vestibular physical therapy treatment of individuals exposed

MILITARY MEDICINE, 00, 0/0:1, 2021

Vestibular Physical Therapy Treatment of Individuals Exposedto Directed Energy

LTC Carrie W. Hoppes, SP, USA*; Karen H. Lambert, DPT†; Brooke N. Klatt, DPT, PhD‡;Orlando D. Harvard, DPT‡; Susan L. Whitney, DPT, PhD‡

ABSTRACTIntroduction:Following suspected sonic attacks onU.S. Embassies, a subset of individuals presentedwith a unique cluster of symptomsbelieved to have resulted from exposure to directed energy. Directed energy has been described as exposure to a uniquesound/pressure phenomenon such as infrasonic or ultrasonic acoustic or electromagnetic energy. The Joint Force does nothave an established protocol to guide vestibular physical therapy for individuals exposed to directed energy. Therefore,we have provided evidence-based guidance for the treatment of oculomotor- and vestibular-related impairments fromsimilar populations.

Materials and Methods:Published evidence was used to inform suggestions for clinical best practice. We offer resources for the management ofnon-oculomotor- and non-vestibular-related impairments, before discussing physical therapy interventions for dizzinessand imbalance.

Results:The physical therapist should design a treatment program that addresses the individual’s health condition(s), bodystructure and function impairments, activity limitations, and participation restrictions after suspected directed energyexposure. This treatment program may include static standing, compliant surface standing, weight shifting, modifiedcenter of gravity, gait, and gaze stabilization or vestibular-ocular reflex training. Habituation may also be prescribed.Interventions were selected that require little to no specialized equipment, as such equipment may not be available in allsettings (i.e., operational environments).

Conclusions:Evidence-based guidance for prescribing a comprehensive vestibular physical therapy regimen for individuals exposed todirected energy may aid in their rehabilitation and return to duty. This standardized approach can help physical therapiststo treat complaints that do not match any previously known medical conditions but resemble brain injury or vestibularpathology.

INTRODUCTIONIn 2016 and 2017, U.S. government personnel in U.S.Embassies in Havana, Cuba, and Guangzhou, China, reportedexposure to a sound/pressure phenomenon. Following thesesuspected sonic attacks, a subset of individuals presentedwith a unique cluster of symptoms believed to have resultedfrom exposure to directed energy. Directed energy hasbeen described as exposure to a unique sound/pressurephenomenon1 such as infrasonic or ultrasonic acoustic or

*U.S. Army Medical Center of Excellence, Army-Baylor UniversityDoctoral Program in Physical Therapy, Fort Sam Houston, TX 78234, USA

†Hearing Center of Excellence, San Antonio, TX 78236, USA‡Department of Physical Therapy, University of Pittsburgh, Pittsburgh,

PA 15219, USAThe views and information presented are those of the authors and do not

represent the official position of the U.S. ArmyMedical Center of Excellence,U.S. Army Training and Doctrine Command, Hearing Center of Excellence,Department of the Army, Department of the Air Force, Defense HealthAgency, Department of Defense, or U.S. government.

doi:10.1093/milmed/usab202Published by Oxford University Press on behalf of the Association of

Military Surgeons of the United States 2021. This work is written by (a) USGovernment employee(s) and is in the public domain in the US.

electromagnetic energy.2 Twenty-five diplomatic personnelreported dizziness, unsteadiness, cognitive impairments, otal-gia, tinnitus, and hearing loss following the suspected sonicattack in Cuba.1 These complaints did not match any previ-ously known medical conditions but resembled impairmentstypically associated with mild traumatic brain injury and/orvestibular pathology. It is possible that the externally directedforces may have caused injuries to the peripheral vestibu-lar apparatus (semicircular canals and/or otoliths), vestibularnerve, or central vestibular pathways. Such injuries couldexplain their complaints of dizziness and imbalance andwould require vestibular physical therapy to facilitate reha-bilitation and return to duty.

