Concussion/mTBI Screening
RATIONALE
Unlike a severe or even moderate traumatic brain injury (TBI), a concussion or mild traumatic brain injury (mTBI) may not be readily identified. Recognizing the importance of early detection, the Department of Defense (DoD) and Department of Veterans Affairs (VA) have established system-wide screening and assessment procedures to identify concussion/mTBI in service members and veterans at the soonest opportunity and through multiple points of care.
Screening for concussion/mTBI involves a quick evaluation of possible exposure to a traumatic event including injuries that may occur during deployment, leave, or even civilian life following active duty. Clinicians work to establish if there was an alteration of consciousness (AOC) associated with the injury or traumatic event, and if the event resulted in any neurologic changes or symptoms.
PRE-DEPLOYMENT
The current conflicts in Iraq and Afghanistan have made the assessment of concussion/mTBI an important focus of medical care. Following recommendations from various task forces and Presidential Commissions, the Assistant Secretary of Defense for Health Affairs issued an interim policy letter dated May 28, 2008 calling for the Services to “begin implementing baseline pre-deployment neurocognitive assessments for your service members.” In order to
accomplish this objective, Health Affairs (HA) capitalized on an existing program within the Army to implement pre-deployment baseline testing for all services. The Defense and Veterans Brain Injury Center (DVBIC) was designated the Office of Responsibility for this DoD wide program, referred to as the
Neurocognitive Assessment Tool (NCAT) program.
The goal of the NCAT program is to enhance the assessment of service members post concussion/mTBI and to provide additional information for treatment and return to duty decisions. To support the program long-term and to facilitate the availability of test data wherever a service member receives medical care, the Defense Health Information Management System (DHIMS) is developing capabilities for NCAT test results to become part of the medical record and to be accessible world-wide.
The NCAT is used in conjunction with clinical practice guidelines for managing concussion which have been developed for deployed and non-deployed settings. The NCAT is one of many capabilities for healthcare providers in assessing and managing concussion/mTBI. While its use has been mandated for DoD, other agencies have also expressed interest. Currently, the Coast Guard is also participating in this program.
IN-THEATER
Ideally, screening should occur immediately following the injury event or as soon as operationally feasible. The
Military Acute Concussion Evaluation (MACE) is a screening tool developed by DVBIC in 2006 that allows medics/corpsmen and front line providers to quickly measure four cognitive domains: orientation, immediate memory, concentration, and memory recall. When combined with other clinical information, the MACE score can help reveal basic cognitive performance and guide recommendations including evacuation to a higher level of care. The MACE is currently undergoing further validation studies in a combat environment and DVBIC continues to work to ensure screening for concussion/mTBI at all levels and environments of care. The MACE alone does not diagnose concussion/mTBI.
LANDSTUHL REGIONAL MEDICAL CENTER
Service members with significant injuries or non-battle medical conditions that require evacuation from theater, undergo screening for concussion/mTBI at Landstuhl Regional Medical Center (LRMC) in Germany. This process identifies any history of previous brain injury (combat or non-combat related) and assesses for the presence or absence of current concussion/mTBI-related symptoms. Identification of newly symptomatic patients results in triage to a stateside medical facility that can more fully evaluate and, if necessary, provide treatment for concussion/mTBI.
POST-DEPLOYMENT
Because concussion/mTBI is not always recognized in the combat setting, screening of active duty service members also occurs through post-deployment health assessments (PDHA). Four questions, that are adapted from the
Brief Traumatic Brain Injury Survey (BTBIS), appear on the PDHA. Positive responses on all four questions should prompt a clinician interview to more fully evaluate for concussion/mTBI.
VETERANS
Screening for concussion/mTBI of veterans occurs upon entry into the Veterans Health Administration (VHA) system, using a TBI Clinical Reminder tracking system. The first step of the reminder is to identify possible Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF) participants based on whether date of separation from military duty or Active Duty status occurred after September 11, 2001. The screening for concussion/mTBI is done once for all individuals who report deployment to OEF/OIF Theaters. For those who confirm OEF/OIF deployment and do not have a prior diagnosis of concussion/mTBI, the instrument proceeds using four sequential sets of questions, once again based on the
BTBIS. Arrangements for further evaluation are offered for those who screen positive for concussion/mTBI.
CONCLUSION
It is important to realize that not all individuals whose screen is positive have a concussion/mTBI.
Therefore, it is critical that patients not be labeled with the diagnosis of concussion/mTBI on the basis of a positive screening test. Positive screens should always be followed by a clinical interview and examination to confirm or negate the diagnosis of concussion/mTBI. In the absence of temporally-related symptoms, screening serves two main purposes: 1) to identify those individuals in whom a concussion/mTBI is suspected and 2) to establish the incidence and prevalence of this injury. For those with ongoing symptoms, screening can facilitate appropriate care, however, symptom reporting is not required when confirming the diagnosis. Symptoms such as fatigue, irritability, depression and difficulty concentrating may occur alone or in combination with the more classic signs of TBI: dizziness, nausea, headache and other physiological problems.
If you are a provider and would like more information on the evaluation or treatment of concussion/mTBI, DVBIC can help. Call us at 1.800.870.9244 or use our
Contact Us form to send a message online. One of our clinicians will be happy to assist you.
mTBI/CONCUSSION CLINICAL PRACTICE GUIDELINES (CPGs)
ADDITIONAL RESOURCES
REFERENCES
Schwab KA, Ivins B, Cramer G et al. (2007). Screening for traumatic
brain injury in troops returning from deployment in Afghanistan
and Iraq: Initial investigation of the usefulness of a short screening
tool for traumatic brain injury. Journal of Head Trauma Rehabilitation,
22(6):377-389.
Terrio H, Brenner LA, Ivins BJ, Cho JM, Helmick K, Schwab K, Scally K,
Bretthauer R & Warden D. (2009). Traumatic brain injury screening:
Preliminary findings in a US Army brigade combat team. J Head
Trauma Rehabil; 24(1): 14-23. [abstract]