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Copyright (c) Association of Military Surgeons of the U.S. All rights reserved.
MILITARY MEDICINE, 177, 8:67, 2012
Mild Traumatic Brain Injury Screening, Diagnosis, and Treatment
Kathryn R. Marshall, MS, MPH, PA-C*; Sherray L. Holland, PA-C*; Kimberly S. Meyer, MSN, ACNP*†;
Elisabeth Moy Martin, RN-BC, MA*; Michael Wilmore, MPAS, PA-C*; Col Jamie B. Grimes, MC USA*
ABSTRACT The majority of combat-related traumatic brain injury (TBI) within the U.S. Armed Forces is mild TBI
(mTBI). This article focuses specifically on the screening, diagnosis, and treatment aspects of mTBI within the military
community. Aggressive screening measures were instituted in 2006 to ensure that the mTBI population is identified and
treated. Screenings occur in-theater, outside the contiguous United States, and in-garrison. We discuss specific screening
procedures at each screening setting. Current diagnosis of mTBI is based upon self-report or through witnesses to the
event. TBI severity is determined by specific Department of Defense criteria. Abundant clinician resources are available
for mTBI in the military health care setting. Education resources for both the patient and the clinician are discussed in
detail. An evidence-based clinical practice guideline for the care of mTBI was created through collaborative efforts of the
DoD and the U.S. Department of Veterans Affairs. Although symptoms following mTBI generally resolve with time,
active treatment is centered on symptom management, supervised rest, recovery, and patient education. Medical specialty
care, ancillary services, and other therapeutic services may be required.
INTRODUCTION
Traumatic brain injury (TBI) is a widely recognized injury
resulting from the current conflicts in Afghanistan and Iraq.
TBI occurs when a trauma-induced external force results in
temporary or permanent neurologic dysfunction. TBI severity
ranges from mild to severe; TBI may be classified as a closed
or penetrating injury. The majority of combat-related TBI
within the U.S. Armed Forces fall in the mild TBI (mTBI)
range, which is commonly known as concussion.
1
The overall
Department of Defense (DoD) approach to TBI care follows a
continuum of care. This continuum includes the prevention,
surveillance, screening/assessment, diagnosis, case manage-
ment, treatment, rehabilitation, and reintegration of service
members who have suffered a TBI.
2
This article focuses spe-
cifically on the screening, diagnosis, and treatment aspects of
mTBI within the military community.
SCREENING
Approximately 77% of TBI cases seen within the U.S. military
population are classified as mTBI.
1
Aggressive screening mea-
sures were instituted in 2006 to ensure that the mTBI popula-
tion is captured by military TBI surveillance.
3
TBI screenings
occur in-theater, at Landstuhl Regional Medical Center
(LRMC) in Germany, at military treatment facilities (MTFs),
at home duty stations after deployment, and within the Vet-
erans Affairs (VA) system. From the year 2000 through
November 15, 2011, there have been 233,425 medically diag-
nosed TBIs worldwide within the DoD, of which 178,961
were classified as mild.
4
Reliance on service member self-
report,
5,6
and co-occurring conditions
7,8
can make TBI screen-
ing very challenging. If a service member has been exposed to
an external force or mechanism of injury that could potentially
cause TBI (i.e., blast exposure, vehicular crash and/or rollover,
blunt trauma, fall, sports-related injury, gun-shot wound
above the neck, or a combination of these entities), immediate
screening is indicated.
9
In-theater, event-based screening occurs as soon as safely
possible following exposure to a traumatic event.
10
This initial
evaluation is commonly performed by combat medics/corpsmen
on the front line or by forward operating bases. Severe inju-
ries are usually easily recognized, requiring resuscitation and
evacuation. Those without obvious injuries are then assessed
for TBI. The Military Acute Concussion Evaluation (MACE)
is widely used as a screening tool for mTBI (Table. 1).