Jauchem and Cook described three categories of poten-tial effects of audible, acoustic energy: (1) aural effects(temporary or permanent effects on hearing), (2) extra-auraleffects because of activation of the sympathetic nervous sys-tem (increased heart rate and blood pressure), and (3) non-aural effects (pain, vertigo, nausea, and vomiting).3 Theauditory organs could be injured by focused sound with large-amplitude pressure waves via direct pressure transmissioninto the cochlea.4 The possible effects of infrasonic and

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PT Treatment Following Directed Energy Exposure

low-frequency acoustic energy were less clear.3 It has beenhypothesized that multiple sources of ultrasound (acousticfrequencies higher than humans can perceive) can, throughnon-linear interactions, form a focal composite wave pro-ducing audible sensations and inducing biologic disruption.5

Others have proposed that the symptoms reported in Cubacould be because of mild brain injury, a functional disorder,or even mass hysteria or mass psychogenic illness.6

Hoppes et al. proposed a physical therapy evaluation pro-tocol for individuals exposed to directed energy.7 However,there is no established protocol to guide vestibular physi-cal therapy interventions for individuals exposed to directedenergy. The primary purpose of this manuscript is to pro-vide evidence-based guidance for the treatment of personsexposed to directed energy who present with oculomotor-and vestibular-related impairments. Individuals exposed todirected energy have also reported cognitive deficits, otalgia,tinnitus, hearing loss, epistaxis, headache, photophobia, sleepdisturbance, anxiety, and neuroendocrine dysfunction (NED).We offer resources for the management of non-oculomotor-and non-vestibular-related impairments, before discussingphysical therapy interventions for dizziness and imbalance ingreater detail. Interventions were selected that require littleto no specialized equipment, as such equipment may not beavailable in all settings (i.e., operational environments).

Management of Non-Oculomotor- andNon-Vestibular-Related Impairments

Individuals exposed to directed energy who report cogni-tive impairments can be managed according to the CognitiveRehabilitation for Service Members and Veterans FollowingMild to Moderate Traumatic Brain Injury DoD Clinical Rec-ommendation (available at https://health.mil/Reference-Center/Publications/2020/07/30/Cognitive-Rehabilitation-for-Following-Mild-to-Moderate-TBI-Clinical-Recommendation-Full). Those with otalgia, tinnitus, and hearing loss may benefitfrom referral to an otolaryngologist and/or audiologist. Becket al. offer a treatment algorithm for epistaxis.8

Headache was reported by 76% (16 out of 21) of indi-viduals exposed to directed energy with 57% (12 out of 21)requiring medication for management of their headache.9

Individuals who report headache can be managed accordingto the Management of Headache Following Concussion/MildTraumatic Brain Injury: Guidance for Primary Care Manage-ment in Deployed and Non-Deployed Settings DoD ClinicalRecommendation (available at https://health.mil/Reference-Center/Publications/2020/07/31/Management-of-Headache-Following-ConcussionmTBI-Clinical-Recommendation).

Photophobia was reported by 82% (9 out of 11)of individuals exposed to directed energy.9 Dependingon comorbid symptoms, complaints of photophobia mayrequire referral. As an acute ocular symptom, severe pho-tophobia is considered a serious concern and warrantsurgent referral to ophthalmology/optometry.10 Photophobia

without associated headache requires non-urgent referralto optometry/ophthalmology.10 Uncontrolled headache withphotophobia requires non-urgent referral to neurology/neuro-ophthalmology.10

Sleep disturbance was reported by 86% (18 out of 21)of individuals exposed to directed energy with 71% (15 outof 21) requiring medication.9 Individuals who report sleepdisturbance can be managed according to the Managementof Sleep Disturbances Following Concussion/mTBI: Guid-ance for Primary Care Management in Deployed and Non-Deployed Settings DoD Clinical Recommendation (availableat https://health.mil/Reference-Center/Publications/2020/07/31/Management-of-Sleep-Disturbances-Following-ConcussionmTBI-Clinical-Recommendation).

