Toward Effective Virtual Reality–Based Go/No-Go Cognitive Training to Support Return-to-Activity Following Mild Traumatic Brain Injury in Service Members

INTRODUCTION: Service members recovering from mild traumatic brain injury (mTBI) frequently experience deficits in decision-making, impulse control, and multisensory integration-domains crucial for safe and accurate threat discrimination in complex operational environments. Traditional rehabilitation tools lack immersive, ecologically relevant scenarios that replicate the cognitive-motor demands of combat. To address this gap, the RehabXR system, a portable virtual reality (VR) platform, integrates Go/No-Go decisions into a realistic warfighter-relevant virtual environment. This study explores whether the RehabXR system can assess and train inhibitory control in a cohort of Special Operations Forces (SOF) personnel with a history of mTBI. MATERIALS AND METHODS: The RehabXR system includes a VR headset, laptop, router, and a 3D-printed replica M4 rifle. Among its training modules, the Barricade Wave Defense game incorporates Go/No-Go demands by presenting civilian (No-Go) and enemy (Go) stimuli. Two metrics quantified inhibitory control: Civilian Hit Rate (commission errors; hits/min) and Dwell Ratio (percentage of aim time directed at civilians vs. civilians plus enemies). Fifteen SOF personnel with persistent vestibular symptoms participated in a four-week rehabilitation program at the Center for the Intrepid. Linear regression for each participant evaluated changes in inhibitory control over time, reporting slopes and coefficients of determination (R2). RESULTS: Performance patterns varied across participants. Six of 15 never hit civilian targets, reflecting intact inhibitory control. Among the remaining nine, trends generally showed declining Civilian Hit Rates over repeated gameplay. For example, one participant (Participant 11) demonstrated a negative slope (-0.55 hits/min/round; R2=0.46), indicating improving inhibitory control across eight rounds. Dwell Ratio, a more continuous indicator of intent, could be calculated for all participants. Thirteen participants demonstrated an average declining slope of -0.21%/day (mean R2=0.44). Individual examples (e.g., Participant 2) showed clear reductions in dwell time on civilians across treatment sessions, supporting improvement in inhibitory control. CONCLUSIONS: Preliminary findings suggest that the RehabXR system effectively integrates Go/No-Go cognitive training into an immersive, combat-relevant VR environment and offers quantifiable metrics of inhibitory control. Across a four-week program, SOF personnel with mTBI generally demonstrated improved restraint, reduced dwell behavior, and fewer civilian-hitting errors. The RehabXR system addresses key gaps in existing rehabilitation tools by providing portable, multisensory, military-specific scenarios. Although promising, study limitations include small sample size, individualized game settings, and restricted civilian stimuli. Future work should employ standardized scenarios, expand Go/No-Go complexity, and evaluate larger cohorts to validate RehabXR's utility for return-to-duty assessment.