11
The cognitive evaluation portion of the MACE uses the
Standardized Assessment of Concussion (SAC),
3
which is
well validated in sports concussion. The MACE has recently
been updated in February, 2012 (Table I) with different versions
of the SAC to avoid familiarization with repeated adminis-
trations. The MACE typically takes less than 10 minutes to
administer. In addition to the history and brief neurologic
exam (eye, motor, speech, and balance testing), it measures
four cognitive domains including orientation, immediate
memory, concentration, and delayed recall.
12
Appropriate
administration of the MACE requires that the clinician avoid
altering the word lists, digit spans, or order of the exam.
According to the new version of the MACE, All three com-
ponents of the MACE should be recorded in the medical
record following the mnemonic CNS
— Cognitive results (Total out of 30)
— Neurologic exam results (Green =allnormalexam,
Red =any abnormal exam results)
— Symptom results (A =No symptoms, B =1ormore
symptoms)
The MACE is intended to be given during the initial
assessment and as part of the cognitive evaluation during
*Defense and Veterans Brain Injury Center, 1335 East West Highway,
Suite 6-100, Silver Spring, MD 20919.
†Trauma Institute, University of Louisville Hospital, 530 South Jackson
Street, Louisville, KY 40202.
MILITARY MEDICINE, Vol. 177, August Supplement 2012 67
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exertional testing.
11
If no loss of consciousness (LOC) or
alteration of consciousness (AOC) is noted during the initial
portion of the MACE, the MACE can be stopped, and clini-
cians should consider other causes for the service member’s
symptoms. The concussion management algorithm states that
a cognitive score of <25 or the presence of symptoms requires
consultation with a provider. It is important to remember that
MACE scores do not diagnose a concussion.
11
Acute assessment of concussion is very important on the
battlefield as it may lead to better outcomes and increased
rates of return to duty (RTD).
12
Medics must determine
which level of care is required next for the service member
based on the Concussion Management Algorithms for the
deployed setting (discussed in the “Treatment” section).
10
The Concussion Management Algorithm for deployed set-
tings (CMA) was recently updated in 2012 (Table II). A copy
of the updated CMA can be requested online: http://www
.dvbic.org/material/concussion-management-algorithm-cma-
pocket-.cards. Important updates to the CMA are included
(Table II). All service members exposed to a blast or other
mechanism of injury, including those who screened nega-
tive, are mandated to rest for 24 hours before returning to
duty. The commander/commanding officer, however, has
the right to waive the rest period if the service member is
deemed vital to the mission.
10
Mandatory events requiring concussion evaluation include:
1) Any service member in a vehicle with a blast event,
collision or rollover
2) Any service memeber within 50 meters of a blast
3) Anyone who sustains a direct blow to the head
4) Command directed-such as, but not limited to, repeated
exposures
If there are any red flags noted immediate provider con-
sultation or emergent evacuation is indicated.
Since March 2006, all service members arriving at LRMC
and all Operation Enduring Freedom (OEF) and Operation
Iraqi Freedom (OIF) (changed to Operation New Dawn
[OND] October 2010) service members returning from theater
receive a TBI screen regardless of the medical condition or
injury that required medical evacuation. This ensures that the
majority of service members get an assessment before
returning to their home duty station. LRMC uses a standard
patient questionnaire which inquires about any blast exposures,
motor vehicle accidents, falls, or direct blows to the head
that may have resulted in loss or AOC.
13
From May 2006
to October 2008, nearly 18,000 patients completed this
initial screening questionnaire at LRMC.
13
Of these patients,
16% of outpatients and 31% of inpatients screened positively
for being at risk for TBI.
13
If the service member cannot be
screened because of medical issues such as intubation and/or
heavy sedation, a notation is made in the medical record to
re-evaluate for TBI at a later time. The mTBI screen includes
the date of injury, service member’s recollection of the injury,
distance of the blast, position in the vehicle (if applicable), use
of protective gear, symptoms at the time of injury, specific
injuries to the head/face/neck, and whether there was an
on-scene evaluation.