Specific interventions for anxiety following directedenergy exposure have not been published. However, individ-uals with anxiety following directed energy exposure may bemanaged similar to thosewith an anxiety/mood clinical profilefollowing sport-related concussion. Management may includepsychoeducation, behavioral regulation, addressing sleep dis-turbances, physical activity, desensitization to environmentalstimuli, and/or psychotherapy.11

Symptoms of NED may include fatigue, insomnia, cog-nitive impairments (to include difficulty concentrating), andemotional and mood disturbances.12 Individuals with NEDcan be managed according to the Indications and Conditionsfor Neuroendocrine Dysfunction Screening Post Mild Trau-matic Brain Injury DoD Clinical Recommendation (availableat https://health.mil/Reference-Center/Publications/2020/07/31/Indications-and-Conditions-for-Neuroendocrine-Dysfunction-Screening-Post-Mild-TBI). Similar to individuals withpost-concussion syndrome who present with ongoing cen-tral and systemic physiologic regulatory dysfunction aftertraumatic brain injury,13 we believe that individuals exposedto directed energy with NED benefit from an individuallyprescribed, symptom-guided aerobic exercise program.

Treatment of Oculomotor Impairments

Smooth Pursuit

Swanson et al.9 reported that 91% (10 out of 11) of indi-viduals exposed to directed energy had pursuit impairments.Abnormalities in smooth pursuit eye movements are usuallyassociated with central vestibular or cerebellar disorders.14

To address this impairment, the individual is asked to fol-low a slowly moving target (fingertip or pen tip) horizontally,vertically, diagonally, or circularly. The individual shouldbe instructed to, “follow the target as accurately as possiblewith your eyes.” We found no evidence describing smoothpursuit exercise prescription for this or similar populations.Therefore, based on expert opinion, the authors recommendprescribing 5-10 repetitions of smooth pursuit three timesdaily for a total of 10-12minutes per day. So as not to exceedthe limits of the smooth pursuit system, the target speed mustbe below 100◦/second.15 The physical therapist can use the

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testing parameters described in the Vestibular/Ocular MotorScreening, moving the target at a rate requiring∼2 seconds togo fully from left to right (a distance of 0.91m (3 feet)) whenseated 0.91 m from the individual.16 Smooth pursuit trainingcan be varied by changing the target speed, distance from thetarget, and the complexity of the background.

Saccades

Swanson et al.9 reported that 82% (9 out of 11) of indi-viduals exposed to directed energy had abnormal saccades.Abnormalities in saccadic eye movements are usually associ-ated with central vestibular or cerebellar disorders.14 To treatimpaired saccades, an individual is asked to rapidly shift gazebetween two targets (horizontally and/or vertically). The indi-vidual should be instructed to, “shift your gaze quickly andaccurately between these two targets.” We found no evidencedescribing saccadic exercise prescription for this population,however, Clark et al. describe training using saccadic eyecharts for individuals with sport-related concussion.17 Clarket al. recommended performing 20minutes of saccadic train-ing two times per week in an athletic population.17 Furtherresearch is needed to determine exercise prescription for indi-viduals exposed to directed energy. Saccade training can bevaried by changing the speed, distance from the charts/targets,and the complexity of the background.

