplasticity: Neuroplasticity is the phenomenon of gray matter changing in response
to environmental demands (Draganski et al., 2004). Some therapeutic activities were described
as being targeted explicitly toward changing the brain, such as engagement in novel leisure
activities and visual scanning exercises.
Self-efficacy: Many of the occupational therapy approaches were grounded in self-
efficacy theory (Bandura, 1977). Specifically, actions of the therapists were often intended to
increase efficacy expectations of service members in performing activities within the therapeutic
context. For example, therapists facilitated community outings that incorporated shopping for
items on a list and engaging with store clerks, with the underlying assumption that such activities
will increase patients’ self-confidence in later independently shopping in the community as part
of their instrumental activities of daily living.
Self-regulation: Treatment activities aimed at increasing self-awareness were based on
social cognitive theory (Bandura, 1991). These active ingredients supported self-monitoring of
internal states and emotional reactions and use of appropriate coping strategies. For example,
some patients were coached to practice deep breathing exercises when they become aware of
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acute feelings of anxiety. Employment of groups for some treatment sessions provided social
referential comparisons, which supplied external feedback about performance.
Social support: Social support theory holds that interactions with others influence a
person’s behavior and can increase personal well-being (Shumaker & Brownell, 1984).
Moreover, social support has been characterized as a means of coping with life challenges
(Thoits, 1986). In the present study, therapists also used social support as an active ingredient,
such as in occupation-based group activities.
Treatment targets. The treatment targets identified through the focus group discussions
fell into four broad categories within the OTPF domain: (a) occupations; (b) client factors; (c)
performance skills; and (d) performance patterns (AOTA, 2014).
Occupations. As defined in the OTPF, occupations are “the daily life activities in which
people engage” (AOTA, 2014, p. S6). Occupations are divided into basic and instrumental
activities of daily living, rest and sleep, education, work, play, leisure, and social participation.
Examples of treatment targets that were assigned to this category include community
reintegration, preparation for returning to work or school, self-care, and household management.
Occupations constituted the bulk of the treatment targets that were described in the focus group
discussions.
Client factors. Client factors include the characteristics of an individual that affect
engagement in occupations. Body structures and functions fall under this category, as do values
and spirituality. Many of the client factors described in the focus groups were specific to
managing symptoms related to mTBI or mental health diagnoses.
Performance skills. This category is subdivided into motor, process, and social
interaction skills. Cognition and emotional regulation skills are part of performance skills. The
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Table 5.3: Matrix of Treatment Targets

OTPF
Domain
Sub-
category
Treatment target Active ingredients Active Ingredient Category Hypothesized
Mechanism of
Action
Occupations
ADL/IADL
Manage schedule and
medical appointments
Set up calendars Skills training Habits
Build routines Skills training Habits
Provide assistive technology Skills training Self-efficacy
Use of computer Provide assistive technology Skills training Self-efficacy
Facilitate computer use Simulated occupation Self-efficacy
Drive a motor vehicle Referral to driving specialist N/A N/A
Navigate in community Community-based occupation Self-efficacy
Teach skills for acute stress management Skills training Self-regulation
Manage finances Develop budget Simulated occupation Self-efficacy
Provide assistive technology Skills training Self-efficacy
Manage household Simulate household activities Simulated occupation Self-efficacy
Assign “homework” activities Community-based occupation Self-efficacy
Manage health Educate patient about comorbid health
conditions
Patient education Health beliefs

Facilitate organization and management of
medications
Simulated occupation Self-efficacy
Provide assistive technology Skills training Self-efficacy
Prepare meals Facilitate food preparation activities Simulated occupation Self-efficacy
Education
Identify degree/training
pathways for different
fields
Facilitate development of research skills Simulated occupation Self-efficacy
Prepare for classroom
success
Facilitate development of study skills Skills training Self-efficacy
Simulate classroom activities Simulated occupation Self-efficacy
Provide assistive technology Skills training Self-efficacy

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OTPF
Domain
Sub-
category
Treatment target Active ingredients Active Ingredient Category Hypothesized
Mechanism of
Action
Occupations
Play/Leisure
Explore new leisure
activities
Introduce new leisure activities Community-based occupation Arts/creativity
Facilitate engagement in new leisure activities Skills training Neuroplasticity
Organize community outings Community-based occupation Self-regulation
Incorporate leisure into
routine
Facilitate craft activities Community-based occupation Arts/creativity

Facilitate music/art activities Community-based occupation Arts/creativity

Educate patient about occupational balance Patient education Health beliefs
Facilitate gardening Community-based occupation Self-efficacy
Facilitate volunteer activities Community-based occupation Self-efficacy
Facilitate of community-based activities

Community-based occupation Social support
Connect patient with community organizations Community-based occupation Social support
Facilitate group cooking activities Community-based occupation Social support
Rest/
Sleep
Adopt sleep hygiene
recommendations
Educate patient about sleep hygiene Patient Education Health beliefs
Social Participation
Socialize with others Facilitate community outings Community-based occupation Self-efficacy
Facilitate group-based occupations Community-based occupation Social support
Integrate into community Facilitate community outings Community-based occupation Self-efficacy
Invite family members to therapy sessions Community-based occupation Social support
Connect with social
support
Educate patient about available resources Patient education Health beliefs

Invite family members to therapy sessions Community-based occupation Social support
Participate in family life Invite family members to therapy sessions

Community-based occupation Social support
Assign “homework” activities Community-based occupation Social support

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OTPF
Domain
Sub-
category
Treatment target Active ingredients Active Ingredient Category Hypothesized
Mechanism of
Action
Occupations
Work
Resume full work
schedule
Build routines Skills training Habits
Simulate work activities specific to military
operational specialty
Simulated occupation Self-efficacy
Identify necessary work
accommodations
Assess work site (when possible)

Community-based occupation Self-regulation
Perform basic military
job functions
Facilitate land navigation activities Community-based occupation Self-efficacy

Encourage patient to teach job roles and skills
to therapists
Simulated occupation Self-efficacy

Plan for transition out of
military
Explore careers Community-based occupation Motivation
Facilitate goal setting Community-based occupation Motivation
Build resume Community-based occupation Self-efficacy
Facilitate volunteer opportunities Community-based occupation Self-efficacy
Client Factors
Body Functions
Manage energy levels Facilitate creative expression Community-based occupation Arts/creativity
Build routines Skills training Habits
Facilitate planning for leisure activities Skills training Habits
Teach proper body mechanics Patient education Health beliefs
Provide assistive technology Skills training Self-efficacy
Teach medication management skills Skills training Self-efficacy
Teach relaxation activities Skills training Self-regulation
Teach stress management skills Skills training Self-regulation
Remediate visual deficits Facilitate engagement in video games/virtual
reality
Skills training Neuroplasticity
Teach tracking/scanning exercises Skills training Neuroplasticity
Address mental health
issues
Educate patient about mental health conditions Patient education Health beliefs

Facilitate cognitive restructuring Patient education Health beliefs
Educate patient about self-advocacy Patient education Health beliefs
Teach medication management skills Patient education Self-efficacy
Teach strategies for self-awareness/insight Skills training Self-regulation
Teach stress management skills Skills training Self-regulation
Teach coping skills Skills training Self-regulation
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OTPF
Domain
Sub-
category
Treatment target Active ingredients Active Ingredient Category Hypothesized
Mechanism of
Action
Client Factors
Body
Functions
Manage headaches Educate patient about pain management and
relief strategies
Patient education Health beliefs
Monitor physical
symptoms
Teach biofeedback techniques Skills training Self-regulation
Body
Structures
Manage physical pain Educate patient about pain management and
relief strategies
Patient education Health beliefs
Values-
Beliefs-
Spirituality
Assess importance of
spirituality
Connect patient with chaplain
Connect patient with community group
N/A N/A
Performance skills
Process Skills
Maintain attention to
task
Facilitate craft activities Skills training Arts/creativity
Simulate classroom activities Simulated occupation Self-efficacy
Divide attention among
multiple tasks
Facilitate cooking activities

Simulated occupation Arts/creativity

Facilitate games/leisure activities Community-based occupation Arts/creativity

Facilitate craft activities Community-based occupation Self-efficacy
Manage emotional
responses
Educate patient about available tools to manage
emotions
Patient education Health belief
Teach patients to incorporate breaks and
distractions
Skills training Self-regulation

Comprehend written
content
Simulate study skills

Simulated occupation

Self-efficacy
Facilitate reading comprehension activities Simulated occupation Self-efficacy
Process and retain
auditory information
Employ podcasts and videos to simulate
classroom activities
Simulated occupation Self-efficacy

Organize information
effectively
Build routines Skills training Habits
Provide assistive technology Skills training Self-efficacy
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OTPF
Domain
Sub-
category
Treatment target Active ingredients Active Ingredient Category Hypothesized
Mechanism of
Action
Performance skills
Process skills
Learn strategies to
enhance short-term
memory
Organize calendars Skills training Habits
Assign “homework” activities Community-based occupations Habits
Provide assistive technology Skills training Self-efficacy
Increase awareness of
symptoms and/or deficits
Educate patient about how to recognize
symptom escalation
Patient education Health beliefs

