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.
Screening Tools
• Red Flags. The red flags section aids in identifying potentially serious underlying conditions in patients presenting with Glasgow Coma Scale (GCS) between 13 and 15. A positive red flag prompts the practitioner to stop administering the MACE 2 and immediately consult a higher level of care and consider urgent evacuation. While the red flags are completed first, and advancement to later sections of the MACE 2 is dependent upon the absence of red flags, the red flags should be monitored throughout the completion of the MACE 2. Upon completion of patient demographics and red flags, the remaining sections of the MACE 2 are dedicated to acute concussion screening.
• Acute Concussion Screening. The acute concussion screening portion consists of 4 sections: description of the incident; alteration of consciousness or memory; a “check all that apply” symptom inventory; and a patient history that includes concussions within the past 12 months, headache disorders, and/or behavioral health concerns. The final portion of the acute concussion screening section provides an algorithm to identify a positive or negative concussion screen. When a negative screen is identified, the user is prompted to prescribe a 24-hour rest period and follow up with the SM based on the guidance in the CMT. A positive screen warrants the user to continue administration of the MACE 2.
Neurologic and CognitiveExaminations
• Cognitive Exam Part 1. The initial cognitive examination is designed to assess orientation to time (eg, What is the day of the week, day of the month, the month, the year, and the timeof day?) as well as immediate recall of a short list of concrete words (5 words total, repeated for 3 trials). These tests are based on other neuropsychological measures designed to assess cognitive/mental status and short-term memory.
• The Neurological Exam. The neurological exam section of the MACE 2 includes brief neuropsychologic tests such as speech fluency and word finding. Other sections within the neurological exam assess the
following: grip strength, vestibular function/balance (eg, tandem gait and single leg stance), as well as motor function (eg, pronator drift), autonomic nervous system function (eg, pupil response), and vestibular function (eye-tracking).
• Cognitive Exam Part 2. After completion of the first cognitive examination and the neurologic examination, the second part of the cognitive examination is initiated. Part 2 includes measures of short-term and working memory (eg, digits-reverse tasks, listing the months in reverse order, and a delayed recall task of the short list of concrete words presented in the first part). The final assessment is the administration of the VOMS, a tool developed from the sports concussion field and designed to measure vestibular-ocular function.13 It is critical to note that the VOMS is contraindicated if there is concern of an unstable cervical spine or absence of a trained HCP. An examination summary provides guidance on test scoring and yields a positive or negative indication for concussive injury. A positive test refers users to guidelines listed in the Concussion Management Tool for recommendations. The final page provides coding instructions for entering the results into the patient’s electronic medical record for documentation and future reference.