Vergence

Swanson et al.9 reported that 67% (10 out of 15) of individualsexposed to directed energy had a near point of convergencegreater than 6 cm. To treat convergence, the individual isasked to follow a target slowly moving toward their nose inthe sagittal plane. There are multiple variations of this exer-cise. During pencil push-ups, the patient focuses on a pencileraser as it is slowly moved toward the nose. Brock’s string(a string with multiple, colored beads spaced along its length)can also be used; with the string held to the tip of their nose,the individual is asked to focus on one of the colored beads andthen to fixate on a different colored bead (shifting their gazenearer or further) (Fig. 1). Because of the binocular visualsystem, the individual perceives an “X” made by the string,crossing at the colored bead they have fixated on. To advancethis exercise, over time the beads can be moved closer to thenose to further challenge the convergence system. We foundno published literature describing dosing parameters for useof Brock’s string in this population; however, Clark et al.describe Brock’s string training for individuals with sport-related concussion.17 Convergence training can be varied bychanging the speed, distance between the beads, the angle ofthe string, and the complexity of the background.

Treatment of Vestibular Impairments

Vestibular-Ocular Reflex

Swanson et al.9 reported that 71% (15 out of 17) of individualsexposed to directed energy had vestibular-ocular reflex (VOR)

impairment. The VORx1 viewing exercise is prescribed forthe treatment of gaze instability. In this exercise, the indi-vidual fixates on a stationary target, while they slowly movetheir head left and right (Fig. 2).18 The speed of head move-ment should be just below the point at which the patientreports that the target begins to move or blur. We found nopublished literature describing use of VORx1 viewing in thispopulation; however, it is commonly used for treating VORimpairments. For the treatment of acute unilateral peripheralvestibular hypofunction, Hall et al. recommended perform-ing VORx1 viewing three times daily for a total of 12minutesper day.19 For the treatment of chronic unilateral peripheralvestibular hypofunction, Hall et al. recommended increasingthe frequency to three-five times daily for a total of 20minutesper day.19 This intervention is typically first performed in thehorizontal plane against a plain background. The physicaltherapist may also prescribe this exercise in the vertical plane.The VORx1 exercise can be varied by changing the speed ofhead movement, the complexity of the background, and thedistance to the target.20,21

Subjective Visual Vertical

Two studies1,9 have reported abnormal vestibular-evokedmyogenic potentials in a group of individuals exposed todirected energy. Vestibular-evoked myogenic potential testingassesses the function of the otoliths, and there is no estab-lished treatment for normalizing otolith functioning. Utricularimpairments can result in impaired subjective visual vertical(SVV). Hoffer et al.1 reported that 22 of 25 individuals (88%;prevalence 99%CI 65%-98%) exposed to directed energy hadan abnormal SVV. There is no established treatment for nor-malizing SVV. Chetana and Jayesh reported on performanceon the bucket test (a low-cost method for SVV assessment)in 100 individuals with vestibular disorders.22 Although SVVnormalized in most individuals with vestibular neuritis andbenign paroxysmal positional vertigo within 1 month,22 it isnot known if normalization was because of vestibular reha-bilitation, repositioning maneuvers, or spontaneous recovery.If SVV is impaired, working on aligning to the earth’s grav-ity with the use of a mirror (a tape/plumb line indicating truevertical can be placed on the mirror for visual feedback) withhead/body tilts might be helpful to re-establish the perceptionof true vertical. The patient is asked to, “close your eyes andlean to one side, then, come back to the position where youfeel like you are straight up and open your eyes to check yourposition in the mirror.”

Visual Motion Sensitivity

A clinical practice guideline on vestibular rehabilitation forperipheral vestibular hypofunction recommends habituationexercises as a treatment when busy visual environments exac-erbate dizziness.19 Although common in individuals withvestibular disorders, the prevalence of visual motion sensitiv-ity in individuals exposed to directed energy is not known.


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FIGURE 1. Use of Brock’s string (a string with multiple, colored beads spaced along its length). With the string held to the tip of their nose, the individual isasked to focus on one of the colored beads and then to fixate on a different colored bead (shifting their gaze nearer or further).

FIGURE 2. VORx1 viewing exercise for gaze instability. The individual fixates on a stationary target (“X”), while they slowly move their head right and left.