Provide assistive technology Skills training Self-efficacy
Teach biofeedback Skills training Self-regulation
Facilitate identification of strengths and
challenges
Skills training

Self-regulation
Manage acute and
chronic stress
Build routines Skills training Habits
Provide assistive technology Skills training Self-efficacy
Teach stress management techniques Skills training Self-efficacy
Teach biofeedback techniques Skills training Self-regulation
Incorporate service animals into therapy
process
Skills training Self-regulation
Social
Interaction
Skills
Interact with new people Facilitate community outings Community-based occupation Self-efficacy
Facilitate group-based activities Community-based activities Social support
Use appropriate
language in public (no
profanity)
Facilitate community outings Community-based activities Self-efficacy
Express thoughts clearly Facilitate artistic activities Community-based activities Arts/creativity
Performance
Patterns
Habits and Routines
Manage schedules and
appointments
Organize calendars Skills training Habits
Provide assistive technology Skills training Self-efficacy
Teach medication management skills Skills training Self-efficacy
Organize daily activities Organize calendars Skills training Habits
Facilitate prioritization of tasks
Provide assistive technology
Simulated activity
Skills training
Self-efficacy
Manage stress Educate patient on mental health and comorbid
conditions

Patient education Health beliefs
Teach proper body mechanics Patient education Health beliefs
Encourage self-care activities Patient education Health beliefs
Abbreviations: OTPF: Occupational Therapy Practice Framework; ADL/IADL: Basic and instrumental activities of daily living.
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most significant performance skills identified in focus groups were related to cognitive
processing. Specifically, both patient and therapists groups identified improving short-term
memory and attention to task as being central to reaching their therapy goals.
Performance patterns. As reported in the focus groups, addressing performance patterns
was associated with establishing new daily routines to support attendance at medical
appointments and other obligations, as well as managing stress. Habits and routines were
especially significant in this patient population because patients were accustomed to having
highly regulated schedules during their military service. The transition away from their military
units and towards the role of a patient with an irregular schedule was a noted by therapists as
problematic, whereas patients described the shift in terms of role loss rather than schedule
disruption.
Thematic Analysis
Due to the open-ended nature of the discussion questions, some of the content of the
focus group conversation went beyond what was captured in the matrix of treatment targets.
These data were analyzed thematically and are dominated by the patients’ descriptions of their
experiences and priorities with occupational therapy. The themes are not specific to any
particular treatment target. Instead, they represent foundational elements of the treatment process
that are relevant to all treatment activities.
Therapeutic relationship. When patients were asked what they liked best about
occupational therapy, they described different aspects of positive therapeutic relationships rather
than specific intervention approaches. Fred explained that he felt very comfortable when he met
with his occupational therapist because, “I didn’t get treated like a patient when I first got there. I
was treated like a normal person.” He explained that being treated like a normal person meant
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that the therapist asked about his needs and seemed genuinely interested in his point of view.
Additionally, he became acquainted with all of the occupational therapy staff in the clinic and
they all learned his first name, which increased his comfort level. Other participants endorsed
these sentiments about other occupational therapy providers in the Concussion Care Clinic. Two
patient participants explained that being pushed to do their best was their favorite part of
occupational therapy. Mark said, “They hold you accountable and the girls down here, they’re
not easily pushed over.” Jeff agreed, saying, “That’s good because sometimes you don’t press
yourself as much as you should,” and joked that accountability was also “probably one of the
things I hate the most, too.”
Occupational therapy professionals also expressed the importance of establishing rapport
with their patients. They also voiced concern for the comfort and well-being of their patients in
describing what they consider to be an optimal treatment environment. For example, one
therapist suggested, and the rest of the group agreed, that an ideal setting would have sound-
proof rooms for one-on-one sessions so that service members who are also diagnosed with PTSD
and are hypervigilant would not be easily disrupted during treatment sessions. They also
suggested adding a separate space with access to sensory tools that service members could use to
calm themselves when they became irritable. Therapeutic relationship could have been included
in the treatment model as an active ingredient. However, I chose to include it as a separate theme
because it was significant to the overall intervention process and not specific to a particular set of
treatment targets.
Consistent inclusion of family members. Family members reportedly did not routinely
participate in occupational therapy or any other type of intervention. Nonetheless, service
members explained that they had found it valuable when their spouses or children attended
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appointments with them. For example, Jeff explained how bringing his children to his
occupational therapy sessions helped him with practicing skills at home, as well as engaging
with his family.
I took my kids to occupational therapy here with me…and it’s funny because like, to
them it’s games, so then when I get home, they’re like, ‘hey Dad, let’s play that one
game.’ So not only am I doing stuff to work on my memory in occupational therapy, I’m
also doing it at home because my kids want to play that game that really tortures
Dad…It’s good because when you get your own family involved, like, you want to get
better but your family wants you to get better 1000 times more than you want to. So it
really helps with them being there.

Furthermore, having one’s spouse present was useful, especially for sessions that were focused
on patient education. In these instances, the spouse’s presence reduced pressure on the service
member to remember everything when returning home. In addition, Mark reported that bringing
his wife with him to his appointments “keeps me honest” about reporting symptoms, as he has a
tendency to minimize or underreport issues.
Occupational therapists reportedly welcomed family involvement in sessions and
explicitly encouraged service members to bring family members to certain events, such as a
potluck meal to celebrate the conclusion of a group program. On the other hand, service
members described that, in general, few providers communicated the potential benefits of family
participation in treatment. The patient participants recommended that family involvement be
incorporated into future programs.
Combat vs. non-combat injuries. One concept that came up in two patient focus groups
and one occupational therapy group was the differing needs of combat-injured service members
compared to those injured in a non-combat setting. Mark explained his perspective that they
experience “two completely different effects of the injury. Like getting, playing football, getting
a concussion, it is a concussion but is completely different from being in combat, getting blown
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up, and getting a TBI. There’s no comparison.” His implication was that the stressors of a
combat situation resulted in substantial trauma and more severe psychological symptoms as
compared with a sports-related injury. He and others described conflicts that occurred in group
settings between the individuals with head injuries from combat versus non-combat. Mark
suggested, and others agreed, that service members with combat-related head injuries should not
be included in the same groups as those with non-combat head injuries, even if the diagnosis was
the same, to avoid conflict. He acknowledged that this suggestion was not realistic because, due
to the end of major combat operations in Iraq and Afghanistan, there are now fewer combat
injuries. Fred concurred, explaining that “we don’t think we’re better than anybody,” but that the
experiences of combat were sufficiently dissimilar to make it difficult to relate to others who had
not been through comparable situations. Occupational therapy professionals also identified
different needs for combat-injured veterans, particularly the challenge of addressing mental
health comorbidities, although they did not go so far as to say they should be treated separately.
Role of military culture. Many aspects of military culture influence how service
members experience the health care process. Two elements stood out in patient discussions on
this topic. First, patients expressed frustration that scoring in the “average” range on an
assessment was considered satisfactory for discharge from therapy when, for them, an average
score did not represent a return to full function. Mark expressed that he wished he had a pre-
deployment score for each of the standardized assessments that was administered after his injury.
Because they don’t have any idea to how smart you were, how proficient you were, how
good you were prior [to injury]. They just see you after the fact and then they have to
figure out… [They tell me] ‘You’re in the average, little bit below average so we’re not
that bad.’ But really, where I was prior to that was well above average and you know, I
explain to them, you can’t get to our job field being average.

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Other participants concurred and the subject came up in multiple group meetings. This issue was
especially a concern with respect to physical performance, as military training had helped all
patient participants to reach high levels prior to injury. Post-injury, they were being evaluated
based on norms for the general population.
Second, the loss of their military role was often one of the most difficult challenges. Jeff
summarized it this way:
I tell my therapist all the time, like at this point, it’s finding a purpose. Because when
you’re in combat, you have a purpose, you have a mission, and your whole job is to do it.
So like now, I feel like I don’t have a purpose in life… Because you know everything
about it [role in unit], you know what you’ve got to do, and it’s always exciting.... if we
can find purpose [when Marine career ends], that would probably help.

