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.
Concussion Management Tool
Beyond the initial assessment and concussion evaluation and the promotion of SMs’ timely return to duty, the DoD developed a tool to help endpoint users manage concussion, to include those with more protracted symptoms (Figure 4). The CMT assists HCPs and the SMs they treat in the management of symptoms before and after they return to duty. Specifically, the CMT is designed to be given in combination with guidelines issued by the DoD in the PRA CR but extends management of concussion to include those symptoms experienced more long-term, or symptoms that are not solely addressed during the timeline of the PRA CR. Together, the MACE 2, PRA CR, and the CMT provide endpoint users with a set of tools to comprehensively evaluate, treat, and manage concussions in SMs.
Description
The CMT provides step-by-step guidance for the initial and comprehensive management of concussion, once a diagnosis is made using assessments in the MACE 2. All types of HCPs, particularly those with limited training, such as Navy Hospital Corpsman and Army Combat Medics, are the intended clinical audience for the CMT. This tool was revised in 2019 to better align with the MACE 2, PRA CR, and other DVBIC CRs, and replaces the 2012 Concussion Management Algorithm and the 2014 Army Concussion Management in Garrison Setting Algorithm. The first 2 sections of the CMT are action cards, which provide management guidelines for acute injuries up to 7 days following injury and for comprehensive management beyond 1 week. Guidelines within the CMT partially overlap with those in the PRA CR; however, the PRA is designed for a more acute timeline, whereas the CMT focuses on symptom management following a more protracted recovery. The CMT clinical tool, provider training, instructor guide, and student workbook all can be found on the DVBIC website (Table 3).
Discussion
It is important for HCPs to have the skills and clinically relevant tools to optimize accurate TBI assessment. Early and accurate assessment and effective symptom management allows SMs to receive timely treatment based on clinical recommendations, and prevent and/or minimize secondary injury and prolonged recovery. Several longitudinal studies emphasize the benefits of early diagnosis and systematic follow-up.16-18 Prompt diagnosis, patient education, and early initiation to treatment may help optimize triage to care, mitigate prolonged symptoms by educating the patient on what to expect, and target specific symptoms early.8,10 Beyond the health outcomes of an individual SM, TBI recovery impacts unit readiness and consequently force readiness. As such, health outcomes and medical readiness are a priority of the Defense Health Agency (DHA).
The DHA priorities are, in part, based on DoD policy guidance for the management of concussion in the deployed setting. According to DoD instruction, “Medically documented mTBI/concussion in service members shall be clinically evaluated, treated, and managed according to the most current DoD clinical practice guidance for the deployed environment found in the Defense and Veterans Brain Injury Center (DVBIC) guidance, ‘Medical Providers: Clinical Tools.’”12 In 2018, the Deputy Secretary of Defense issued a memorandum regarding the comprehensive strategy and action plan for warfighter brain health.12 Therein, the memorandum acknowledges the enduring responsibility of the DoD to promote and protect the health and well-being of members of the nation’s armed forces. Particular emphasis was placed on issuing a response to the effects caused by concussive impacts and exposure to blast waves. This response resulted in a commitment by the DoD to understanding, preventing, diagnosing, and treating TBI in all forms. Taken together, the message from the secretary of defense and instruction from the DoD is clear and makes imperative the use of DoD clinical tools to accomplish this commitment.