13
The screener also asks about current
symptoms and any previous concussion/head injury history. If
it is determined that there was a change in consciousness and it
is clinically appropriate (e.g., the service member is not
heavily medicated, in pain, or psychiatrically impaired), the
MACE is then administered to determine cognitive status.
11
Obtaining the history, MACE, initial Glasgow Coma Scale
(GCS) score, and reviewing of the computed tomography (CT)
scan or magnetic resonance imaging (MRI) scan (if performed),
TABLE II. Major Changes in the 2012 Version of the
Concussion Management in Deployed Settings
•Combat Medic/Corpsman Algorithm:
•Includes recommendations for initial management of concussion
in consultation with a provider
•Provides instruction to consult provider with exertional test results
for return to duty determination
•Clarifies directives and emphasizes assessment, identification of
red flags, consultation with a provider, and distribution of
educational brochures to patients
•Initial Provider Algorithm:
•Includes concussion history with added guidance for first, second
and third concussion in 12 months
•Clarifies guidance on neuroimaging/CT and consulation
•Comprehensive Concussion Algorithm:
•Advises to consider NCAT and functional assessment
•Recurrent concussion Algorithm:
•Advises to consider NCAT and functional assessment
•Includes the Balance Error Scoring System (BESS) to guide the
balance assessment
•Other:
•The list of information sheets now includes: Acute Stress
Reaction Fact Sheet, Acute Concussion Educational Brochure,
Neurobehavioral Symptom Inventory, Line Leader Fact Sheet,
Coding Guidance, and DCoE NeuroCognitive Assessment Tool
(NCAT) recommendations
•Exertional testing clarified
•ICD-9 coding tips added
TABLE I. Major Changes in the 2012 Version of the MACE
•Instructions are now embedded with the questions
•The first two pages focus only on whether or not there was an injury
event and AOC/LOC/PTA. Questions about symptoms and previous
concussions have been moved to the end of the tool
•The second page clarifies when to stop the MACE
•Three more versions of the cognitive tests have been added
•A balance test has been added to the neurological evaluation
•The neurological evaluation provides better guidance
•The summary page provides more room to record cognitive test
scores results
•The last page explains the proper interpretation of the cognitive
score, evaluating concussion recovery, and ICD-9 coding tips
MILITARY MEDICINE, Vol. 177, August Supplement 201268
mTBI Screening, Diagnosis, and Treatment
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Copyright (c) Association of Military Surgeons of the U.S. All rights reserved.
allows for accurate determination of whether a service member
has sustained a concussion. If deemed negative, this is doc-
umented and the service member does not need further testing;
this service member may potentially RTD if no other medical
conditions are present. However, if it is determined that the
servicemembersustainedamTBI,thescreeningteammakes
recommendations for disposition. This disposition may be a
home duty station or a designated TBI center based upon
anticipated treatment needs of the service member.
If the service member’s prognosis is presumed critical from
other injuries and/or unlikely to report to duty or managed at
the LRMC outpatient clinic, he/she is medically evacuated to a
major MTF for ongoing care, such as Walter Reed National
Military Medical Center (WRNMMC) in Bethesda, Maryland,
or San Antonio Military Medical Center (SAMMC) in Texas.
Both treat service members from deployments with mTBI and
have the added capability of managing severe comorbidities
and injuries that may co-occur with mTBI.
At the treatment facility, a screener reassesses all inpatients
and outpatients based on their mechanism of injury. For exam-
ple, if a service member screened positive for a mTBI at
LRMC, but was medically evacuated for an unrelated condi-
tion, a mTBI consult note including a treatment plan is still
completed and recorded in the electronic medical record.
Obtaining a good interview is critical, and it is essential that
LOC, AOC, post-traumatic amnesia (PTA), imaging findings,
and initial and current symptoms are clearly noted. The screen-
ing process can be further complicated by ongoing treatment
for other injuries such as frequent surgeries for wound cleaning
and orthopedic surgeries, necessary sedation, pain, and fatigue.
When able, service members fill out symptom questionnaires
on concussion-related symptoms and acute stress symptoms.