While all agreed that the thrill of combat could not be replaced, the theme of clearly
understanding one’s role in the military and the internalization of that role as part of one’s
identity came up repeatedly. In this regard, patients suggested that the focus of therapy needs to
be not just on deciding how to occupy time, but to connect with a new purpose and adjust to a
new identity outside of the Marine Corps.
Discussion
This study begins to fill a gap that was identified by frontline providers about the lack of
research on occupational therapy intervention for mTBI, especially for military service members.
These findings create the foundation of a treatment model to support occupational therapy
intervention for active duty military service members with chronic symptoms attributed to mTBI.
The matrix includes active ingredients and the theoretical bases for a variety of intervention
strategies. Together with the thematic results, it can inform occupational therapy professionals,
especially novices or those unfamiliar with military culture, in developing and implementing
interventions for service members with mTBI. Although not definitive, this model can also be a
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resource for advocating for the expansion of occupational therapy services and can serve as the
groundwork for intervention development in future efficacy studies.
Consistent with the conceptual model of participation that was presented in Chapter 3, the
therapeutic relationship between patient and healthcare provider was of great import to patients
in describing their experience of intervention. In the model, interpersonal connection is described
as an essential component of participation and is applicable to interventional as well as
community-based participation. A positive connection was more highly valued by patients than
performance of specific treatment activities, which underscores the prominence of relationship
building in the intervention context. The therapeutic relationship was a significant factor in
shaping the subjective experiences of the intervention process for patients as well.
Two treatment targets, sleep and chronic pain, were identified by patient participants as
important but were only addressed by occupational therapy providers through patient education.
In the two practice settings represented in this study, other healthcare professionals (i.e., primary
care providers, physical therapists, health psychologists) addressed these targeted outcomes and
there was not a perceived need for occupational therapists to do so as well. However, both areas
continue to be concerns for patients and are within the occupational therapy scope of practice.
Sleep is clearly labeled as an area of occupation in the OTPF (AOTA, 2014). An AOTA
fact sheet suggests numerous approaches for addressing sleep, including teaching sleep hygiene,
modifying the sleep environment, and developing stable routines (Picard, 2012). Currently, there
are few studies to support the efficacy of occupational therapy intervention for sleep (Leland,
Marcione, Niemiec, Kelkar, & Fogelberg, 2014). New research is emerging to identify
interventions within the occupational therapy scope of practice, which could spur future efficacy
studies (Gutman et al., 2016). The therapists in the present study did address sleep through
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patient education about sleep hygiene; however, education interventions could be supplemented
by other strategies such as activity analysis, home assessment, and environmental modifications.
The role of occupational therapy in management of chronic pain is to facilitate
participation in everyday life alongside pain management strategies (Rochman, 2014). As with
sleep, evidence for occupation-based interventions aimed at chronic pain is limited, although
there is support in the literature for psychological interventions such as cognitive behavioral
therapy (Hesselstrand, Samuelsson, & Liedberg, 2015; Robinson, Kennedy, & Harmon, 2011).
Robinson and colleagues have called for more research to support the efficacy of occupation-
based interventions for chronic pain. In addition, Robinson et al. suggest that practitioners
develop expertise in evidence-based practice so that they can better discern which interventions
developed by other disciplines best fit with the philosophy of occupational therapy. As with
sleep, the patients who participated in the present study reportedly received treatment for pain
from other disciplines, such as primary care and physical therapy. Occupational therapists used
intervention strategies that may have indirectly helped with pain management, such as teaching
patients to plan breaks in their daily schedules. Nonetheless, opportunities remain for
occupational therapy to take on a greater role in supporting chronic pain management for
military service members with mTBI. In this regard, occupational therapists could support other
disciplinary interventions through approaches such as teaching energy conservation strategies
and provision of assistive technology.
Another topic that was discussed among the patient groups was the significance of the
loss of one’s military role. Though the occupational therapy professionals also noted this issue, it
was not described explicitly as a treatment target. As depicted in the thematic analysis above, the
patients had incorporated their military job into their identities and felt that they had a clear and
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important role within the Marine Corps. More perspicuous emphasis on establishing one’s role in
the civilian context, beyond treatment activities such as career exploration, is one approach to
addressing this life change in the therapeutic context.
This study provides a baseline for future occupational therapy intervention research,
which has been quite limited in active duty military populations. Specifically, the current results
are a resource for the development of manualized interventions that could be tested in future
efficacy and effectiveness studies. The findings may also be relevant for veterans with chronic
symptoms attributed to mTBI who have already separated from military service, although
additional qualitative work is needed to identify whether the treatment targets would be the same
and to understand the role of veteran culture. Because the military population with mTBI
frequently has not sought or received medical attention in the acute phase of injury, the findings
may also inform future research about civilians who delay diagnosis and treatment for mTBI.
Limitations
The patients who participated in this study were all from the same service branch (Marine
Corps) and were recruited from a single clinic. Other military branches and clinics may have
different approaches to care, which would affect the patient experience. Moreover, a limited
range of military ranks was represented and half of the patients served as infantry. Greater
variety of positions and work roles could have resulted in different priorities and goals, and
therefore led to dissimilar approaches and values in the treatment process. In addition, all service
member participants were all planning to retire or be medically discharged from active service.
Individuals who still hoped to return to full duty may have responded differently to the
discussion questions.
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The occupational therapy professionals came from only two clinics. Dissimilarities
between the two sites were identified during discussion. For example, the occupational therapist
who worked in the neurorehabilitation clinic had a more diverse caseload and his clinic was
physically closer to many of the other services. Representation from more or different facilities
could have resulted in additional treatment targets and active ingredients. Additionally, the
occupational therapy providers had, on average, fewer than five years of practice experience and
fewer than three years working with patients with mTBI in a military setting. More experienced
clinicians may have responded differently to the discussion questions. Use of different research
approaches, such as medical record review or participant observation, may have yielded different
results as well. For example, a medical record review would provide data about what billing
codes were used and how time was allocated which may have resulted in a different description
of current practice than indicated by the qualitative reports. Likewise, an outsider perspective
added by participant observation may have provided different insights and ideas about the active
ingredients and mechanisms.
Researchers have long called for the objective definition of rehabilitation processes for
research and measurement purposes (Whyte & Hart, 2003). In the present study, I used Whyte
and colleagues’ (2014) construct of treatment theory as a guide to define the process; however,
other models have been suggested (Gracey, Evans, & Malley, 2009). My study largely
documents current practice and there may be areas in which treatment strategies can be improved
or optimized. The hypothetical mechanisms of action may be incomplete, as they were not
always clearly identified in focus group discussions. Rehabilitation is a complex process and
there are likely interactions between the various active ingredients, such as self-efficacy and self-
regulation, which are not captured in the matrix of treatment targets. On the other hand, the
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treatment targets identified in the present study were consistent with those of the prior needs
assessment, in which the inputs of a range of healthcare professionals and a different set of
service members were included. Nevertheless, the treatment model presented herein is likely
incomplete.
Conclusions
A clear understanding of how and why interventions work will facilitate appropriate
strategies to measure changes in targeted outcomes and has the potential to support the
implementation of research evidence into clinical practice. Moreover, including both patients and
frontline clinicians in the research process can help to close the evidence-practice gap. The
findings of this study demonstrate not only that service members with chronic symptoms after
mTBI experience deficits across the array of the occupational therapy practice concerns, but also
that the therapeutic relationship may be more important to patients than any specific intervention
strategy. Investigation into effective occupation-based interventions for the inadequately studied
areas of sleep and chronic pain is critical to enhance services for this patient population.
Although this study provides a baseline description of current practice from which future
interventions could be designed, further work is necessary to ensure the completeness of the
matrix of treatment targets, to explore other active ingredients that may be effective for
achieving desired outcomes, and to uncover interactions among the various treatment approaches
and goals.

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Appendix: Focus Group Guiding Questions

Therapist group #1
 Thinking about your caseload in mTBI, what challenges with day-to-day activities do
patients typically report in your assessment?
 Thinking about your caseload in mTBI, what are patients’ most prominent complaints?
 What kinds of changes do you observe in those chief complaints during the course of
treatment?
 What problems do you think people with mTBI need the most support with?
Therapist Group #2
 Review list of treatment targets identified in first meeting
 Select most important areas
o Cognition
o Mental health
o Community reintegration
o Energy conservation/management
 For each area, what do they (or could they) do as a provider and how do patients change?
Therapist group #3
 For each area, what do they (or could they) do as a provider and how do patients change?
o Vision
o Return to duty/productivity during transition or “limbo” phase
o Leisure
o Driving
o Communication/social interaction
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o Household management
Questions:
 Do you ask them about spirituality?
 Do you ask them about sexuality?
Therapist group #4
 If you were to offer an OT continuing education course, what are you an expert in that
you could teach others?
 If you could take any continuing education course, what would it be?
 If we were designing a clinic from the ground up, what would it look like?
 Space? How allocated?
 Where would you do the activities we identified last week?
 What kind of equipment?
 What would you use it for?
Patient Group #1
 Thinking back when you first went to the concussion care clinic, what were the problems
you were having in your day-to-day life?
 How did those problems affect your daily routines and activities?
 What areas have you been working on the most in the concussion care clinic (in OT or
other areas)?
 What areas do you wish you would have had more help with? Take 2 minutes to think
about it and write it down on the paper in front of you.
 Go around the room and have each person read off their list
 Write list on white board/flip chart
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 If time, have each person rank list
 Are there any problems that you did not get help with and that you would have wanted
to?
Patient group #2
 How were goals of therapy set? What was the process?
 How have you communicated your challenges with sleep and pain to your providers?
 Choose the top 3 areas that you needed (or currently need) help with?
o Community reintegration/participation
o Managing symptoms and identifying triggers
o Medication/health management
o Schedule & routine management
o Cognition/thinking/memory
o Vision problems
o Driving
o Returning to duty or preparing for transition out of service
o Managing energy level
o Leisure participation
o Stress reduction techniques
 Are these items more or less important than sleep and pain for you?
Patient Group #3
 What did you do in any of your therapies that you felt was most beneficial?
 What did you like best about attending occupational therapy?
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 Did you do anything in any of your therapies that you thought did not work or was a
waste of time?
 What did you like least about going to the CCC?
 What do you think could be done to make it easier for active duty Marines to get the kind
of medical care they need?
Patient Group #4
 Have you heard about any treatments or programs that you did not receive but thought
would have been helpful? What were they? What about them seemed good to you?
 If you were designing a program for Marines like you, what would it look like?
 What would patients spend the most time on?
 What would be required?
 What would be optional?
 What would you skip or make lower priority?

