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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

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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In this episode of Picking Your Brain, Traumatic Brain Injury Center of Excellence Branch Chief Capt. Scott Cota and clinical moderator Amanda Gano interview the Senior Enlisted Advisor to the Chairman of the Joint Chiefs of Staff (SEAC), Ramón Colón-López. The discussion covers the health impacts of TBI and blast-related concussion stemming from the demands of combat and training. The SEAC also addresses the importance of maintaining medical readiness through education and military leadership. Listen to more Picking Your Brain episodes at www.health.mil/TBIPodcasts, on DVIDS, or wherever you listen to podcasts.

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After a motorcycle accident, Master Sergeant Stalnaker started having symptoms of traumatic brain injury, or TBI. He tells his story about his symptoms and his road to recovery from physical and emotional wounds as a result.

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A Retired Navy SEAL Discusses his TBI

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PRA Training Video 6: The Return to Duty Screening

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In this lesson, we cover how to perform the Return to Duty, or RTD screening, which now includes both vestibular/physical and neurocognitive examinations. The purpose of the RTD screening is to objectively measure whether a service member is ready for return to full duty. Each video in the Progressive Return to Activity training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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PRA Training Video 8: Clinical Case Scenario

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This is an interactive clinical case scenario to test your understanding in applying the Progressive Return to Activity (PRA). We hope this will help medical providers become more familiar with the PRA process when treating service members with concussion. Each video in the PRA training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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PRA Training Video 7: Symptom-Guided Management and Specialty Referral Guidance Tables

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This lesson covers how to use the Progressive Return to Activity, or PRA's Symptom-Guided Management and Specialty Referral Guidance tables. This lesson also details primary care management strategies for service members who are not progressing as expected in the PRA. Each video in the Progressive Return to Activity training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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PRA Training Video 3: Understanding Relative Rest

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In this lesson we explain the differences between complete rest and relative rest in a staged concussion recovery process, and provide examples of activities that promote relative rest. The revised Progressive Return to Activity (PRA) Clinical Recommendation uses the term 'relative rest' to emphasize the importance of early introduction of physical and cognitive activities that do not provoke symptoms following TBI. Each video in the PRA training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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In the first of TBICoE's Progressive Return to Activity (PRA) video training series, you will learn about the reasons for using a progressive return to activity process and receive an overview of the 2021 PRA algorithm and its associated tools. By the end of lesson one, providers will better understand the PRA process, and explain that process to service members diagnosed with concussion. Each video in the PRA training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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PRA Training Video 2: Six Major Changes

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In this lesson we review the six major changes in the TBICoE's revised 2021 Progressive Return to Activity (PRA) Clinical Recommendation that differ from the original recommendation. The changes reflect the latest TBI research, and will make it easier for providers to manage the recovery process and return service members with concussion to full duty as quickly and safely as possible. Each video in the PRA training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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PRA Training Video 5: The Six Stages of the PRA

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In this lesson, we cover the key activity objectives for each of the six stages of the Progressive Return to Activity (PRA) Clinical Recommendation and provide activity examples for each stage. Each stage is designed to gradually increase the intensity and duration of a service member's physical and cognitive activity as they advance in the PRA process. Each video in the PRA training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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PRA Training Video 4: PRA Progression Criteria

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MHS Minute March 2021

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Last Updated: March 21, 2022

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