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TBI Resources for Medical Providers

TBICoE develops practical, easy-to-use clinical recommendations and tools to support health care providers in assessing and treating service members who have sustained a TBI. The recommendations address common symptoms associated with mild TBI, such as headache, sleep disturbances, and vision problems. Most clinical recommendations have related patient resources to help educate service members, their families, and caregivers through recovery.

Interested in learning more about the potential effects of low-level blast exposure? Discover which occupations and heavy weapon systems are associated with increased risk of LLB exposure and learn how to best document, manage, and care for your patients—to optimize warfighter brain health.

Need training on any of the clinical tools? Email us to schedule a training with our network dissemination specialists. Supplemental "Provider Education" materials are also available.

Acute Concussion Care Pathway

DHA established the Acute Concussion Care Pathway as part of the FY21 Quadruple Aim Performance Plan. The goal is to standardize acute concussion assessment and care across the MHS.

The ACC Pathway aims to improve recovery times and outcomes and to ensure timely access to repeat evaluations with personalized treatment plans that align with a progressive return to activity process.

The ACC Pathway—a standardized assessment and treatment plan for acute concussion—mandates:

  1. Use of the MACE 2 for acute assessment at the initial appointment 
  2. Follow-up within 72 hours after diagnosis of concussion
  3. Completion of a progressive return to activity process prior to return to full duty

A helpful fact sheet and educational video defines the ACC Pathway and outlines how each element works together to improve concussion outcomes across the MHS. 

 Thumbnail image of the downloadable fact sheet on the acute concussion care pathway. What is the Acute Concussion Care Pathway?

Download the ACC Pathway Fact Sheet Watch the ACC Pathway Video

TBICoE offers a quarterly "Acute Concussion Care Pathway: MACE 2 & PRA" virtual training. Attendees may earn two CEUs through the Defense Health Agency Continuing Education Program Office.

Related Policy Information

  • The DHA Procedural Instruction 6490.04, titled “Required Clinical Tools and Procedures for Assessment and Clinical Management of Mild Traumatic Brain Injury/Concussion in Non-Deployed Setting,” establishes the required clinical tools and procedures for management of mild TBI, or concussion, in a non-deployed setting.
  • The DOD Instruction 6490.11, titled "DOD Policy Guidance for Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting" establishes policy, assigns responsibilities, and provides procedures on the management of mild TBI, or concussion, in the deployed setting.

TBICoE's MACE 2, PRA clinical recommendation, Recurrent Concussion Evaluation, and ICD-10 Coding Guidance for TBI support the ACC Pathway, the DHA-PI 6490.04, and the DODI 6490.11.

MACE 2

The MACE 2 is an acute assessment tool for all medically trained personnel who treat service members involved in a potentially concussive event. It includes current TBI information, including a vestibular-ocular-motor screening.

Thumbnail image of the MACE 2

Tactical MACE

To further aid in standardizing acute concussion assessment and care, the Joint Trauma System collaborated with TBICoE to create a concussion screening tool for use in the combat casualty environments called the Tactical MACE. The T-MACE is only appropriate for austere environments and training is available through JTS. The T-MACE products are located within the Prolonged Casualty Care for Combat Medics/Corpsmen Collection on the Deployed Medicine platform.

MACE 2 References

  1. McCrea, M. (2001). Standardized mental status testing on the sideline after sport-related concussion. Journal of Athletic Training, 36(3), 274–279.
  2. McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S.… Vos, P. E. (2017). Consensus statement on concussion in sport—The 5th international conference on concussion in sport held in Berlin, British Journal of Sports Medicine.
  3. Mucha, A., Collins, M. W., Elbin, R., Furman, J. M., Troutman-Enseki, C., DeWolf, R. M., Kontos, A. P. (2014). A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions preliminary findings. American Journal of Sports Medicine, 40(10), 2479-2486.

Progressive Return to Activity

The 2021 Progressive Return to Activity: Primary Care for Acute Concussion Management clinical recommendation is an evidence-based return to activity protocol for primary care managers and concussion/TBI clinic providers.

What's the best way to recover from a concussion? Returning to duty too soon after a concussion can lead to prolonged symptoms, decreased readiness, poor marksmanship, accidents and falls, and increased risk of more concussions. Progressively increasing activity in a step-wise manner can help you resolve your symptoms and return to duty safely. Ask your primary health care provider about TBICoE's Progressive Return to Activity to help you return to duty as quickly and safely as possible. Visit health.mil/TBICoE. The PRA is a six-step approach that begins after the provider performs the MACE 2 and diagnoses the patient with a concussion, or mild TBI. The PRA stages start with relative rest and allow service members to gradually increase activities until they receive clearance for return to full duty or activity. In each stage, the PRA offers general and military specific activities and options to help providers manage their patients' primary symptom clusters. The PRA also offers recommendations on specialty referrals and handouts are available in the appendix for providers to give patients and leadership.