A service member’s current state of health is evaluated
soon after returning from the theater (no later than 30 days),
using the Post Deployment Health Assessment (PDHA)
14
at
the unit during out-processing. The PDHA is an electronic
questionnaire mandated by the Assistant Secretary of Defense
for Health Affairs that assesses the service member and
assists military health providers in identifying and providing
present and future medical care.
14
Questions on the PDHA
include whether the service member (1) has experienced any
mechanism of injury that may have caused a head injury,
(2) was diagnosed with a concussion/head injury in theater,
(3) is experiencing symptoms, and (4) circumstances follow-
ing the event (see “Diagnosis” section for specifics).
14
If the
service member answers “yes” to any of the questions, a refer-
ral is made to a provider for further evaluation. A recent study
showed that out of these four questions, questions 1 and 2 above
demonstrated a higher correlation to clinician-diagnosed TBI.
15
Another screening tool used within the Defense Depart-
ment is the Warrior Administered Retrospective Casualty
Assessment tool (WARCAT). This was developed at Evans
Army Community Hospital, Fort Carson, Colorado, in June
2005. It has subsequently been adopted by some of the other
stateside concussion clinics. This tool is used in addition to the
PDHA and PDHRA to capture more detailed information
about possible injuries and symptoms. In comparison, the
WARCAT is more detailed about type of improvised explo-
sive device blast, direction and approximate distance from
blast, specific vehicle type and position, helmet information,
and initial treatment on the scene. It also inquires about prior
history of concussions, whereas the PDHA and PDHRA
inquire only about the recent deployment. The WARCAT is a
standardized form that the service member fills out for the
provider to review. It can be found at: http://evans.amedd
.army.mil/srp/.
In April 2007, the VA health care system implemented a
mandatory computer-based screening tool to identify OEF/
OIF veterans who sustained a mTBI.
16
This screen is com-
pleted whenever a veteran presents at the VA for any clinical
appointment including but not limited to primary care, mental
health, or dental appointments.
16
It is not indicated if the
veteran has a separation date before September 11, 2001 or
did not serve in OEF/OIF or current conflicts. The screen
is not necessary if a prior diagnosis of concussion was made.
The screen consists of questions very similar to other screen-
ing tools. These questions are:
— Whether the veteran experienced any exposures to blast/
explosion, vehicular accident, fragment, bullet wound,
or fall
— Which symptoms were immediately noticed neurologi-
cally and physically
— Symptoms that may have begun or gotten worse after
the event
— Current symptoms
When a veteran answers “yes” to one or more questions in
each of the four sections, then the VA considers the veteran to
have screened positive for a possible mild TBI and this veteran
should be offered a follow-up evaluation with a specialty pro-
vider who can determine whether the veteran has a mild TBI.
DIAGNOSIS
TBI severity is determined by specific criteria: initial GCS
score (if available), AOC, LOC, PTA, and structural imaging
(Table III).
9
The initial GCS score with mTBI is normally
between 13 and 15. Theater conditions are often challenging
as the attending combat medic/corpsman may be treating sev-
eral casualties under grueling conditions while under fire and
assessing for life or death injuries. The GCS can also be
obscured by other factors such as medications or hypovolemic
shock. AOC must be immediately related to the head trauma.
9
Typical symptoms are looking and feeling dazed and uncertain
of what is happening, confusion, difficulty thinking clearly or
responding appropriately to mental status questions, and being
unable to describe events immediately before or after the
event.
9
An AOC of less than 24 hours is considered a mTBI
according to the Defense Department severity rating.
17
PTA is any loss of memory for events immediately before
or after the injury.
9
With a mTBI, this period can extend up to
MILITARY MEDICINE, Vol. 177, August Supplement 2012 69
mTBI Screening, Diagnosis, and Treatment
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24 hours.
9
Abnormal structural imaging attributed to the injury
will result in the individual being considered clinically to have
greater than mild injury.