A simple means to habituate visual motion sensitivity is toask the patient to face a visually complex area (e.g., physicaltherapy gym). With their arm outstretched, the patient is asked

to fixate on their thumb as they rotate their head and trunk enbloc 80◦ to the right and left (Fig. 3). The individual perceivesblurring of the visual world. The use of optokinetic stimuli and


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FIGURE 3. Habituation exercise for visual motion sensitivity. While facing a visually complex area and with their arm outstretched, the patient is asked tofixate on their thumb as they rotate their head and trunk en bloc 80◦ to the right and left.

virtual reality environments has been shown to decrease visualvertigo symptoms when incorporated into a rehabilitation reg-imen.23,24 Exposure to optokinetic stimuli has been used in thetreatment of service members with traumatic brain injury.25

Following sport-related concussion, a combination of vestibu-lar, oculomotor, and optokinetic treatment was effective indecreasing symptoms and postural instability in a professionalice hockey player.26 Although optokinetic stimuli are oftenutilized by clinicians, evidence-based stimulus parameters fordelivery of optokinetic stimuli are not yet known. There ispreliminary evidence supporting the use of a fixation targetduring habituation exercises.27 The authors recommend thistreatment approach for patients with visual motion sensitiv-ity after directed energy exposure. The training can be variedby changing the complexity, contrast, speed, and direction ofmoving visual stimuli.

Static and Dynamic Balance

Swanson et al.9 described static and dynamic balance deficitsin individuals exposed to directed energy. Scores on theBalance Error Scoring System ranged from 7 to 50 (higherscores indicate greater impairment) with a mean score of 29in 16 individuals exposed to directed energy.9 The samplereported in Swanson et al. had a mean age of 43 years; nor-mative performance for 40-49 year old healthy, community-

dwelling adults is a mean score of 11.88 (5.40).28 Scoreson the Functional Gait Assessment ranged from 18 to 30(lower scores indicate greater impairment) with a mean of26 in 17 individuals exposed to directed energy.9 Scores onthe Sensory Organization Test ranged from 20 to 78 (lowerscores indicate greater impairment) with a mean of 55 in 15individuals exposed to directed energy.9

Klatt et al. have proposed six different exercise categorieswhen developing a balance program aimed at improvingpostural control: static standing, compliant surface stand-ing, weight shifting, modified center of gravity, gait, andgaze stabilization or VOR training.18 The authors believe thisapproach can be used in the population exposed to directedenergy. Progression of exercises includes five stance posi-tions (in order of increasing difficulty as the base of supportbecomes narrower: feet apart, feet together, semi-tandemRomberg, tandem Romberg, and single-leg stance) and foursurface types (in order of increasing difficulty: firm, firm withincline, firm with decline, and foam).18 The patient can befurther challenged by closing their eyes in all exercise cate-gories except VOR training (during which visual fixation isrequired).18 Static to dynamic standing can be progressed byincluding upper extremity movements with no weight, lightweight, heavier weight, or by decreasing the speed at whichlifting movements are performed.18 Head movement can beprogressed by incorporating pitch plane and then yaw plane


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head movement.18 Cognitive or manual dual-tasks can alsobe used to progress the difficulty of a balance program duringboth standing and gait.

The environment can also affect the difficulty of a balanceexercise. Whether or not the environment is quiet or loud,empty or crowded, high or low visual contrast, and predictableor unpredictable will all affect performance.29,30 Similarly,the type of compliant surface (foam density, carpet type, out-door surface type, and consistency of surface type); the typeof lighting (fluorescent, iridescent, and natural) and amountof light; the presence or absence of physical assistance (fromthe support of a physical therapist, family member, assistivedevice, or even a wall or other stable object/surface for sup-port); and the tone/inflection of the tester’s instructions orcommands will all affect performance.29 Light touch can beapplied during balance training to reduce body sway.31

Gait training can be progressed from self-selected pace tofast and finally to slow speed.32,33 Walking forward can beprogressed to walking backward. Other gait variations can beincluded to further challenge a patient such as changing gaitspeeds within a given trial, incorporating quick stops/starts,stepping over objects of different sizes, sidestepping, braid-ing, marching, completing 180◦ and 360◦ turns, walkingon toes, and/or walking on heels.34 Cognitive and/or manualdual-tasks can also be incorporated into gait training.