*NEW* Progressive Return to Activity Provider Training, DHA LMS Course #DHA-US1226 (CAC authentication required) 
TBICoE has developed and launched the Progressive Return to Activity Provider Training on the Defense Health Agency Learning Management System (hosted by Joint Knowledge Online). The PRA DHA LMS training is a convenient, detailed course that breaks down key concepts of the PRA clinical recommendation. This training includes periodic knowledge checks, interactive content, and a case study to test the learner’s understanding of the content. There is a one-hour continuing education credit attached through DHA’s Continuing Education Program Office

Additional provider education for the PRA include:

Recurrent Concussion Evaluation

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

Clinical Recommendations and Support Tools for Mild Traumatic Brain Injury

TBICoE optimizes clinical care by combining evidence from medical literature, health care research, and expert opinion to develop and provide clinical recommendations and tools to help providers deliver evidence-based treatment and address the challenges associated with mild TBI.

  • Clinical recommendations provide guidance on assessing and managing mild TBI symptoms.
  • Clinical support tools offer an algorithmic approach to evaluating, managing, and referring mild TBI patients for specialty care.
  • Training material to show providers how to identify and treat patients with mild TBI-related symptoms.
  • Fact sheets and patient guides that provide tips and tools to help service members and veterans cope with a mild TBI.

UPDATED! Assessment and Management of Headache Following Concussion Clinical Suite

Thumbnail image of the downloadable assessment and management of headache following concussion clinical recommendation.This is a major revision of the 2016 clinical recommendation. Some key changes to new “Assessment and Management of Headache Following Concussion/Mild Traumatic Brain Injury: Guidance for the Primary Care Manager” include:

  • Expansion of both non-pharmacologic and pharmacologic treatment of the most common types of post-traumatic headaches.
  • Inclusion of three additional post-traumatic headache subtypes—trigeminal, occipital neuralgia, and vestibular migraines, as well as increased focus on medication overuse headache.
  • Addition of considerations and precautions for preventive treatment options and treatment efficacy criteria to help primary care managers ensure optimal and effective treatment.

The revised patient education fact sheet on managing headache after concussion helps patients understand behavioral and pharmacological strategies their primary care manager may use to manage their PTH.

The all-new fact sheet on medication overuse headache should be reviewed with the patient, as it has space for clinicians to outline a treatment plan. It explains the basics of MOH, as well as treatment and prevention strategies.

The Neuroendocrine Dysfunction Following Concussion/Mild TBI Provider Fact Sheet is a one page document that gives primary care managers an overview of neuroendocrine dysfunction that can occur after concussion, or mild TBI. It highlights conditions with overlapping symptoms, screening and treatment considerations, risk factors, and referral guidance for suspected NED.

Thumbnail image of the Neuroendocrine Dysfunction Following Concussion/Mild TBI Provider Fact Sheet.

The Neuroimaging Following Concussion/Mild TBI clinical recommendation is a concise and interactive clinical algorithm with guidance on imaging modalities in the acute (≤ 7 days post-injury) and post-acute (>7 days post-injury) timeframes. This clinical recommendation allows primary care managers to make an informed, evidenced-based decision regarding whether or not imaging is indicated following a concussion.

This clinical recommendation provides medical staff with a single, comprehensive reference for the assessment and management of dizziness and visual disturbances following mild TBI. Dizziness and visual disturbances often present with overlapping symptoms and should prompt a provider to perform a visual and dizziness—or vestibular—assessment.

Provides step-by-step guidance to help primary care managers assess and manage sleep disturbances associated with mild TBI. The 2020 update includes dosing recommendations for relevant medications, clearer specialty referral timelines, and a more comprehensive coverage of sleep disturbances that include restless legs syndrome, insufficient sleep syndrome, and parasomnias.

Sleep After Concussion. Service members with TBI report 3 times more sleep problems. TBIs can happen anywhere, only 16.9 percent of TBIs happen while deployed. Visit health.mil/TBIFactSheets to learn more about sleep problems and how to improve them

Helps providers treating service members and veterans with persistent cognitive challenges after traumatic brain injury. The clinical suite consists of full clinical recommendations, a short version of the recommendations, a referring provider resource, and appendices.

This clinical recommendation provides background on pre-deployment neurocognitive testing and the use of automated neuropsychological assessment metrics following a concussion in the deployed setting.

Additional Clinical Support Tools

Check out the latest resource, "Medical Devices for Assessment of Traumatic Brain Injury." This fact sheet defines the different regulatory terms and pathways of medical devices, provides an overview on what devices are currently FDA approved for assessing TBI, and provides some considerations for clinicians and researchers before using a device.

Thumbnail image of the downloadable medical devices and TBI fact sheet.