9
Symptoms especially the cluster of headaches, dizziness,
nausea, and vomiting are common after an acute concus-
sion
18,19
. However, it is important to note that these symptoms
alone do not constitute a diagnosis of mTBI. Further work is
needed to identify clinically useful self-report measures that
assess mTBI and post-traumatic stress disorder (PTSD) and
associated symptoms among OEF/OIF Veterans.
5,20
Abnormal physical findings on exam, whether noted on the
brief neurological exam (completed by the attending combat
medic/corpsman), or the more comprehensive evaluations
(Level II–Level V facilities and the VA) are critical signs of
potentially serious health conditions. The neurologic exam
should include assessment of eyes (pupillary reflex, extraocular
movements), speech (fluency and word finding), motor (grip
strength and pronator drift), balance (tandem Rhomberg test),
and a cognition (concentration, delayed recall). CPGs exist to
guide the primary care management of symptoms after the diag-
nosis is confirmed and are reviewed in the “Treatment” section
below.
9
Those with neurologic deficits should be considered for
management at a location where imaging is available.
A service member who has prolonged symptoms without
signs of improvements should be screened for concomitant
psychological distress, which is most commonly an acute
stress reaction or PTSD. If positive, the service member is
referred to behavioral health for further evaluation.
9
Conventional head CT and MRI scans are normal for the
majority of mTBI patients
21,22
. Furthermore, these tools are not
sensitive to detecting diffuse axonal injuries (DAI) in mTBI.
22
The MRI technique of diffusion tensor imaging (DTI) can detect
microscopic white matter tract lesions in the brain.
23
DTI has
provided a tool for detecting DAI and other microstructural
changes in white matter
24,25
associated with mTBIinjury sever-
ity.
26
The DoD is currently interested in using DTI as a bio-
marker and has assisted in the research on this modality. Other
research studies proposed for TBI diagnosis are serum bio-
markers,
27
other advanced neuroimaging studies (including
spectroscopy and positron emission tomography scans),
28,29
brain acoustic monitoring,
30
state-of-the art developments in
research with blast waves,
31
and cumulative concussions.
32
TREATMENT
There are abundant resources for clinicians caring for mTBI in
the military health care setting. Because these resources must
undergo revisions as new information becomes available, it is
best for the provider to access the most up-to-date resources
online. Resources and references for mTBI treatment in the
military are discussed in the following sections.
In general, treatment of mTBI is centered on symptom man-
agement, supervised rest, and recovery. Symptoms usually fall
into three categories: somatic (e.g., headache, dizziness, weak-
ness, sensitivity to light and sound), cognitive (e.g., difficulties
with attention, memory, and language), and psychological/
behavioral
33
(e.g., irritability, depression, anxiety, personality
changes). All of these symptom areas need to be addressed.
Often, there is an overlap of symptoms of concussion and
psychological/psychiatric disorders that need to be treated
concurrently.
7,34–37
Physical injuries sustained in addition
to the mTBI must also be taken into consideration.
36,38
Clinicians are being encouraged to treat nonspecific symp-
toms regardless of etiology.
39,40
Sleep disorders are also
common.
41
In addition to medical specialty care, ancillary
services, neuropsychological testing,
42
and other therapeu-
tic services may be required.
41
In addition to symptom management, patient education
regarding expected outcomes can play an important role in
mTBI treatment.
43
Education should emphasize rest and
recovery, gradual supervised resumption of work and social
responsibilities, compensatory strategies, and modification of
the environment.
9
Additionally, the service member should
be educated about prevention of further injuries.
9
It is impor-
tant that the service member understands what their diagno-
sis is and what the expected course of recovery will be.
Approximately 85% to 90% of patients who have sustained
a combat mTBI improve with no lasting clinical difficul-
ties.
9,41
Service members should be reassured and encour-
aged that their condition is transient and that full recovery is
expected. Typically, recovery is seen within hours to days,
with a small portion taking longer.
9,41
In a small minority,
symptoms may persist
44
beyond 6 months to a year.
9
In the
civilian sector, it has been shown that educating individuals
regarding this positive expectation for recovery is associated
with positive outcomes.
