Mild TBI/Concussion Clinical Tools for Providers Used Within the Department of Defense and Defense Health Agency
Background: Military personnel are at greater risk for sustaining mild traumatic brain injury (mTBI), or concussion, whether they are in a combat or garrison setting. Consequently, mTBI is a major health concern for health practitioners to understand, in order to provide timely assessment and treatment to service members (SM) who are suspected to have mTBI.
Observations: Providing early diagnosis and effective management of symptoms can optimize recovery and promote healthy outcomes. Understanding what resources and guidelines are available is important for those evaluating active duty SMs within the Military Health System.
Conclusions: This article showcases clinical tools for screening, evaluating, and diagnosing concussion used within the US Department of Defense, and provides resources for practitioners to find these clinical tools online.
Military Acute Concussion Evaluation 2
Early concussion identification and evaluation are important steps in the treatment process to ensure timely recovery and return to duty for SMs. As such, DVBIC assembled a working group of military and civilian brain injury experts to create an evidence-based clinical practice guideline for the assessment and management of concussion in a military operational setting that could be learned and effectively used by corpsmen and combat medics in the battlefield to screen for a possible concussion.7 This team created the first version of the MACE, a clinical tool that prompted a systematic assessment of concussion related symptoms, neurologic signs, and cognitive deficits. The cognitive assessment portion was based on the standardized assessment of concussion (SAC) that had been reported by McCrea and colleagues in 1998.11 Soon after its creation, field utilization of the MACE for screening of concussion was mandated by the Army through an All Army Action (ALARACT 178/2008) and for all of the Services through the DoD Instruction (DoDI) 6490.11 published in 2014.12
The MACE has been updated several times since the original version. Most recently, the MACE was revised in 2018 to include a vestibular oculomotor assessment section, and red flags that immediately alert the HCP to the need for immediate triage referral and treatment of the patient possibly at a higher echelon of care or with more emergent evaluation.13-15 Additionally, the neurologic examination was expanded to increase clarity and comprehensiveness, including speech and balance testing. Updates made to the tool were intended to provide a more thorough and informative evaluation of the SM with suspected concussion.
This latest version, MACE 2, is designed to be used by any HCP who is treating SMs with a suspected or potential TBI, not just corpsmen and combat medics in theater. The MACE 2 is a comprehensive evaluation within a set of portable pocket cards designed to assist end-users in the proper triage of potentially concussed individuals. The DoD has specified 4 events that require a MACE 2 evaluation: (1) SM was in a vehicle associated with a blast event, collision, or roll over; (2) SM was within 50 meters of a blast; (3) anyone who sustained a direct blow to the head; or (4) when command provides direction (eg, repeated exposures to the events above or in accordance with protocols).12 Sleep deprivation, medications, and pain may affect MACE 2 results, in addition to deployment related stress, chronic stress, high adrenaline sustained over time, and additional comorbidities. This tool is most effective when used as close to the time of injury as possible but also may be used later (after 24 hours of rest) to reevaluate symptoms. The MACE 2 Instructor Guide, a student workbook, HCP training, and Vestibular/Ocular-Motor Screening (VOMS) for Concussion instructions can be found on the DVBIC website (Table 3).
Description
The MACE 2 is a brief multimodal screening tool that assists medics, corpsman, and primary care managers (PCMs) in the assessment and identification of a potential concussion (Figure 1). Embedded in the MACE 2 is the Standardized Assessment of Concussion (SAC), a well-validated sports concussion tool, and the VOMS tool as portions of the 2-part cognitive examination. The entirety of the tool has 5 sections: (1) red flags; (2) acute concussion screening; (3) cognitive examination, part 1; (4) neurologic examination; and (5) cognitive examination, part 2. The end of the MACE 2 includes sections on the scoring, instructions for International Classification of Diseases, Tenth Revision, TBI coding, and next steps following completion of the MACE 2. The latest version of this screening tool impacts TBI care in several noteworthy ways. First, it broadens the scope of users by expanding use to all medically trained personnel, allowing any provider to treat SMs in the field. Second, it combines state-of-the-science advances from the research field and reflects feedback from end-users collected during the development. Last, the MACE 2 is updated as changes in the field occur, and is currently undergoing research to better identify end-user utility and usability.