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Chapter 6: Divergent perspectives of chronic symptoms attributed to mTBI among patients
and healthcare providers
Target Journal: Military Medicine
Abstract
Introduction: The nature of the causes of persistent symptoms among individuals who
experience mild traumatic brain injury (mTBI) events are not well understood. However,
healthcare providers and patients develop beliefs that are sometimes inconsistent with each other
about the mechanisms that cause these symptoms. In this paper, I present data about varying
patient and healthcare provider perspectives about the causes of symptoms that are attributed to
mTBI, as well as potential clinical problems created by these divergent views.
Materials and Methods: Individual interviews and focus groups were conducted in two
qualitative descriptive studies. Participants included (a) active duty service members with
histories of mTBI (study 1: n=12; study 2: n=6) and (b) healthcare providers with experience
treating this patient population (study 1: n=14; study 2: n=5).
Results: Typically, patients did not attribute chronic symptoms such as sleep disturbance,
headaches, and photosensitivity to mTBI events until they eventually sought medical attention,
which was often months or years after their injuries had occurred. Provider perspectives fell into
three main categories: (1) symptoms are caused by physiological mechanisms; (2) symptoms are
caused by psychological mechanisms; or (3) symptoms are frequently exaggerated or fabricated
for secondary gains.
Conclusion: Disparate views among providers can create confusion for patients and possibly
have negative impacts on the recovery process. However, a coordinated, collaborative approach
to patient education within multidisciplinary clinics that emphasizes the complex interplay of
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underlying factors in symptom occurrence could support continuity of care. Additional research
is needed to better understand how provider beliefs about the underlying mechanism of
symptoms affect patient outcomes.

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Introduction
A traumatic brain injury (TBI) is defined by the U. S. Departments of Defense and
Veterans Affairs as a “traumatically induced structural injury and/or physiological disruption of
brain function as a result of external force” (Management of Concussion-mild Traumatic Brain
Injury Working Group, 2016, p. 6). The criteria for mild traumatic brain injury (mTBI) include
normal findings on structural brain imaging, loss of consciousness for fewer than 30 minutes,
alteration of consciousness for fewer than 24 hours, and less than 24 hours of posttraumatic
amnesia (Management of Concussion-mild Traumatic Brain Injury Working Group, 2016). More
than 80% of the over 350,000 brain injuries reported among military service members since 2000
meet these criteria (DVBIC, 2016b). Although most people who experience an mTBI recover
completely within 3 months, 15-20% have symptoms that persist for much longer (Carroll et al.,
2014). Existing interventions for mTBI-related symptoms are designed to be delivered in the
acute phase after injury (e.g., McCulloch et al., 2015; Nygren-de Boussard et al., 2014) and there
is an absence of evidence for effective interventions in the chronic phase.
The reasons why some people recover completely and others have chronic impairment
are poorly understood. Although numerous researchers have examined the connections between
persistent cognitive, physical, and emotional symptoms and mTBI events, a clear relationship
and approach to resolving problems has proved elusive (e.g. (Brenner et al., 2010; Brenner et al.,
2009; Lange et al., 2010; O'Neil et al., 2014). Moreover, many service members with a history of
mTBI have comorbidities, including mental health diagnoses, which complicate the clinical
course (Bahraini et al., 2014; Vanderploeg et al., 2012).
The diagnosis of mTBI among military and veteran populations has been somewhat
controversial among healthcare providers and researchers ("Care of war veterans with mild
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traumatic brain injury [Letters to the editor]," 2009; Hoge, Goldberg, & Castro, 2009). Some
have argued that naming the condition “mTBI” gives an impression of a more serious, long-
lasting injury and that, in contrast, referring to such injuries as “concussions” would promote
anticipation of healing and thereby improve outcomes (Hoge et al., 2009). There is evidence that
interventions delivered during the acute phase of a concussion can promote positive expectations
of recovery and predict fewer symptoms and less disability in civilian populations (Comper,
Bisschop, Carnide, & Tricco, 2005; Ponsford et al., 2002; Snell, Surgenor, Hay-Smith, &
Siegert, 2009). However, because service members typically do not seek medical care
immediately after injury (Brenner et al., 2009), the efficacy of such approaches in the military
population is questionable. Furthermore, attributing symptoms to a previous mTBI event without
a well-documented symptom history and timeline may suggest to patients that their condition is
unlikely to improve (Vanderploeg & Belanger, 2013).
Divergent views about the nature of chronic symptoms do more than create an academic
debate, as assumptions about underlying causes inform the treatment approach for any condition
(Whyte et al., 2014). For example, the literature on chronic pain establishes that providers’ views
and assumptions about the nature of a condition affect both treatment decisions and patient
health beliefs, and possibly outcomes as well (Darlow et al., 2012; Ramond et al., 2011). For
instance, providers who have a strong biomedical orientation typically exclude psychosocial
factors in their clinical reasoning processes and are likely to promote fear-avoidance beliefs by
recommending that patients limit physical activity (Darlow et al., 2012; Nijs, Roussel, Paul van
Wilgen, Koke, & Smeets, 2013). Such beliefs are associated with poorer patient outcomes
(Ramond et al., 2011).
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In this paper, I report on the findings of qualitative research that describes diverse views
among healthcare providers and military service members about the nature of mTBI and the
mechanisms responsible for the prolonged, nonspecific sequelae. These topics pertaining to how
the condition of chronic mTBI is conceptualized were not addressed in the original research
questions, which were aimed at identifying the needs of service members after mTBI and
developing a treatment model for occupational therapy intervention. Nevertheless, the
unanticipated findings reported here emerged during semi-structured individual interviews and
focus groups, ostensibly conducted to address other aims. My intention is not to perpetuate
debate as to whether chronic symptoms are due to mental or physical causes. Rather, I report
these findings to bring awareness to potential problems that disparate views could create in
clinical practice and to suggest possible avenues for future inquiry.
Materials and Methods
The results reported in this paper were derived from a subset of findings from two
studies. The first was aimed at identifying the needs of service members with chronic symptoms
after mTBI and the purpose of the second was to establish a model for occupational therapy
intervention to optimize participation for this population. In the first study, I conducted
individual semi-structured interviews with (a) healthcare providers in a military medical facility
in Southern California who treat patients with a history of mTBI (n=14), and (b) active duty
service members who had received occupational therapy services for persistent symptoms
attributed to mTBI at the same facility (n=12). Providers in this study were recruited by members
of the research team with the goal of sampling a variety of disciplines and clinical settings.
Service members were recruited by posting fliers in the occupational therapy area of a
concussion care clinic; those who expressed interest were connected to the research team by
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clinic staff. Healthcare provider interviews lasted an average of 28 minutes (range: 7-52). I
conducted thirteen of these interviews and another member of the research team did one. Service
member interviews averaged 67 minutes in duration (range: 41-87) and were all conducted by
the author. All interviews took place between February 2015 and January 2016 and were
conducted in private offices in the military medical facility.
Data for the second study stemmed from two series of four focus groups each. The first
series included occupational therapy professionals (n=5) and the second active duty military
service members who had been previously been treated in the same concussion care clinic as in
the first study (n=6). Each focus group meeting was 60 minutes long and was held in a
conference room at the military medical facility. The focus groups were held between October
and December of 2016.
All participants in both studies completed an informed consent process. The Ohio State
University Traumatic Brain Injury Identification (OSU-TBI-ID) structured interview (Bogner &
Corrigan, 2009) was used to verify head injury history for all patient participants. The
institutional review boards of Naval Medical Center San Diego and the University of Southern
California approved both studies. All interviews and focus groups were audio recorded and
transcribed verbatim.
Data analysis was descriptive and was completed using NVivo software (QSR
International, Inc.). In the first study, I read through all of the interviews as they were
transcribed, identified initial codes, and confirmed codes relevant to the research question with
the other members of the study team who had experience as healthcare providers in military
medical facilities. The main findings of this study, which describe the occupational challenges
experienced by service members with mTBI (Chapter 4), are under review elsewhere. I identified
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the emergent themes regarding the mechanisms underlying chronic symptoms attributed to mTBI
and categorized the respective data by according to the different perspectives. Analysis of focus
group data began by using a priori codes aimed at the primary study purpose of developing a
treatment model, and additional codes were created when data did not fit existing codes or went
beyond the scope of the treatment model. When data related to the nature of chronic symptoms
emerged in this second study, I organized the findings according to the same themes identified in
the first study. These themes were confirmed through peer review by a colleague with experience
in qualitative research methods who was not involved in either the pilot or focus group study. All
names used in describing the results are pseudonyms.
Results
Participants
Demographic and background data for healthcare providers and patient participants are
summarized in Tables 6.1 and 6.2, respectively. Three providers participated in both an
individual interview in the first study and the series of focus groups in the second. All service
member participants in both studies were male enlisted Marines, with the exception of one Navy
corpsman who participated in an individual interview. Service member participants in both
studies had previously received occupational therapy treatment in a concussion care clinic, as
well as services from multiple other health disciplines within and outside of that clinic.
Variable Perspectives of mTBI
There were no explicit questions about participants’ beliefs about the underlying causes
of persistent symptoms that were attributed to mTBI, as this was not an objective of either study.
Patient participants’ views of mTBI came up in response to a question about why they had been
treated in the concussion care clinic. Providers expressed their beliefs about the nature of
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Table 6.1: Provider Background Variables
Individual Interviews (n=14) Focus Group (n=5)*
Healthcare specialty

