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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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MACE 2 Provider Training: Student Workbook

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7/31/2020

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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Vestibular Ocular Motor Screening (VOMS)

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7/31/2020

The VOMS for Concussion Instructions is a clinical support tool for use with the MACE 2.

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ICD-10 Coding Guidance for TBI

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7/31/2020

TBICoE developed this quick reference resource based on the latest coding guidance and the Military Health System Professional Services and Specialty Medical Coding Guidelines Version 5.0, to facilitate consistent and accurate coding for TBI diagnoses and related symptoms and conditions.

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Provider Training Slides for Management of Headache Following Concussion/Mild TBI

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7/31/2020

Presentation that educates health care providers about the intent of and how to use the Management of Headache Following Concussion/Mild TBI clinical recommendation (includes knowledge tests and case studies).

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Management of Sleep Disturbances Following Concussion/mTBI Clinical Recommendation

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7/31/2020

This TBICoE clinical recommendation outlines how to identify and assess sleep disturbances following a concussion; primary care manager initial treatment options; and recommended conditions for referral to sleep medicine.

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Cognitive Rehabilitation Following Mild to Moderate TBI Clinical Recommendation - Short

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7/30/2020

This short version of the Cognitive Rehabilitation Following Mild to Moderate TBI Clinical Recommendation provides an at-a-glance overview of the full-length version for quick access and use on the job.

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Cognitive Rehabilitation for Following Mild to Moderate TBI Clinical Recommendation - Full

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7/30/2020

This TBI clinical recommendation is broken down into three primary categories: Modifications for Service Members and Veterans; Interventions and Strategies to Address Cognitive Dysfunction; and, Delivery of Rehabilitation for Patients with Cognitive Challenges. Each category contains clinical recommendations, the background and rationale behind them, evidence review references, and clinical resources.

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Cognitive Rehabilitation Following Mild to Moderate TBI Clinical Recommendation Appendices

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7/30/2020

The appendices to the Cognitive Rehabilitation Following Mild to Moderate TBI Clinical Recommendation include a glossary of terms, outcome measures, evidence tables, and other useful resources.

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Cognitive Rehabilitation Following Mild to Moderate TBI - Referring Provider Resource

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This resource answers common questions that referring providers may have, such as how to determine if a patient is having cognitive difficulties or whether the patient is a good candidate for cognitive rehabilitation following a mild to moderate traumatic brain injury.

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Military Acute Concussion Evaluation 2 (MACE 2)

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7/30/2020

The 2018 Military Acute Concussion Evaluation 2 (MACE 2) is an acute assessment tool for all medically trained personnel who treat service members involved in a potentially concussive event. The MACE 2 incorporates current state-of-the-science traumatic brain injury information, including vestibular-ocular-motor screening. The MACE 2 is an update to and replaces the original MACE.

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Recurrent Concussion Evaluation

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7/30/2020

The TBICoE Recurrent Concussion Evaluation card is designed to guide providers in the management of patients with a history of three or more documented concussions within a 12-month span.

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TBI Awareness Fact Sheet

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This fact sheet describes the main causes of traumatic brain injury and the importance of prompt and proper treatment.

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Ways to Improve Your Memory Following Concussion/mTBI Fact Sheet

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This TBICoE fact sheet can be used by health care providers to educate patients with concussion, or mild traumatic brain injury, on how to manage memory problems related to their injury.

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Neck Pain Following Concussion/mTBI Fact Sheet

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7/30/2020

Neck pain can occur together with headaches following a concussion. This TBICoE fact sheet provides information to help patients manage neck pain. Various techniques are explained, including the use of heat or cold therapy, neck stretches, proper sleep positions and common activities that may contribute to neck strain.

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Concussion/Mild TBI Signs and Symptoms Spanish Version Fact Sheet

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7/30/2020

This fact sheet — in Spanish — identifies major physical, cognitive and emotional symptoms of concussion/mild TBI, and provides coping and recovery tips.

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Last Updated: September 01, 2022
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