Objectives: PTSD and mTBI are persistent and frequently comorbid in the military community, yet current therapies often achieve only modest impact. Motion-assisted, Multi-modular Memory Desensitization and Reconsolidation (3MDR) is a novel treatment for PTSD featuring participant-selected music and pictures and an eye movement (EM) task in an immersive virtual environment utilizing the Computer Assisted Rehabilitation Environment (CAREN). The EM task is adapted from eye movement desensitization and reprocessing (EMDR) therapy, but dismantling studies of EMDR have questioned EM benefit. The purpose of this pilot study is: 1) obtain an initial estimate of the efficacy of 3MDR in service members with comorbid PTSD and mTBI, and 2) determine the impact of the EM component of EMDR on treatment response. We hypothesize that 3MDR will significantly improve symptom severity, both with (EM+) and without EM (EM-).
Methods: Participants with probable PTSD (PCL-5 ≥ 34) and mTBI were randomized to EM+ or EM- across 10 sessions. Participants selected music and pictures representative of their trauma(s) and rated them on their level of emotional intensity. The images were used as the participant walked on the CAREN’s treadmill through the 3MDR virtual environment. While walking in the 3MDR virtual environment, participants started with a song to bring them back to the time of their trauma, and then traversed two hallways, actively walking toward emotionally evocative pictures that they then discussed with their therapist. The therapist queries about associated memories and emotions, while keywords are superimposed over the picture. EM+ participants see a ball with numbers cross the screen and recite the numbers. EM- participants continue walking toward the picture. This is repeated for up to seven pictures each session. Change in PCL-5 score from pre- to post-intervention was the primary outcome, with additional measures at 3 and 6 months.
Results: 20 enrolled participants (50% female; mean age 45) of whom 16 completed the intervention (8 EM+, 8 EM-); 9 (6 EM+, 3 EM-). 9 had resolution of their PTSD diagnosis, 2 had significant improvement in symptom severity without resolution, and 5 did not achieve significantly reduced symptom severity. The average PCL-5 score of those who completed the intervention, declined from 52.0 at baseline to 33.6 post-intervention (p < 0.01), which is a highly clinically significant improvement. Those in the EM+ achieved statistically significant improvement (p=0.01) while those in the EM- group did not (p=0.10), but the numbers are small in each group. The improvements observed in completers at the end of the intervention were largely sustained at the 3- and 6-month follow-up assessments, with average PCL-5 scores of 37.0 and 36.0 respectively. All 4 who withdrew from the study did so prior to starting in the CAREN, 3 of them because of COVID-related interruption of the study.
Conclusions: For veterans with PTSD and comorbid mTBI, 3MDR is effective and the EM component may add value. Participants were thoroughly engaged and invested throughout the intervention; allowing them to choose pictures and music to incorporate into the virtual environment represents personal investment, making withdrawal far less common than for other PTSD interventions. Further study is warranted to confirm these results. This pilot study is thus a catalyst for our currently approved follow up study, CARE4PTSD. This follow up study will further examine the impact of 3MDR on a larger scale to corroborate the reported results and include a CAPS-5 diagnostic assessment for PTSD. Most significantly, CARE4PTSD will evaluate the efficacy of the Microsoft Hololens head-mounted display and a conventional treadmill as a more cost-effective method of delivery for 3MDR, compared to the million-dollar CAREN.
Disclaimer: The authors have no conflicts of interest to disclose. The views expressed in this presentation are solely those of the presenter and do not necessarily represent those of the Uniformed Services University, the U.S. Army, Department of Defense, the Defense Health Agency, or the U.S. government and should not be construed as such.