Occupational therapy: n=4
Physical therapy: n=2
Primary care (physician; physician
assistant; nurse practitioner): n=5
Mental health (psychiatrist; psychologist):
n=3
Occupational therapy: n=5
 Occupational therapist: n=3
 Certified occupational therapy
assistant: n=2
Practice Setting

Concussion care clinic: n=7
Mental health clinic: n=2
Battalion aid station: n=3
Other: n=2
Concussion care clinic: n=4
Neurorehabilitation occupational therapy
clinic: n=1
Duty Status

Civilian: n=10 (n=1 retired from Navy)
Active duty Navy: n=4
Civilian: n=5
Gender

Male: n=5
Female: n=9
Male: n=1
Female: n=4
*Three individuals participated in both individual interviews and focus groups.
symptoms typically attributed to mTBI both by describing their treatment approach (and thus,
their underlying assumptions about the causes of symptoms) and by explaining their personal
points of view overtly.
Patient perspectives: “I never really even thought about TBI.” Commonly self-
reported symptoms included disordered sleep, memory loss, migraine headaches,
photosensitivity, difficulty paying attention, and physical pain. Most of the participating service
members in both studies stated that they did not seek immediate healthcare after an mTBI event
nor did they initially attribute the subsequent appearance of symptoms to it. As Ryan, a master
sergeant, explained,
I never really even thought about TBI. I mean, I always knew about that RPG [rocket
propelled grenade] blast and all but I never really thought anything about it, because I
never, like I said never went and saw the doctor afterwards. I just sucked it up and did my
job because I was out in the field and if I would have left, it would have been sergeants
and below [and they shouldn’t] have been by themselves.

The RPG event occurred during a deployment to Iraq, and Ryan reported a brief loss of
consciousness (approximately one to two minutes) at the time. Another service member,
Lorenzo, first learned that his symptoms could be connected to his previous head injuries when
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Table 6.2: Service Member Demographics
Individual Interviews (n=12) Focus Group (n=6)
Age (years) 35.2 (22 – 49) 36.5 (25 – 44)
Years of Service 13.7 (3 – 28) 15.6 (7 – 20)
Number of
combat
deployments
2.4 (1 – 5) 2.7 (2 – 3)
Number of
recalled lifetime
head injuries
3.8 (1 – 10)

9.0 (5 – 16)

History of blast
exposure
n=11

n=6
Marital Status Married: n=9
Unmarried: n=2
Separated: n=1
Married: n=5
Separated: n=1
Ethnicity African American: n=2
Asian American: n=1
Caucasian: n=6
Hispanic/Latino: n=3
Caucasian: n=3
Hispanic/Latino: n=3

Military rank Corporal (E4): n=1
Sergeant (E5): n=3
Staff Sergeant (E6): n=3
Gunnery Sergeant (E7): n=1
Master Sergeant (E8): n=2
Master Gunnery Sergeant (E9): n=1
Navy corpsman: n=1
Sergeant (E5): n=1
Staff Sergeant (E6): n=1
Gunnery Sergeant (E7): n=3
Master Sergeant (E8): n=1
Military
Operational
Specialty
Infantry: n=3
Logistics: n=3
Mechanic: n=3
Engineer: n=1
Reconnaissance: n=1
Corpsman: n=1
Infantry: n=3
Engineer: n=1
Ammunition & Explosive Ordinance
Disposal: n=1
Communications: n=1
Duty Status Full Duty: n=2
Limited Duty: n=4
Wounded Warrior Battalion: n=6
Full Duty: n=1
Limited Duty: n=2
Wounded Warrior: n=3
Full Duty: still in prior work role; Limited Duty: assigned to prior unit but with reduced responsibilities; Wounded
Warrior Battalion: non-deploying unit with focus on injury recovery

he saw a pamphlet posted at work: “And… they had symptoms of TBIs, we didn’t know what it
was until they had a little pamphlet hanging on the walls and I’m like, oh, I have all those
symptoms.” When he sought help for chronic insomnia, Jake’s healthcare provider identified his
history of mTBI events and referred him for specialty concussion care.
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One of the doctors at the, the psychologist that I saw, you know, started talking about
blast history and head injury history and stuff like that… They said basically, you know,
we’re going to refer you to these people because we think there might be something
physically wrong with you, is the wording he said… So, you know, I realized it at the
shop and then I vocalized it and then, you know, it was like, the running joke is that I
have brain damage.

In addition to not attributing symptoms to mTBI events, most service member participants
reported symptoms that worsened over time. All described reaching a point at which they
became overwhelmed by daily challenges or when symptoms interfered with their ability to
perform their work duties before seeking medical help. For example, Lorenzo described that he
“felt like I was doing a losing battle with it, like it just kept getting worse and worse.” In some
cases, service members were required by their commanding officers to undergo a medical
evaluation because of problems at work.
Provider perspective: “We’re trying to build new neural pathways.” Some providers
understood chronic sequelae attributed to mTBI as the result of neurological damage from the
injury event and used intervention approaches that reflected this view. For example, a physical
therapist who specializes in vestibular rehabilitation described how she relies on objective
outcome measures that assess performance of balance-related tasks for her evaluation process
and employs interventions that “retrain aspects of [vestibular] system.” Through these
interventions, patients are expected to improve their task performance over time as a result of
adaptive neural changes. Occupational therapists in both studies described using cognitive
rehabilitation strategies aimed at “brain training.” Jaclyn recounted how she explained some of
the treatment strategies to patients: “We're trying to build new neural pathways for you, and just
lots of education on you know, how the brain works and what happens after a concussion and all
that kind of stuff.”
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Providers with a neurological orientation to mTBI acknowledged that mental health was
an important consideration in developing their intervention priorities and strategies, particularly
because of the high frequency of comorbid diagnoses. Amanda, a certified occupational therapy
assistant, explained that what is unique about their practice setting was “understanding the
military versus the sports-related concussion.” She further explained that, in addition to the
neurological changes that occur as a result of a brain injury event, mental health comorbidities
create additional challenges for providers and that professionals without exposure to military
settings would not likely understand this complexity.
Provider perspective: “It’s all mental health.” Mental health professionals, in
particular, held a very different view of persistent symptoms. They tended to characterize all
symptoms as mental health issues rather than attributing them to physical injury resulting from
an mTBI event. As one psychologist who was part of the concussion care team summarized, “it’s
all mental health.” They often described a belief that the injury event had created psychological
rather than physical trauma because of the requirement of negative findings on structural
imaging. “It is a special category when they have a concussion in theater. It’s both the
concussion and the PTSD but it’s not structural effects of the concussion because the MRIs are
always clean.” Another psychology professional described the “halcyon days” effect, in which
patients attribute every headache, memory lapse, and sleep disruption to an mTBI event and
claim to have never experienced those symptoms prior to the injury event, even though such
symptoms are fairly common among healthy adults.
Providers who viewed chronic symptoms associated with mTBI as arising from
psychological rather than physical causes also believed that symptoms worsened when they were
attributed to an mTBI event.
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Concussion and mild TBI are interchangeable terms. But you go mild TBI, you know, it
has a different connotation, that this is a life-long kind of issue where it’s not going to
heal like a sprain or broken bone. And so they can get wed to that thought. So, that’s the
struggle.

One provider, a psychiatrist, suggested that more psychoeducation about the normal responses to
a combat environment and early intervention for mental health symptoms would reduce long-
term sequelae. “If we could get these men more mental health support earlier on, I think we
would have much better outcomes.” This provider did not imply that a historic mTBI could only
cause mental health challenges; rather, she believed psychological and physical injuries
“exacerbate each other… the depression …fuels the pain, which fuels the cognitive issues, and
then the insomnia. It’s all interconnected, but I think each alone is significant.” She suggested
that treating mental health needs early after deployment would help to normalize service
members’ experiences and facilitate the reduction of symptoms.
I would really like to provide a lot of psychoeducation for our men before they leave and
when they get back…And then if these men understand what’s going on with them, if
they just understand it and it’s normalized, and we give them coping mechanisms to deal
with the irritability instead of screaming and then escalating the anger… Simple things
like that can save marriages, can save families, can save careers, can prevent them from
drinking.