45
Many free educational resources are offered online. The
Defense and Veterans Brain Injury Center (DVBIC) website,
dvbic.org,
46
offers resources about mTBI and include symp-
tom management for memory, sleep, mood changes, and
headache difficulties. The Defense Centers of Excellence for
Psychological Health and Traumatic Brain Injury (DCoE),
47
TABLE III. Severity Ratings for TBI
Criteria Mild Moderate Severe
Structural Imaging Normal Normal or Abnormal Normal or Abnormal
LOC 0–30 minutes >30 minutes and <24 hours >24 hours
AOC/Mental State £24 hours >24 hours >24 hours
PTA £24 hours >24 hours and <7 days >7 days
GCS
a
Score: 13–15 Score: 9–12 Score: 3–8
a
GCS is not part of the official DoD definition for TBI but is commonly used in practice.
MILITARY MEDICINE, Vol. 177, August Supplement 201270
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traumaticbraininjuryatoz.org, brainlinemilitary.org, and
afterdeployment.org also offer many resources available to
service members and providers. Some education materials
are meant to be provided in combination with verbal review
of the information with their health care provider.
9
As stated earlier, most service members with recent onset
of symptoms following a single mTBI can be successfully
managed in the primary care setting. For the majority, referral
to specialty care for mTBI is not required.
9
However, because
many service members sustain an mTBI in the context of
combat, their care can be complex and multifaceted, requiring
consultation with rehabilitation therapists, neurologists, phar-
macists, mental health, and social support.
9,41,48,49
Service members who are in-garrison and have suffered an
mTBI can be cared for using the VA/DoD CPGs.
9
In April
2009, an evidence-based CPG was created through the collab-
orative efforts of the Defense Department and VA to establish
guidelines for treating service members with ongoing symp-
toms following mTBI injury. The intent of these in-garrison
guidelines is for the service member to receive care from their
primary care provider at their home duty station. The follow-
ing are the three algorithms contained in this CPG: (1) initial
presentation, (2) management of symptoms, and (3) follow-up
of persistent symptoms. The most up-to-date version of the
VA/DoD CPG guidelines with algorithms can be found online
at www.dcoe.health.mil.
9
Algorithm A of the CPG describes next steps that a pro-
vider should follow once a service member has been diag-
nosed with an mTBI. If he or she has no concussion-related
symptoms at the time of diagnosis, then mTBI education is to
be provided. The service member should also be screened for
stress, substance use, and mental health conditions. If the
service member is symptomatic, algorithms B, C, or in-theater
guidelines can be used depending on the situation.
9
Algorithm B of the CPG outlines management of symp-
toms of mTBI in steps (Table IV). Steps are explained in
further detail in the full version of the CPG.
9
Algorithm C is used when a concussed service member
continues to have persistent symptoms beyond 4 to 6 weeks
and is not responding to initial treatment. Reassessment of
symptoms and functional status is recommended as well as a
complete psychosocial evaluation.
9
If symptoms such as
mood, behavior, or sleep difficulties have not improved, the
service member is assessed for possible alternative causes for
the persisting symptoms. It has been found that a service
member may not demonstrate psychological impairment in
the immediate time frame following a concussion and may
arise as a result of returning home and readjusting from a
combat deployment.
20,50
Alternative causes should be treated
according to VA/DoD guidelines, and the service member
should be considered for a referral to mental health for evalu-
ation and treatment. If persisting symptoms are physical, cog-
nitive, or emotional, they may also need a specialty referral for
services.
9
Available interventions for mTBI patients through-
out the services can be found in Table V.
41
A useful tool for any clinician caring for a service member
with mTBI is the Mild Traumatic Brain Injury Pocket Guide
created by the Defense Department, DCoE and DVBIC
(Fig. 1). This pocket guide includes management guides for
common mTBI symptoms such as headache, dizziness,
fatigue, vision difficulties, irritability, and appetite changes.