Additional tools to assist in the identification, treatment, and management of patients with mild TBI in deployed and non-deployed settings are also available. Click below to download copies of the Glasgow Coma Scale, Epworth Sleepiness Scale, Insomnia Severity Index, Neurobehavioral Symptom Inventory, and a number of other evaluation tools.

ICD-10 Coding Guidance for TBI

TBICoE developed this 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.

Epworth Sleepiness Scale (ESS)

The ESS is widely used in the field of sleep medicine as a subjective measure of a patient's sleepiness. The test is a list of eight situations in which you rate your tendency to become sleepy on a scale of 0 - no chance of dozing, to 3 - high chance of dozing.

Dizziness Handicap Inventory (DHI)

The 25-item self-assessment evaluates the impact of dizziness on daily life imposed by vestibular system disease.

Glasgow Coma Scale (GCS)

The GCS is used to assess the consciousness and neurological functioning of a person who has just received a TBI. The total score is the sum of the scores in three categories: eye-opening response, verbal response and motor response.

Headache Impact Test (HIT-6)

The six-item HIT-6 provides a global measure of adverse headache impact and is used to screen and monitor patients with headaches in both clinical practice and clinical research. The HIT-6 items measure the severity of headache pain and the adverse impact of headache on social functioning, role functioning, vitality, cognitive functioning and psychological distress. (Source: NIH)

Insomnia Severity Index (ISI)

The ISI is a brief, validated, seven-item self-report questionnaire useful for the initial assessment of insomnia symptom severity and ongoing monitoring of treatment response.

Neurobehavioral Symptom Inventory (NSI)

The NSI is used as a subjective measure for symptom reporting. The NSI is a 22-item symptom inventory of non-specific but common mild TBI symptoms.

Patient Global Impression of Change (PGIC)

The PGIC captures clinically meaningful change that makes a difference to the patient. Consisting of one question rated on a seven-point Likert scale, the PGIC offers a quick and simple method of quantifying clinical progress. The patient is asked to describe the change in activity limitations, symptoms, emotions and overall quality of life related to the concussion.

Patient Health Questionnaire (PHQ-9)

The PHQ-9 is a nine-item tool commonly used in the primary care setting to assess the presence and severity of depression symptoms.

Posttraumatic Stress Disorder Checklist -5 (PCL-5)

The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including: monitoring symptom change during and after treatment, screening individuals for PTSD and making a provisional PTSD diagnosis.

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TBICoE's Low-Level Blast Research Infographic

What is TBICoE doing to help warfighters exposed to low-level blast? Leading the charge: 1. Collaborated on Military weapons training studies and Epidemiology studies 2. Led health and performance efforts in support of the Section 734 Program Advancing the science: 1. Measured LLB exposure effects on performance 2. Provided recommendations on LLB surveillance 3. Advanced DOD’s understanding of LLB health and performance effects Answering the call: 1. Outlined next steps for LLB research 2. Helped to develop guidance for managing brain health risk from blast overexposure 3. Recommended the development of a tool to capture career blast exposure These efforts are in support of the Warfighter Brain Health Initiative LLB Relevant Aims 1. Understand the known and emerging threats and hazards to brain health 2. Monitor warfighters for brain exposures 3. Reduce risk of brain exposures that may negatively impact brain health

This infographic illustrates TBICoE's research activity on understanding how low-level blast influences warfighter brain health. This work directly supports Line of Effort 2 of the Warfighter Brain Health Initiative. Learn more about low-level blast exposure and TBI at health.mil/LLB.

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What is the Acute Concussion Care Pathway?

What is the Acute Concussion Care Pathway? The Acute Concussion Care Pathway is one of the DHA Director’s Quadruple Aim Performance Plan projects. The intent is to equip providers with state-of-the-science tools to standardize concussion assessment and care across the MHS. It is supported by the DHA Procedural Instruction 6490.04 which establishes the infrastructure to ensure patients achieve optimal concussion clinical outcomes.

TBICoE developed this infographic as a quick reference tool that demonstrates application of the standardized acute concussion assessment and care process. By adhering to this established pathway of care for mild TBI, providers across the MHS can ensure a reduction in unwarranted variation and foster an integrated, standardized system of readiness and ...

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Returning to Duty After Concussion

What's the best way to recover from a concussion? Returning to duty too soon after a concussion can lead to prolonged symptoms, decreased readiness, poor marksmanship, accidents and falls, and increased risk of more concussions. Progressively increasing activity in a step-wise manner can help you resolve your symptoms and return to duty safely. Ask your primary health care provider about TBICoE's Progressive Return to Activity to help you return to duty as quickly and safely as possible. Visit health.mil/TBICoE.

This TBICoE infographic gives an overview of the risks of returning to duty too soon after a concussion and explains how a progressive increase in activity can help get you back to duty safely. Returning to duty too soon after concussion can lead to prolonged symptoms, poor marksmanship, decreased readiness, accidents and falls, and increased risk of ...

Last Updated: September 10, 2024
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