Provider perspective: “It all starts sounding like a tape recorder.” Several providers
across disciplines and perspectives about underlying causes raised concerns about the objectivity
of symptom reporting. Because most patient complaints are not objectively measurable and rely
on self-report (e.g., headache severity), these providers believed that some service members
exaggerated their injury and symptom reports for financial gain or to avoid work responsibilities.
As one occupational therapist explained,
A lot of guys, they are going to be compensated well for… anything that’s happened to
them in their Marine Corps career…So there’s a lot of very subjective things you can
report from a mental health category, and there’s not really a whole lot we can do to
dispute that, you know? …That’s why you really have to dig deep, because after you
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work with these guys, it all starts sounding like a tape recorder, every guy that comes in,
it’s almost like someone’s choreographing these conversations with them, because
they’re all saying the same things, you know?

Another physical therapist stated that “sometimes I don’t know how genuine they are” about
reporting symptoms, especially for patients who were in the review process for being medically
separated from the military (i.e., “med board”). All providers explained that they believed most
patient complaints were legitimate; however, those who brought up the issue of seeking care to
attain a higher disability rating at discharge from active service reported that existing assessment
tools were insufficient for impartially assessing patient progress. Moreover, they stated that they
had a responsibility to treat all patients as if their claims were valid.
Conflict in the clinical setting. Since participants were not asked specifically about
whether they had experienced conflict with others over their perspectives about the underlying
causes of chronic symptoms after mTBI, data illustrating problems in practice are limited.
Nonetheless, there were reports of issues in both a patient-provider relationship and among
providers.
All providers described part of the intervention process as educating patients about their
diagnosis and the available courses of treatment. Because providers hold diverging perspectives
of the mechanisms that cause chronic symptoms, the education patients receive from different
providers is likely to conflict regarding the underlying causes. Additionally, patients may adopt a
perspective based on the education provided by one clinician and receive a conflicting message
from another. In one case, Fred, a focus group participant who reported six blast-related injuries
in the OSU-TBI-ID interview (one with loss of consciousness; five with alteration of
consciousness) described a recent dispute with a psychotherapist.
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…they flat out told me that this is all in my head. But the provider doesn’t understand
that I’ve been blown up multiple times by IEDs and being in combat and telling me that
this is all in my head, so how does a provider come off saying those kind of comments?

In addition to interpreting this comment as a dismissal of his experience and the legitimacy of his
symptoms, Fred also noted that younger, more junior military personnel with mTBI may not be
aware of appropriate ways to respond to this kind of comment, such as filing a complaint or
requesting a different provider. This situation exemplifies one way that contrasting views among
providers and patients about the underlying causes of chronic sequelae could have a negative
effect on patient experiences.
A clinical psychologist alluded to a situation of conflict among providers. She perceived
chronic symptoms to be attributable to mental health but not to the physical effects of the injury
and described explained her process of educating patients about their injuries. “And you know,
most of them will listen to me and will get it… but sometimes staff doesn’t get it. And that
frustrates me, to have the staff – it’s like the staff that is kind of buying into that pathologizing
the patient.” Although this description was not of a specific problematic encounter, the statement
reflects the belief that attribution of symptoms to physiological mechanisms prevents patients
from recovering and that other providers were contributing to the perpetuation of disability.
Discussion
Multiple views on the underlying causes of chronic symptoms after mTBI events are
represented among healthcare providers and patients, which, in some cases, are inconsistent with
one another. Such divergent perspectives can create confusion for a patient who is trying to
understand his condition and course of treatment. As in the case of Fred as described above,
some positions are perceived by patients as invalidating their experiences of combat-related
injuries. It is beyond the scope of these studies or this manuscript to determine if a particular
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perspective is best; however, it is important to consider the evidence supporting the various
points of view as well as the possible implications for patient care and research.
Disciplinary training is likely a strong influence on the perspectives of individual
providers. Healthcare providers who had a predominantly physiological understanding of mTBI
and related symptoms represented the professions of medicine, nursing, occupational therapy,
and physical therapy. On the other hand, psychologists held beliefs that the injuries were
principally mental health concerns. Service members who participated in these studies did not
typically equate their difficulties to prior mTBI events before receiving medical care,
notwithstanding efforts within the military to promote awareness of brain injuries, such as “Brain
Injury Awareness Month” (DVBIC, 2016a), and to reduce the stigma of seeking health care
(Quartana et al., 2014).
Recent studies suggest that service members with combat-related mTBI, and specifically
blast events, have different recovery patterns than those of civilians who experience concussions.
Four different trajectories among service members have been identified: (a) good recovery with
minimal or no persistent symptoms, (b) psychiatric symptoms, (c) cognitive symptoms, or (d) a
mixture of cognitive and psychiatric symptoms (Bailie et al., 2016). Moreover, there is a
preponderance of evidence that mTBI due to blast exposure is associated with diffuse axonal
injury, resulting in white matter damage and indicating a possible structural basis for chronic
symptoms (A. L. Clark et al., 2015; Cogan, 2016; D. R. Miller et al., 2016). Miller and
colleagues (2016) reported a correlation between white matter damage and persistent physical
symptoms. Likewise, researchers have recently uncovered a pattern of astroglial scarring that
was unique to chronic blast exposure in a post-mortem tissue analysis, insinuating an additional
physiological mechanism that could be related to chronic symptoms (Shively et al., 2016). In
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addition, worsening of symptoms over time, as described by participants in interviews and focus
groups, is inconsistent with traditional models of concussion (Management of Concussion-mild
Traumatic Brain Injury Working Group, 2016). It is possible that the underlying neurological
mechanisms for symptom progression are related to white matter damage or astroglial scarring.
Psychological trauma also can alter brain physiology and has been documented in individuals
with PTSD (Karl et al., 2006), which is likely a contributing factor to symptom development and
perpetuation.
On the other hand, there is also evidence to support a “halcyon” or “good old days” effect
in which any current symptoms or complaints are attributed to an mTBI event and individuals
claim to have never experienced them prior to injury. Such reports are unlikely to be accurate
given that many of the associated symptoms such as headache and fatigue are reported among
healthy adults with no injury history (Iverson et al., 2010; Lange et al., 2010). Additionally,
studies have demonstrated positive correlations between symptom reporting and involvement in
litigation related to the injury event among civilians (Ghaffar, McCullagh, Ouchterlony, &
Feinstein, 2006; Lange et al., 2010; Williams et al., 2010). Individuals who continually are
involved in legal action have an interest in remaining disabled for financial gain, which invites
greater scrutiny into their claims of disability. Nearly all of the service members who
participated in these two studies had recently been or were expecting to be assessed for disability
ratings, which would determine their financial compensation rate upon separation from service.
The findings presented here, however, do not support the notion that symptoms worsen as
a result of attributing them to a brain injury event that meets the criteria for mTBI. On the
contrary, many service members experienced ongoing, worsening symptoms and did not connect
them to a prior injury event until after diagnosis, which was usually many months post-injury.
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The results, however, raise a number of crucial questions. First, how do inconsistent messages
from different providers about a condition affect patients? At best, patients may become
confused about their condition and course of treatment; at worst, they might abandon helpful
therapeutic approaches based upon the beliefs they adopt. Studies of the experiences of patients
who have received concurrent care from multiple providers could help to illuminate answers to
this question, as could investigations of implicit and explicit provider assumptions regarding
mechanisms to identify commonalities and differences across disciplines.
Second, what happens if a patient expects a complete recovery from an injury event and
does not exhibit evidence of physical injury on outcome measures or imaging studies, yet
continues to experience symptoms? A lack of physiological evidence for the cause of a person’s
symptoms does not support a conclusion that their symptoms are not real or valid, as existing
clinical tools may not be sufficiently sensitive to detect relevant biological factors. Alternatively,
symptoms may be chiefly psychological in nature. However, there is evidence that pain of
psychosomatic origin is often dismissed as being in the patient’s imagination, suggesting that the
patient is at fault (Toye & Barker, 2010). Such attitudes from providers are not conducive to
effective care and minimize patient experiences and self-knowledge. Some studies on the best
approaches to ameliorate persistent symptoms or compensate for them in everyday life have been
done (e.g., (Azulay et al., 2013; E. G. King et al., 2013) and more research is needed until
efficacious interventions are found. In the interim, providers should be aware that there is likely
a complex interplay between biological and psychological mechanisms in the development of
chronic symptoms.
The present findings imply a need for a shared understanding of mTBI and related
symptoms across healthcare professions, and especially within multidisciplinary clinical settings.
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Furthermore, patient education should be consistent among providers and acknowledge both
physiological and psychological aspects of mTBI. Regardless of the underlying causes, teaching
patients compensatory strategies for symptom management and participation in daily life can be
included in all interventions.
Strengths and Limitations
This research identified a potentially important clinical problem – disparate
understandings of the mechanism underlying symptoms attributed to mTBI among healthcare
professionals and patients. To the best of my knowledge, such perspectives have not been
previously investigated. The inclusion of service members and healthcare providers in both
studies allowed for comparison of their points of view as well as some insight into possible
consequences of mismatched perceptions. Although active duty service members have been
included in cross-sectional studies, their perspectives are not well represented in the literature,
therefore this paper adds their voices to the larger body of knowledge.
The current findings were extracted from two small qualitative studies that were
conducted as part of a doctoral research project, with nearly all interviews and focus groups
conducted by the author. Although there was a peer review of the thematic coding process and
findings, this reliance on a single researcher for the bulk of data collection and analysis increases
the potential for bias in the findings. The objectives of the qualitative studies from which these
data originated were to identify patient needs and to develop a treatment model of occupational
therapy practice with this patient population. I did not focus on patients’ or clinicians’ views of
chronic symptoms that are attributed to mTBI. More work is needed to better understand how
these perspectives manifest in clinical encounters as well as in multidisciplinary collaboration
among healthcare providers. The service members who participated in this study represent only
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one military branch (Marines) and were all treated in the same concussion care clinic. A further
limitation is the possibility that patients who participated in the study were not completely
accurate or truthful in describing their symptoms and healthcare experiences. Additionally, all
but one of the participating clinicians worked at the same military base, although they
represented different specialties and clinical settings.
Conclusions
Although it may be useful to have different conceptualizations of illness to drive research
on diverse approaches to treatment of persistent symptoms associated with mTBI events,
multiple perspectives can be problematic in a clinical setting. Different messages to patients
about the nature of their symptoms and the best approaches to resolve them could create
uncertainty and discontinuity of care within a clinic. These issues may be mitigated by an
intentional, collaborative, multidisciplinary approach to patient education that minimizes
confusion and respects service members’ experiences. Going forward, deeper investigation into
the clinical implications of divergent professional perspectives is essential.

