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Concussion Care Pathway Streamlined for Better Results

Image of Dr. Gregory Johnson, Tripler Concussion Clinic medical director, conducts a neurological exam on Army Spc. Andrew Karamatic, a combat medic, having him follow his finger with his eyes, at Tripler Army Medical Center, in Honolulu, Hawaii. Neurologic exams are part of the MACE 2 diagnostic tool to assess service members’ Acute Concussion Care Pathway. (Photo: Army Staff Sgt. Christopher Hubenthal, DMA Pacific – Hawaii Media Bureau). Dr. Gregory Johnson, Tripler Concussion Clinic medical director, conducts a neurological exam on Army Spc. Andrew Karamatic, a combat medic, having him follow his finger with his eyes, at Tripler Army Medical Center, in Honolulu, Hawaii. Neurologic exams are part of the MACE 2 diagnostic tool to assess service members’ Acute Concussion Care Pathway. (Photo: Army Staff Sgt. Christopher Hubenthal, DMA Pacific – Hawaii Media Bureau)

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Traumatic Brain Injury

The Defense Health Agency has developed a comprehensive clinical care program to manage concussions based on the military medical community’s many years of experience with injured service members. 

Known as the Acute Concussion Care Pathway, the aim is to provide proactive care immediately after a potential head injury, followed by a standardized process for consistent care until a service member is able to return to duty. 

“It’s no longer ‘come back if you're getting worse,’” Dr. Katharine Stout, assistant branch chief at the Traumatic Brain Injury Center of Excellence, said. “It's, ‘I need to see you back in 72 hours to make sure everything's going in the right direction.’” 

The Acute Concussion Care Pathway evolved from years of research and data about patients with traumatic brain injury, or TBI. The TBICoE consolidated a vast array of information on acute concussion care into a singular pathway for effective care. 

A key component of the program is based on an algorithm that optimizes patient care by evaluating a patient’s symptoms at different stages of care. 

For medical providers, the pathway provides a suite of updated tools to evaluate a patient’s progress, and offers clear steps for service members to return to duty. 

“This is really about performance and not so much about diagnosis,” Navy Capt. (Dr.) Scott Cota, the TBICoE’s branch chief, said. “It's more a performance-based tool and a performance-based process to return individuals to duty through a monitored system.” 

The First Test 

Diagnosis and the initial phase of care can start moments after a concussive event occurs. That could be exposure to a blast or explosion, a vehicle accident, or a sports injury. 

Health care providers in the field can use a screening tool called the Military Acute Concussion Evaluation, or MACE 2, to identify symptoms and diagnose a potential concussion. 

The MACE 2 is a standardized and comprehensive test of brain functions—cognitive, neurological, visual, hearing, balance, and memory. It’s most effective when administered as soon as possible after an injury. 

An early MACE 2 evaluation can reveal critical information that will inform future treatment and improve the likelihood of an effective recovery. 

“We know that early implementation can identify small deficits that could become bigger problems with time, affecting work, family life, and personal satisfaction,” Navy Capt. Duneley Rochino, lead of DHA’s neuromusculoskeletal clinical community, said. “Although it’s more common for patients to be evaluated in an emergency room, a medic or corpsman can perform the initial screening in a field environment, too.”  

A traumatic brain injury is a recoverable yet complex injury with a broad spectrum of symptoms including headaches, memory problems, attention deficits, mood swings, and others. The MACE 2 diagnostic tool allows for health care providers to assess service members more comprehensively after exposure to a concussive event to better determine their care pathway. (Photo: Navy Petty Officer 2nd Cl. Jonathan D. Chandler, Fleet Combat Camera Pacific)
A traumatic brain injury is a recoverable yet complex injury with a broad spectrum of symptoms including headaches, memory problems, attention deficits, mood swings, and others. The MACE 2 diagnostic tool allows for health care providers to assess service members more comprehensively after exposure to a concussive event to better determine their care pathway. (Photo: Navy Petty Officer 2nd Cl. Jonathan D. Chandler, Fleet Combat Camera Pacific) 

Return to Duty

After a service member is diagnosed with a concussion, they should avoid returning to duty too soon. The care pathway provides a tool to determine when it is safe and appropriate to return to work. The standardized evaluation tool for this is known as the Progressive Return to Activity Following Acute Concussion, or PRA.

The TBICoE developed the tool in collaboration with military service branches, an expert working group, and an end user group.

"It's a six-step approach," Cota said. "The PRA starts with resting. Then, there's a gradual increase in activities until they receive clearance to return to full duty or activity."

When a service member initially returns to their unit, they're able to move on to the next stages. That includes specific military activities related to their jobs, Cota said. If they perform those and have no symptoms, then they are cleared to return to full duty.

If an individual doesn't make it through the stages or has persistent symptoms in their PRA stages, they are returned to the previous stage to "restart the process" until they are cleared. If problems persist, doctors can refer them to specialty care.

Goals

Stout said the care pathway and the evaluation tools have been updated in recent years. They are intended to ensure "long-term readiness and avoid long-term consequences of concussion through a standard, acute approach that involves a more proactive follow-up."

Experts emphasize a key component for success is early evaluation using the MACE 2 and using the data to personalize the follow-on care. The pathway initiative makes it easier for caregivers to identify and manage concussions, Rochino said.

"Earlier identification leads to earlier definitive treatment that can prevent further damage that may lead to further medical and behavioral disability," he said.

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