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Military Health System

Five Clinical Tools To Help Assess and Treat TBI

Image of An Army 'gun team' brace for the concussion of a 105mm howitzer during operations in Iraq in 2008. (Photo: Master Sgt. Kevin Doheny). An Army 'gun team' brace for the concussion of a 105mm howitzer during operations in Iraq in 2008. (Photo: Army Master Sgt. Kevin Doheny)

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Traumatic Brain Injury Center of Excellence

Traumatic Brain Injury, or TBI, is a major health concern for the military. Over the past two decades, nearly 450,000 service members have suffered a first-time TBI. While some occur in a deployed setting, the majority happen closer to home – during training, sports, recreation, car accidents, or slips and falls.

Left untreated, even mild TBIs can have serious long-term complications. TBIs, also known as concussions, can affect mental health, impacting mission readiness and the ability to deploy.

But there is hope. TBI is treatable. With appropriate care, service members can expect a full recovery. The Military Health System offers the following tools and clinical recommendations to help providers in the identification, treatment and management of mild TBI.

1. Dizziness and Vision following Concussion/Mild TBI Clinical Recommendation

Dizziness and visual problems are among the most common symptoms after a mild TBI. In November 2021, the Traumatic Brain Injury Center of Excellence released the Dizziness and Visual Disturbances Clinical Recommendation. It's a vital tool for primary care managers treating mild TBIs. It provides a single, comprehensive reference for the assessment and management of dizziness and visual problems following concussions.

Providers should perform a visual and dizziness assessment. Learn more here.

2. Military Acute Concussion Evaluation 2

The MHS provides tools to quickly assess and diagnose service members with a potential TBI. The Military Acute Concussion Evaluation 2, or MACE 2, is a step-by-step tool that medical personnel can use to diagnose a possible concussion at the scene of an injury.

The TBICoE helped design the MACE 2 to improve care for service members. Users in the field can screen in for common symptoms, cognitive deficits, and neurological signs of a concussion. The latest version of the MACE 2 also assesses balance and eye motion.

Learn more here.

3. Progressive Return to Activity following Acute Concussion/Mild TBI

Service members should avoid returning to duty too soon after a concussion. That can lead to prolonged symptoms, poor marksmanship, decreased readiness, accidents and falls, and increased risk of more concussions.

To help determine when it's time to return to duty, military health care providers can use a tool known as the Progressive Return to Activity Following Acute Concussion (PRA). It helps ensure a safe return to full duty. The TBICoE developed the tool in collaboration with military service branches, an expert working group, and an end user group.

The PRA involves a six-step return to activity protocol. It helps service members to manage their symptoms and ensure a full recovery. Returning to duty gradually helps reduce long term complications.

Learn more here.

4. Sleep Disturbances following Concussion/Mild TBI Clinical Recommendation

Sleeping problems are common with mild TBI. The most common include insomnia, obstructive sleep apnea, circadian rhythm sleep-wake disorders, and restless legs syndrome. Early treatment of sleeping problems can promote recovery and prevent chronic TBI symptoms.

TBICoE's Sleep Disturbances following Concussion/Mild TBI Clinical Recommendation provides step-by-step guidance to help primary care managers assess and manage sleeping problems linked to mild TBI. The recommendation includes guidelines for medical dosing, specialty referral timelines, and more detailed information for treating sleeping problems like restless legs syndrome, insufficient sleep syndrome, and parasomnias.

Learn more here.

5. Cognitive Rehabilitation following Mild to Moderate TBI

The Cognitive Rehabilitation following Mild to Moderate TBI Clinical Recommendation helps providers to treat service members and veterans with persistent cognitive challenges like memory and attention problems. Evaluating a patient with those symptoms is especially challenging because they can overlap with other problems like post-traumatic stress or depression. The clinical recommendation ensures consistency in cognitive rehabilitation practices across MHS hospitals and clinics.

Learn more here.

The MHS is committed to protecting the brain health of our service members. These are just a few clinical tools out of many that the MHS is using to better identify, care for, and treat service members and veterans who are affected by TBI.

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Prior history of TBI may predispose an individual to increased risk of subsequent TBI, which may result from less force, and lengthier recovery from post-injury symptoms. Activities such as contact sports and military service carry particular risk for multiple TBI. In addition to acute post-injury difficulties, cumulative TBI may increase the risk of chronic cognitive and functional impairment. Conservative management of post-injury symptoms as part of a medically monitored, progressive plan for returning to activities is recommended for individuals with a history of TBI.

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This research review provides an overview of the topic of co-morbid mild TBI and posttraumatic stress disorder. This review focuses on symptoms, diagnosis, and treatment of PTSD and mild TBI symptoms in patients with mild TBI history. While it can be difficult to differentiate symptoms of mild TBI from PTSD symptoms, especially months or years after the injury event, this review aims to present information relevant to understanding these often complex cases.

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Back to School Guide for Academic Success After TBI

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This booklet provides guidance to service members and veterans who have ongoing symptoms from a TBI and are going to college, university or vocational school. It gives answers to common questions about accommodation plans, financial aid, and assistive technology.

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This guide is intended to help service members and veterans who have experienced a concussion recover as quickly and safely as possible. It outlines each stage of the recovery process, explains what affected individuals should expect throughout the recovery process, provides guidance on how to track progress and includes a table to track developments.

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Full-length medical provider training material for the Military Acute Concussion Evaluation 2 (MACE 2).

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This clinical recommendation outlines the assessment and management of headache following mild TBI. It includes specific recommendations regarding how health care providers can help patients manage pharmacologic and non-pharmacologic treatment of post-traumatic headache (PTH).

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This clinical support tool uses an algorithmic approach for health care providers to help assess and manage headache in service members and veterans who sustain a mild TBI and experience post-traumatic headache (PTH). The tool offers providers a step-by-step process to determine the type of headache following mild TBI and indications for emergency or specialty referral.

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The MACE 2 Student Workbook is for use with the MACE 2 training slides to learn how to properly use the MACE 2.

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Last Updated: September 01, 2022
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