It also provides guidance for physical examination, medica-
tion management, and referrals. A mobile application of this
guide is available to the provider at http://t2health.org/apps/
mtbi. Table VI describes the information contained in this
pocket guide.
The Co-occurring Conditions Toolkit: mTBI and Psycho-
logical Health, is another tool that can be accessed online
from the DCoE website. This toolkit has additional manage-
ment guides for sleep, mood, attention, and chronic pain. A
companion video is available, which is designed to show the
provider how to use the toolkit. A copy of both of these
pocket guides can be found online (www.dcoe.health.mil/
ForHealthPros/TBIInformation.aspx)
51
or obtained by con-
tacting info@dvbic.org or calling 1800-870-9244.
In addition to the CPG, another resource to consider is
the Clinical Guidance for Evaluation and Management of
Concussion/mTBI management for both acute and subacute
nondeployed care. This guide was updated in May 2008.
It was created by an interdisciplinary work group through the
DVBIC. The work group included both U.S. military services
TABLE IV. Steps Outlined in Algorithm B of the CPG for
Management of Symptoms
(1) History and physical exam (labs, MSE, psychosocial evaluation)
(2) Clarify symptoms and build therapeutic alliance
(3) Evaluate and treat co-occurring disorders
(4) Determine treatment plan
(5) Educate patient and family on symptoms and expected recovery
(6) Provide early (nonpharmacologic) interventions
(7) Sleep hygiene, relaxation techniques, limit caffeine/tobacco/
alcohol, graded exercise, monitored progressive RTD/work/activity
(8) Initiate symptom-based treatment (consider case management)
(9) Follow-up and reassess in 4– 6 weeks
(10) If symptoms are unresolved, proceed to Algorithm C: follow-up
of persistent symptoms
(11) If symptoms are resolved, follow-up with patient as needed and
address: RTD, community participation, and family/social issues
TABLE V. Core TBI Therapies and Interventions Available
Throughout the Services
12
Medication Management
Vestibular Rehabilitation
Vision Therapy
Cognitive Rehabilitation
Driving Rehabilitation
Balance Training
Life skills Training
Assistive Technology
Tinnitus Management
Complementary and Alternative Medicine Interventions
MILITARY MEDICINE, Vol. 177, August Supplement 2012 71
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and civilian representation. The group provided expert guid-
ance regarding appropriate management of symptomatic
concussed service members in a military setting. The full
report with algorithms for the clinician can be found online
(www.dcoe.health.mil).
51
Regarding concussion management in the Deployed set-
ting, the Concussion Management in the Deployed Settings
pocket guide was updated in 2012 (Table II) and offers three
algorithms which include:
1) Combat Medic/Corpsman Algorithm
2) Initial Provider Algorithm
3) Comprehensive Concussion Algorithm
This pocket guide can be obtained by submitting a
request online at: http://www.dvbic.org/material/concussion-
management-algorithm-cma-pocket-cards.
Telemedicine services are currently being used for mTBI
identification, management of symptoms in theater, and
improving the overall care of TBI throughout the Defense
Department and VA. TBI.consult@us.army.mil is an elec-
tronic consultation service specifically for deployed military
health care providers. It is monitored 7 days a week, staffed by
TBI medical specialists, and offers a response within hours.
This service provides consultation on a variety of TBI-related
questions including how to screen for a TBI, RTD decisions,
strategies for symptom management, and TBI and psycholog-
ical health overlap questions. The tele-TBI clinic
52
uses neu-
rologists, neuropsychologists, pain management specialists,
and rehabilitation therapists via video teleconferencing to
assist service members in more remote sites.
52
Duty restrictions after mTBI vary among the services. RTD
status should be based upon the service members symptoms
and allow for progressive return to full duty.
9
The service
member may need to restrict some work and other activities
to allow for healing and to decrease risk of further injury.