DISCUSSIONAlthough non-lethal, the reported effects of directed energyexposure on the U.S. government personnel negativelyimpacted their health and ability to effectively perform theirdiplomatic mission. The Joint Force does not have an estab-lished protocol to guide vestibular physical therapy for indi-viduals exposed to directed energy. The Joint RequirementsOversight Council Memorandum 019-19 (issued on March18, 2019) stated that the DoD is lacking knowledge andunderstanding of such threat sources, the pathophysiologicalresponse within the body leading to the clinical symptoms,and the ability to identify, diagnose, treat, and clinicallymanage exposed personnel. This evidence-based guidance forvestibular physical therapy is a first step in addressing gaps intreating and clinically managing exposed individuals. Basingour vestibular physical therapy treatment recommendationson the body structure and function impairments, activity lim-itations, and participation restrictions reported by a smallcohort of individuals and published en masse is a limita-tion of this work, and further research and case studies areneeded.

Hoppes et al. proposed a physical therapy evaluation pro-tocol for individuals exposed to directed energy.7 Followingthe examination, treatment should address the individual’sbody structure and function impairments, activity limitations,and participation restrictions. Based on the specific oculomo-tor impairment, smooth pursuit, saccades, and/or vergenceexercises may be prescribed. When prescribing exercisesfor oculomotor impairment, care should be taken to avoid

triggering or exacerbating headache because of overworkingthe oculomotor system.

Based on the specific vestibular impairment, gaze stabilityand/or habituation exercises may be prescribed. For individu-als with impaired gaze stability, VORx1 viewing is indicated.Although Hall et al. provided specific dosage recommen-dations for the treatment of acute and chronic unilateralperipheral vestibular hypofunction,19 dosage after directedenergy exposure has not been established. Interventions forotolith dysfunction or deficits in SVV are also not estab-lished. Dosage recommendations for the treatment of visualmotion sensitivity in individuals exposed to directed energyare not known. Although Klatt et al. have proposed a log-ical sequence in progressing balance exercises for personswith vestibular disorders,18 exercise progression after directedenergy exposure is lacking. In the absence of evidence-basedrecommendations, treatment should focus on the individual’sactivity limitations and participation restrictions. During thephysical therapy interventions suggested above, patient symp-toms should be monitored and exercise prescription modifiedbased on the patient’s response.

CONCLUSIONSEvidence-based guidance for prescribing a comprehensivevestibular physical therapy regimen for individuals exposedto directed energy may aid in their rehabilitation and return toduty. As there was no established protocol to guide rehabil-itation in this population, we provided evidence-based guid-ance for the treatment of oculomotor- and vestibular-relatedimpairments in similar populations (individuals with centraland peripheral vestibular disorders). We also offered resourcesfor the management of non-oculomotor- and non-vestibular-related impairments. Further research is needed to advancethe care of individuals exposed to directed energy whosepresentation does not match any previously known medicalconditions but resembles brain injury or vestibular pathology.

ACKNOWLEDGMENTSThe authors wish to thank MAJ Jamie Morris and 1LT Stefanie Faull for theirassistance with the figures.

FUNDINGNone declared.

CONFLICT OF INTEREST STATEMENTNone declared.

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https://academic.oup.com/milmed/advance-article/doi/10.1093/milmed/usaa562/6046745

https://health.mil/Reference-Center/Publications/2020/07/31/Assessment-and-Management-of-Visual-Dysfunction-Associated-with-Mild-TBI-Clinical-Recommendation






vestibular physical therapy treatment of individuals exposed

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