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Chapter 7: Conclusions, Reflections, and Next Steps
There were two specific aims guiding this dissertation work. First, I set out to create a
conceptual model of the construct of participation. Second, I sought to develop a treatment
model of occupational therapy intervention for military service members with chronic symptoms
following mTBI. Below is a summary of the findings, implications, my reflections on the
research process, and a description of possible next steps to continue this line of research.
Summary of Key Findings
The third chapter of this dissertation presents a conceptual framework of the construct of
participation. After a thorough review of the literature, I (working closely with Dr. Mike
Carlson) identified performance, subjective experience, and interpersonal connection as the
essential components of what is called participation. In order to participate, individuals must
choose from the opportunities that are available to them. This paper represents a unique
contribution to the literature by categorizing participation into two contexts – interventional and
community-based. Although both are contexts have previously been referred to in the literature,
what we named as interventional participation has been characterized as patients’ engagement in
a medically prescribed process, such as adherence to a healthcare provider’s recommendations or
the display of enthusiasm during a therapy session. Instead, I have characterized interventional
participation as a specialized context in which participation occurs, but one in which the
subjective experience of the patient and interpersonal connections between the individuals
present for the intervention are still relevant. Moreover, in contrast to the “more is better” idea
about participation that pervades the literature, the model emphasizes that the role of
participation as being either a health-promoting or harmful is determined by the individual life
circumstances of the person who is participating.
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The results of the pilot study are conveyed in Chapter 4. Service members indicated
needs across all areas of the occupational therapy domain of practice, with sleep disruption being
reported by all as a significant challenge. These findings helped to formulate the focus group
questions for the second study of this dissertation. Furthermore, clarity of future plans was
variable with seven of 12 participants describing only vague ideas about what they would do
after the conclusion of their military service. This result highlights the need for interventions
with service members in this transitional period to address preparation for civilian life, including
short- and long-term goal setting. Many service members identified a spouse or family members
as their strongest sources of support. Military culture played a significant role in how and when
service members sought care for chronic symptoms. In all but two cases, service members did
not seek any assistance after the initial injury event. Instead, they waited until symptoms
significantly interfered with their ability to perform their day-to-day routines. These themes will
be useful to consider in the future development of intervention protocols.
Chapter 5 of this dissertation embodies the bulk of the focus group study, which
culminated in a matrix in which treatment targets are mapped to active ingredients and
hypothesized mechanisms of action. The matrix represents current occupational therapy practice
for military service members who experience chronic symptoms after a diagnosis of mTBI and
lays the groundwork for the development of an intervention protocol for a future efficacy study.
In addition to the matrix, four themes emerged – therapeutic relationship, consistent inclusion of
family members, combat vs. non-combat injuries, and role of military culture – that can further
inform the overall structure of an intervention protocol. These findings may also be useful for
current practitioners in planning their treatment strategies, especially those who are new to a
military practice setting.
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In Chapter 6, I present a surprising finding that arose during my pilot work and again in
the focus group study about the various perceptions about the attribution of chronic symptoms to
an mTBI event. Among military service members, mTBI diagnoses are often made
retrospectively and frequently coincide with mental health diagnoses such as PTSD. Providers
across the pilot study and focus groups shared perceptions characterized chronic symptoms either
as resulting from (a) a primarily physiological injury with some concurrent mental health issues,
(b) mental health issues without any organic brain alterations, and (c) sometimes as malingering
for financial gain or work avoidance. I was curious about these different perspectives as they
came up during my pilot work and realized their potential significance when a patient in the
focus group study shared that a provider had told him “it’s all in your head,” which he found
upsetting and disrespectful of his combat experiences. The paper raises some important questions
about how providers understand a condition, how they communicate with one another, and how
variable points of view could impact patient care.
Implications
Future research. The participation framework, if accepted within the rehabilitation
community, offers a somewhat different perspective than what has been represented elsewhere in
the literature that could inform the design of future research, interventions, and measurement
tools. It is possible that the model could be revised if future findings uncover new related
concepts or further explicate constructs already contained in the framework. It may also
influence the way healthcare providers think about patient participation in treatment encounters.
Specifically, the view of interventional participation as being based on opportunity and choice,
as well as emphasis on the subjective experience and interpersonal nature of therapy in addition
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to patient performance could bring attention to the roles that institutions and providers have in
supporting patient participation in treatment.
Further work is needed before a potentially effective occupational therapy intervention to
enhance participation of service members with chronic symptoms after mTBI is ready to be
evaluated in a randomized controlled trial. Research similar to the focus group study with
representation from a greater variety of clinics will help to ensure that the matrix is valid
complete, as would use of data from different sources such as medical records and observation.
Additionally, new active ingredients may be identified through literature review.
The findings described in Chapter 6 identify a need for further research into the
alignment between provider beliefs and patient outcomes. Additionally, there is a more
immediate need for collaboration and cooperation among healthcare providers with different
disciplinary backgrounds to come to a shared understanding about mTBI to guide delivery of
consistent patient education, particularly in multidisciplinary clinics.
Occupational science. My dissertation has at least three implications for the discipline of
occupational science. First, Chapter 3 incorporates occupational science literature on different
aspects of the conceptual model of participation together with research and perspectives from
other disciplines. As occupational science has traditionally been interdisciplinary (F. A. Clark et
al., 1991), this chapter expands on and provides further support for existing concepts, such as the
social nature of participation. Although the framework was developed with rehabilitation
population in mind, it is likely applicable to other groups and could be incorporated into the
design of future studies.
Second, military populations have not previously been studied in occupational science
research. My findings include insights into military culture and how it influenced the processes
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of seeking healthcare and planning for life after military service. The influence of military
culture on occupation choice and performance, social participation, or other concepts may be of
interest in future occupational science research. I have previously written about military
deployment as an occupational transition and these data about military culture could also provide
a lens through which to study the experience of transitions from the perspectives of military
service members and their families (Cogan, 2015).
Third, the intervention mapping methodology that I used to create the treatment model in
Chapter 5 may be a tangible way to link occupational science research to occupational therapy
practice. The founders of occupational science intended that basic occupational science research
would “reshape” occupational therapy practice (Zemke & Clark, 1996), but this translation has
arguably not occurred consistently. Using a modeling approach to intervention development that
includes the theoretical basis for each intervention approach may be useful to build a bridge
between basic research and intervention design.
Limitations
A single researcher, principally, conducted the work described in this dissertation.
Although I received close guidance from Dr. Mike Carlson while developing the participation
framework and others participated in study administration at NHCP, it is possible that a larger or
different team of researchers would have organized their findings differently. The focus group
patient participants represented only a single clinic site and were all Marines. Because each
service division has different job functions, patient experiences may vary among branches. Only
two clinics were represented among the occupational therapy provider participants. Other clinics
may use different treatment strategies. As described by one of my coauthors in Chapter 4, the
role of occupational therapy varies among military concussion care clinics. Moreover, there may
132