When a service member has recovered from symptoms that
TABLE VI. Information Contained in the mTBI Pocket
Guide (CONUS)
TBI Basics
A Summary of the CPG
A Management Guide to mTBI
A Management Guide to Headaches
A Management Guide to Other Symptoms: dizziness, fatigue, vision,
irritability, appetite changes
DoD ICD-9 Coding Guidance
Cognitive Rehabilitation for mTBI Consensus Conference Clinical
Recommendations
Patient Education
Clinical Tools and Resources
Dizziness Handicap Inventory
Epworth Sleepiness Scale
GCS
Multidimensional Assessment of Fatigue
Neurobehavioral Symptom Inventory
Patient Health Questionnaire
PTSD Checklist (PCL-M)
Other Tools
Additional Resources
FIGURE 1. Pocket guides that are available to help clinicians caring for mTBI service members.
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were previously functionally limiting, exertion testing should
be performed.
9
This includes a brief period of aerobic activity
followed by re-evaluation for both physical symptoms and
cognitive function. Before full duty status, the service member
should be able to
— Pass a physical fitness test
— Pass “warrior training” if needed for duty
— Have psychological health issues controlled and moni-
tored by a primary care clinician
— Have neuropsychological testing that is within functional
limits if cognitive impairment was noted after injury.
9
In 2008, the National Defense Authorization Act HR 4986
was signed into law, which led to the Defense Department to
establish a Neurocognitive Assessment Tool (NCAT) pro-
gram.
53
The program establishes and monitors a prede-
ployment neurocognitive battery of tests to assess and
document cognitive functioning of service members before
deployment. The Automated Neurocognitive Assessment
Metrics (ANAM) was the tool chosen by a Defense Depart-
ment expert consensus panel as an interim program pending
further evaluation of other NCATs. The Army Neuro-
cognitive Assessment Branch office has distributed to OEF
and OND numerous laptops loaded with ANAM capability
for postinjury assessments by theater providers. Following
injury, the ANAM can be repeated and compared to the
individuals own baseline when considering cognitive func-
tion and RTD.
53,54
It is important to note that the ANAM is
not intended to be a diagnostic tool for TBI (as many other
conditions may cause decreased cognitive function), but is
meant to assist providers in making medical and report-to-
duty decisions. Capabilities are developing for web-based
access to predeployment ANAM scores, but currently pro-
viders in need of an individual’s baseline ANAM to compare
with a postinjury assessments should submit the request
with demographic information to anam.baselines@amedd
.army.mil.
There are numerous opportunities available for more in-depth
training regarding mTBI. Some of the learning opportunities
available include:
— DVBIC’s Annual Defense and Veterans Military TBI
Summit
— Annual training conference held annually since
2007 in Washington, DC area
— Annual Blast Conference
— Held annually since 2004 hosted by DVBIC and
the James A. Haley Veterans’ Hospital
— TBI modules via Military Health System Learning Portal
— Defense Department personnel may access online
training courses
— Staff lecture series (WRNMMC)
— First Thursday of every month 2 to 3 p.m. (EST)
— Available through tele/video conference
— TBI Grand Rounds
— Second Tuesday of each month
— Access via tele/video conference from participat-
ing sites
Table VII lists other TBI information resources in addition
to those included in this article.
CONCLUSIONS
Since 2006, many initiatives have been implemented to
improve care for service members with TBI, specifically
mTBI. Surveillance efforts aimed at identifying the incidence
and prevalence of combat-related TBI have improved the
availability of TBI-specific resources both in-theater and
in-garrison. This is largely attributable to enhanced screening
methods, which occur at various locations throughout the
deployment cycle. Mandated CPGs standardize care and pro-
vide both evaluation and treatment recommendations to those
on the battlefield as well as stateside. Opportunities for TBI
education have expanded, now including regional/national
conferences, online case studies, training modules and instruc-
tion at some deployment platforms. The evolution of tele-
health capabilities allows providers the ability to treat injured
service members in-theater, which may minimize the need for
evacuation from theater or transfer to major MTF. Finally,
ongoing research seeks to identify ways to mitigate blast expo-
sure and effects, determine similarities/differences between
blunt and blast TBI, and establish treatment paradigms to
enhance TBI care.
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