Army Refines Medical Management of Concussion

By Cheryl Pellerin

American Forces Press Service

WASHINGTON  – Over the past 20 months, the Army has been working to refine the way it tracks and treats the most common form of battlefield brain injuries -- concussion, also called mild traumatic brain injury, or mTBI.

The job isn’t easy, because even in the United States, where civilians experience traumatic brain injuries at the rate of 1.7 million a year, according to the Centers for Disease Control and Prevention, no single diagnostic standard exists for TBI.

In the words of experts at the 2nd Annual Traumatic Brain Injury Conference last month in Washington, treatment of TBI and especially acute, or rapid-onset, TBI is still “a major unmet medical need” worldwide.

“This is why we have our program,” Army Col. (Dr.) Dallas Hack, director of the Army’s Combat Casualty Care Research Program, told American Forces Press Service.

“This is why Congress in 2007 issued a special appropriation of $300 million to start funding traumatic brain injury and psychological health research for our troops,” he added, “and has continued to [add] significant amounts of funding,” up to $633 million today.

In the research program, scientists try to find ways to look into the brain noninvasively to measure the effects of brain trauma, using brain scans, electroencephalograms for measuring brain electrical activity, eye-tracking systems that offer a window into the brain, and more.

Objective measurements are critical for mild brain trauma, which is called an invisible injury because effects on the brain of falls or explosions or vehicle accidents aren’t always obvious.

Today, while processes and devices sensitive enough to measure mild brain trauma are in development, on the battlefield and at home mild TBI tends to be assessed in large part using the best tools available -- questionnaire-type assessments.

During a recent briefing at the Pentagon, Army specialists in behavioral health and in rehabilitation discussed the evolving behavioral health system of care for TBI.

A hallmark of the Army’s standard of behavioral health care is a screening process administered to soldiers before they deploy, while they are in theater, as they prepare to return home, and while they are in garrison, said the behavioral health specialist.

The assessment process includes the following questionnaires:

-- Predeployment: All incoming service members are screened with the neurocognitive assessment tool, called NCAT, which is used as a baseline for future concussion or mTBI injuries.

-- In theater: Immediately after injury, the Military Acute Concussion Evaluation, called MACE, is used to quickly measure orientation, immediate memory, concentration, and memory recall. Combined with clinical information, a MACE score can guide recommendations, including evacuation to a higher care level.

-- Postdeployment: Because mTBI is not always recognized in the combat setting, active duty service members receive postdeployment health assessments. Four questions adapted from the Brief Traumatic Brain Injury Survey are asked during the assessments. Positive responses on all four prompt an interview with a doctor for an mTBI evaluation.

-- Veterans: Vets are screened for mTBI when they enter the Veterans Health Administration system. A TBI clinical reminder tracking system identifies all who were deployed to Iraq or Afghanistan. Those who report such deployment and don’t have a prior mTBI diagnosis are screened using four sets of questions based on the Brief Traumatic Brain Injury Survey. Those who screen positive for mTBI are offered further evaluation.

“Part of what they do is complete those questionnaires,” the rehabilitation specialist said. “The other part of any of those screenings is a face-to-face interview with a primary care provider. If there’s something the primary care provider or the screening instrument identify as indicating some kind of psychological distress, then the soldier will also see a behavioral health provider face to face.

“The other part of our system of care includes something we call embedded behavioral health that we’re rolling out across the Army right now,” the behavioral health specialist said.

This involves putting behavioral health specialists in the physical location of brigade combat teams, she said. In such a setting, she explained, “[care] providers develop a habitual relationship with the commanders so they feel trust about communicating appropriate information about the soldier’s health.”

The Army is reaching out, she added, “trying to connect with soldiers at the various touch points, in their unit areas and also in primary care clinics, so they have every opportunity to access behavioral health care at any point in their health care and in their daily lives.”

The current protocol for the traumatic brain injury system of care in theater, said the rehabilitation specialist, comes from a 2010 Defense Department directive-type memorandum that makes screening mandatory for soldiers who are involved in four kinds of events, even if they don’t appear to be hurt.

Those who must be screened have been near a blast, sustained a blow to the head, are involved in a vehicle accident, or have commanders who are concerned about them and want to enter them in the protocol.

Anyone involved in a mandatory event receives the MACE evaluation, a medical evaluation and at least 24 hours of rest. And they must be cleared by a medical provider before returning to duty, the rehab specialist said.

Slightly different guidelines cover those who have had multiple concussions.

For somebody who has suffered a second concussion in theater, she added, the minimal 24-hour down time is extended to a minimum of seven days.

Those who have a third diagnosed concussion in theater receive seven days of down time and a comprehensive concussion assessment that consists of consultations with specialty care providers and a functional assessment -- for example, one that assesses their ability to keep their balance.

Also in theater are 11 concussion care centers with specialty providers and a restful environment.

In Afghanistan, for moderate or severe TBI, three neurologists staff Role 3 advanced hospitals, along with a neurology consultant who oversees the TBI neurology specialists.

Telemedicine -- the remote diagnosis and treatment of patients using telecommunications technology -- is also used to treat TBI, and those visits doubled from fiscal 2011 to 2012, the behavioral health specialist said.

The Army has invested more than $530 million to improve access to care, quality of care and research, and TBI screening and surveillance. But the best clinical treatment for service members and civilians with mild TBI may be months and years in the future.

Hack says it’s the state of the science.

The Defense Department’s protocol “is as good as we have,” he said. “I am completely supportive of it. I’m trying to do better,” he added.