be strategies other than intervention mapping or the treatment theory model (Whyte et al., 2014)
that would be equally or more effective for defining an intervention. Nonetheless, because I had
a consistent group of participants throughout the focus group study, I was able to increase the
credibility of my findings through member checking by presenting initial analyses of content to
each group at subsequent meetings. In addition, the analysis of the themes in Chapter 6 about
disparate perspectives of the nature of chronic symptoms was reviewed by one of my peers.
Reflections on the Research Experience
In hindsight, I recognize the ambitious scale of my original research proposal.
Establishment of treatment theory is a relatively new idea, and I chose to approach the task by
adapting intervention mapping methodology. Although I believe this methodology was
appropriate for the study aims, the size of the task proved to be greater than I had anticipated.
Going forward, I would recommend that such an undertaking be approached with a team and aim
for representation from multiple institutions.
I realized shortly after beginning the data collection process that I began with biases
about occupational therapy professionals. As an occupational therapist myself, I assumed shared
values and understandings which turned out to be inaccurate. This recognition forced me to self-
reflect and explicate the biases and beliefs that I brought into the study and to maintain ongoing
awareness about them in the context of the group meetings. For instance, I had assumed that the
occupational therapy group members would have greater interest in expanding their practices in
response to some of the needs identified by patients, such as sleep and chronic pain management.
Instead, they expressed that there was no need for them to focus on these areas because other
providers were addressing them. Furthermore, the occupational therapy professionals perceived
other needs, such as vision therapy, to be of far greater importance and prioritized training and
133

attainment of equipment for those purposes that they believed were not yet being adequately
addressed. In contrast, I had few pretenses about the experiences of the Marines in my focus
group study because I did not have a shared experience with them.
The recruitment of occupational therapy professionals to participate in the study proved
to be more challenged than I had predicted. Although all study activities were scheduled outside
of work hours and did not involve sharing any sensitive patient information, there may have been
other factors related to scheduling, such as family or other outside commitments, which limited
professionals’ willingness or ability to participate. In the effort to bridge the gap between
research and practice, front-line clinicians will need to be engaged in the process alongside
researchers. In the future, it may be useful to engage clinical leaders early in the research process
to mitigate any concerns about possible conflicts of interest, identify optimal days and times to
accommodate busy clinic schedules, highlight the value of clinicians’ engagement in research,
and promote the potential benefits of participation such as networking with other professionals
and producing clinically relevant research.
The unexpected retirement of my collaborator, LCDR Eric Harmon, shortly after the
study received IRB approval created delays in moving forward with recruitment of both patients
and providers. In future research with military medical facilities, I will plan to have a larger team
and incorporate both civilian and active duty collaborators to mitigate against unpredictable
changes in personnel. I was fortunate that CDR Paul Sargent, the director of the Concussion Care
Clinic, was very supportive of my work and stepped in to serve as the Navy principal
investigator for the remainder of the study.
One of the most powerful things I learned from the focus groups was that patients were
less concerned about the specifics of what providers did than they were with how they did it. The
134

most important aspects of the intervention process that patients raised were not about which
skills they learned or improved upon, but were instead about the welcoming environment, the
feeling that their therapist was invested in the process and focused on their goals, and that
everyone in the clinic knew their name. This finding also supported my framework of
participation, in which interpersonal connection is crucial in both the interventional context and
in the community. Although the therapist group talked about the importance of building rapport,
they were much more concerned with being able to offer a range of services and specialty
equipment. In contrast, patients rarely mentioned devices they used in therapy other than the
smart phones that they already had.
Possible Next Steps
My original plan had been to use the matrix of treatment targets to develop a manualized
occupational therapy intervention. I now feel that a manual would be premature at this stage, as
additional formative research is necessary to create a protocol that is more likely to be effective.
Different research methodologies, such as secondary analysis of medical record data, may be
useful to bolster the matrix of treatment targets. Because the findings presented in this
dissertation relied entirely on qualitative data, quantitative findings of treatment documentation
could uncover how frequently different active ingredients are being used, how they correlate to
patient outcomes, the intensity of intervention, and other variables. Quantitative data could also
corroborate or challenge the qualitative descriptions of occupational therapy practice.
Observation of current practice might also yield new insights, as could representation of
occupational therapy professionals from a variety of clinics.
In the context of intervention development, it will be important to identify the most
appropriate outcome measures for the treatment targets and the hypothesized mechanisms of
135

action. For example, for the treatment target of managing acute and chronic stress, the
hypothesized mechanisms of action for the various active ingredients included the establishment
of habits, an increase in self-efficacy for stress management, and an increase in the ability to self-
regulate. Ideal measures would assess not only whether acute and chronic stress are improved,
but also whether they changed because of the predicted mechanisms. Another area for
exploration is to identify what qualities make an individual more likely to respond to particular
treatment approaches. This kind of research could help to tailor interventions and maximize the
use of treatment time, thereby reducing overall costs.
The two areas identified by patients as being continually problematic – sleep dysfunction
and chronic pain – fall within the scope of occupational therapy practice. Yet, in the present
study, the occupational therapy practitioners provided only limited patient education for these
concerns because their patients received treatment from other providers. Both issues are complex
and patients reported that other approaches (e.g., medication, physical therapy) were marginally
effective, at best. Thus, it is reasonable for occupational therapists to take on a larger,
complementary role in addressing both sleep dysfunction and pain. Nonetheless, there remains a
need for more occupational therapy research on these topics.
Although describing beliefs about the underlying causes of symptoms that are commonly
attributed to mTBI was not an aim of my dissertation research, the diverse perspectives that
emerged during the pilot study interviews and focus group discussions raise several questions for
future investigation. These findings point to possible discord among colleagues as well as
confrontational interactions between providers and patients. Future work could examine how
these views are borne out in practice, how they relate to the therapeutic relationship, and their
136

connection to patient outcomes. Additionally, it is possible that perspectives have evolved over
time as new research is published, particularly in neuroscience.
In conclusion, this dissertation research has addressed a gap in the literature as well as
created many new questions and possible directions for future work. The multifaceted elements
of participation also suggest possibilities for new and diverse ways to measure outcomes in both
military and other populations. Major combat operations in Iraq and Afghanistan have ended and
therefore the number of new combat-related mTBI injuries is declining. Yet, service members
who have already suffered from long-term symptoms will continue to seek assistance in both VA
and civilian healthcare settings. In treating these patients, clinicians (and occupational therapy
professionals, in particular) should not undervalue the significance of the therapeutic
relationship. Establishing and maintaining this rapport should be a central feature of intervention
design.

137

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Abstract (if available)

Abstract Chronic symptoms attributed to mild traumatic brain injury (mTBI) among military services members can disrupt engagement in important activities and life roles. In addition, service members with persistent sequelae after mTBI typically have comorbidities such as mental health diagnoses and chronic pain. Occupational therapy intervention for this population is not well described nor is there substantive evidence to support particular treatment strategies. The general goal of an occupational therapy intervention for military service members with mTBI is to improve their participation in daily life. Although participation is frequently described as an important outcome of rehabilitation interventions, it is not consistently defined or operationalized in practice. ❧ This dissertation consists of two main studies. The purpose of the first study was to define a conceptual framework of participation for rehabilitation. The second study was aimed at developing a treatment model of occupational therapy intervention for military service members with chronic symptoms after mTBI. Prior to beginning these two dissertation studies, I conducted a pilot study, OT for TBI, in which I investigated the occupational needs of service members who receive occupational therapy services for chronic mTBI symptoms. The results of the two dissertation studies and a portion of the results from the pilot study are presented in the form of four manuscripts (Chapters 3, 4, 5, and 6), each of which is tailored to the audiences and formats of the targeted journals. ❧ Chapter 3 (under review at Disability and Rehabilitation, co-authored with Dr. Mike Carlson) conveys the findings of the first study, which is an interpretive synthesis of the literature describing participation and related constructs as they relate to rehabilitation. Our analysis identified that participation consists of three essential dimensions, which we labeled (1) performance, (2) subjective experience, and (3) interpersonal connection. Furthermore, we found that although participation usually referred to community engagement, it was sometimes used to describe what patients do in the treatment setting. We characterized these two distinct contexts in which participation occurs as community-based and interventional. In both settings, participation is predicated by choice from among available opportunities. We created a conceptual framework to incorporate all of these elements and postulate relationships among them. A key finding of this study was that participation is not necessarily a positive or health promoting endeavor

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Asset Metadata

Creator Cogan, Alison M. (author)

Core Title Optimizing participation of military service members with chronic symptoms after mild traumatic brain injury

School School of Dentistry

Degree Doctor of Philosophy

Degree Program Occupational Science

Publication Date 04/03/2017

Defense Date 03/06/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag clinical practice,community integration,mild traumatic brain injury,military personnel,OAI-PMH Harvest,Occupational Science,Occupational therapy,participation,Rehabilitation

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Clark, Florence A. (committee chair), Carlson, Michael (committee member), Lawlor, Mary C. (committee member), Pyatak, Elizabeth (committee member), Ryan, Margaret (committee member)

Creator Email acogan@usc.edu,alisonc79@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-351367

Unique identifier UC11258262

Identifier etd-CoganAliso-5157.pdf (filename),usctheses-c40-351367 (legacy record id)

Legacy Identifier etd-CoganAliso-5157.pdf

Dmrecord 351367

Document Type Dissertation

Rights Cogan, Alison M.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA