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1ConcussionManagement ToolBefore initiating concussion management,complete TCCC, MACE 2, and FDA clearedstructural brain injury device or tool (if available).Initial Management up to Seven Days from Injury1. Review MACE 2, if results are:a. NEGATIVE1) Initiate 24-hour rest A (mandatory if deployed)2) Go to step 2bb. POSITIVE1) Consider using an FDA cleared concussionassessment device/tool (if available)2) Begin initial concussion managementB3) If three or more concussions in 12 months,refer to recurrent concussion evaluationC4) Initiate rest A2. R eevaluate after 24 hoursa. If symptom free at rest, conduct exertional testingGb. If symptom free, go to step 43. Follow up every 24 to 48 hours for up to seven daysa. Review MACE 2 Exam Summary or FDA clearedconcussion assessment device or tool results (if available)to guide primary care and symptom cluster managementDb. Progress through the PCM PRA E1) Go to Comprehensive Management (card 2) if notprogressing as expected through PCM PRA E2) Avoid any potentially concussive eventsc. Refer to Minimum Mandatory Recovery Time chartHd. Consider NCAT testingIe. Consider specialty consultation for any abnormal results4. Return to dutya. Communicate findings to line leadershipb. Document and code findings in health record
2Concussion Management ToolFor use when patient not progressingthrough the PCM PRAComprehensive Management(Typically beyond one week)1. Reviewa. All relevant documentation(PCM PRA E, MACE 2, other tools)b. Progression of symptom clustersDc. F ocused history: current and prior concussion timeline,behavioral health, headache disordersd. If three or more concussions in 12 months,refer to recurrent concussion evaluationC2. Managea. Conduct a comprehensive evaluation and initiation ofRehab PRA Fb. Manage symptoms using symptom cluster chart Dc. F ollow up every 48 to 72 hours as symptoms dictated. If not progressing as anticipated, consider:1) Specialty consultation or teleconsultation2) Functional assessment (physical therapy,occupational therapy)3) NCAT I4) Neuroimaging (per provider judgment)J3. Complete minimum mandatory recovery timeH4. Return to dutya. Communicate findings to line leadershipb. Document and code findings in health recordResource LinksDVBIC Resources (clinical tools and patient education factsheets):https://dvbic.dcoe.mil/resourcesVA/DoD mTBI CPG: mtbi/mTBICPGFullCPG50821816.pdfCards 3 to 8 of the CMT correspond to the red superscripts (A-J)found on action cards 1-2.
3Concussion Management ToolA. Rest1. Rest with extremely limited cognitive activity2. Limit physical activities to those of daily livingand extremely light leisure activity3. Avoid work, exercise, video games, reading or driving4. Avoid any potentially concussive events5. Avoid caffeine and alcoholB. Initial Concussion ManagementIn the initial 24 hours, manage symptoms to facilitaterest and sleep1. Aggressive headache or pain management:-U se acetaminophen every 6 hours, for 48 hours; after 48hours, may use naproxen as needed. Avoid tramadol,Fioricet, and narcotics2. Reduce environmental stimuli3. Review current medications and sleep hygiene4. Provide concussion education and set expectationsfor full recoveryC. Recurrent Concussion EvaluationThree or more documented in 12-month span1. C omprehensive neurological evaluation by neurologistor qualified providera. Review of prior concussion history with focus on timelineor resolution of symptoms/symptom clustersb. Assessment of current symptoms (face-to-face interview byprovider). Consider Neurobehavioral Symptom Inventory,Acute Stress Reaction Questionnaire, Balance Assessment2. Neuroimaging per provider judgementJ3. Neuropsychological assessment by psychologista. Evaluate: attention, memory, processing speed andexecutive functionb. Perform a psychosocial and behavioral assessmentc. Include measure of effortd. Consider NCAT I4. Functional assessment by physical or occupational therapist5. Neurologist or qualified provider determines return to duty status
Concussion Management Tool4Assessment and Management of VisualDysfunction Associated with MildTraumatic Brain InjuryAssessment and Management ofDizziness Associated with Mild TBI(Starts treatment at 6 weeks post injury)Cognitive Rehabilitation for ServiceMembers and Veterans Following Mild toModerate Traumatic Brain InjuryDVBIC Clinical RecommendationVision tibular Therapy(OT/PT)Vision Therapy(OT/PT)AudiologySleep siderationsD. TBI Symptom Clusters guide treatment. Patients often present with overlapping symptoms. Symptomsshould be reevaluated regularly to assess risk of protracted recovery. Use the MACE 2 results and symptomsto guide your treatment and management.Symptom Cluster ActionsCognitive(MACE 2:Q5-8 & Q15-16)Vestibular(MACE 2:Q11-12 & Q17)Identify: vestibular dysfunction, oculomotordysfunction, headaches, medicationside effects, psychological health, sleepdisturbance, substance useConsider: modified BESS, oculomotorassessmentIdentify: headaches, pain, psychologicalhealth, sleep disturbance, oculomotordysfunction, medication side effectsConsider: cognitive rest, reduction of stimuli,Neurocognitive Assessment Test (NCAT),oculomotor assessmentOculomotor(MACE 2:Q14 & Q17)Identify: vestibular dysfunction, oculomotordysfunction, medication side effects, migraineheadaches, psychological health, sleepdisturbancesConsider: VOMS
Concussion Management Tool5D. TBI Symptom Clusters (Continued)Symptom Cluster ActionsIdentify: type of headache(s): (migraine,tension, cervicogenic, neuropathic),psychological health, sleep disturbancesConsider: oculomotor assessmentIndications and Conditions ofNeuroendocrine DysfunctionScreening Post Mild Traumatic Brain InjuryManagement of Headache FollowingConcussion/Mild Traumatic BrainInjury: Guidance for Primary CareManagement in Deployed and NonDeployed SettingsSleep MedicineBehavioral HealthBehavioral ferralConsiderationsIdentify: acute stress reaction,neuroendocrine dysfunctionConsider: Providing the Acute ConcussionEducational BrochureManagement of Sleep DisturbancesFollowing Concussion/Mild TBI:Guidance for Primary CareManagement in Deployed and NonDeployed SettingsDVBIC Clinical RecommendationAnxiety/ Mood(MACE 2: Q4C)Identify: type of sleep disturbance(s):(insomnia, circadian rhythm, sleep apnea),headaches, medication side effects,neuroendocrine dysfunction,pain, psychological healthHeadaches/Migraine(MACE 2: Q4B)SleepDisturbances(MACE 2:Q5-6 & Q15-16)Identify: sources of cervicogenic headaches,musculoskeletal cervicalgia, neuropathiccervicalgia, other sources of neck painPhysical TherapyPhysical Medicineand RehabilitationCervical Spine(MACE 2:Q9 & Q17)Management of Headache FollowingConcussion/Mild Traumatic BrainInjury: Guidance for Primary CareManagement in Deployed and NonDeployed Settings
6Concussion Management ToolE. Progressive Return to Activity Following AcuteConcussion/mTBI: Guidance for the Primary CareManager and RehabilitationThis clinical recommendation details how to help servicemembers progressively return to pre-injury activity andpromotes the standardization of care following a concussion.Stages of the Progressive Return to Activity ProcessStageDescriptionObjectiveSymptom resolution1.Rest2.Light Routine Activity Introduce and promote limited effort3.Light Occupationoriented ActivityIncrease light activities that require acombined use of physical, cognitive and/orbalance skills4.Moderate ActivityIncrease the intensity and complexity ofphysical, cognitive and balance activities5.Intensive ActivityIntroduce activity of duration and intensity thatparallels the service member’s typical role,function and tempo6.Unrestricted Activity Return to pre-injury activitiesConsiderations for moving from the PCM to Rehab PRA: Per provider judgement First and second concussion: Recovery not progressing as anticipated No progression in seven days Symptoms are worsening Symptomatic after exertional testing following Stage 5 Two or more concussions: If symptoms reported are 1 (mild) on the NSI after Stage 1, RestF. Progressive Return to Activity Following AcuteConcussion/ mTBI: RehabilitationThe rehabilitation PRA is used when patient is symptomaticfollowing the initial recovery period (zero to seven days). Rehabilitation PRA daily assessment: NSI Resting heart rate Resting blood pressure Consider medications, prior medical history, and thepossibilty of a previously undiagnosed condition If pre-injury NSI 1, use clinical judgement
7Concussion Management ToolG. Exertional Testing1. Exert to 65-85 percent of target heart rate (THR 220-age)using push-ups, sit-ups, running in place, step aerobics,stationary bike, treadmill and/or hand crank2. Maintain this level of exertion for approximately two minutes3. Assess for symptoms (headache, vertigo, photophobia,balance, dizziness, nausea, visual changes, etc.)4. If symptoms/red flags exist with exertional testing,stop testing, and consult with providerH. Minimum Mandatory Recovery Time If first concussion in past 12 months: 24-hour rest period If second concussion in past 12 months:seven-day rest period post symptom resolution If third concussion in past 12 months:complete Recurrent Concussion EvaluationCI. Neurocognitive Assessment ToolNeurocognitive assessment tools are performance-basedmethods to assess cognitive functioning. The DefenseDepartment uses Automated Neuropsychological AssessmentMetrics (ANAM). Find detailed instructions to administera post-injury ANAM at dvbic.dcoe.mil. For ANAM baselineresults send requests .milJ. Neuroimaging Following Mild TBI in the Non-DeployedSetting Clinical Recommendation and reference cardoffers guidance with a standardized approach to neuroimagingfrom the acute through chronic stages following mild TBI inthe non-deployed setting. (Resource link on card 2)ResourcesMandatory Events Requiring Concussion Evaluation:1. Any service member in a vehicle associated with a blast event,collision, or rollover2. Any service member within 50 meters of a blast (inside or outside)3. Anyone who sustains a direct blow to the head4. Command directed
8Concussion Management ToolOther Resources2015 DoD Definition of Traumatic Brain Injury:A traumatically induced structural injury or physiological disruptionof brain function, as a result of an external force, that is indicatedby new onset or worsening of at least one of the following clinicalsigns immediately following the event:n Any alteration in mental status (e.g., confusion, disorientation,slowed thinking)n Any loss of memory for events immediately before or after injuryn Any period of loss of or a decreased level of consciousness,observed or self-reportedInitial TBI Screening Code: Z13.850TBI Coding Sequence:1. Primary TBI diagnostic code: S06. E L S E. Primary symptomcode, if applicable: (e.g., H53.2 - diplopia)3. Deployment status code, if applicable: (e.g., Z56.82 fordeployed)4. TBI external cause of morbidity code: (For example, Y36.290A[A- use for initial visit] for war operations involving otherexplosions and fragments, military personnel, initial encounter)5. Place of occurrence code, if applicable6. Activity code, if applicable7. Personal history of TBI code: if applicable Z87.820Acronym IndexNSI: Neurobehavioral SymptomANAM: AutomatedInventoryNeuropsychological AssessmentPCM PRA: Primary CareMetricsBESS: Balance Error Scoring System Management Progressive Return toActivityCPG: Clinical Practice GuidelineDVBIC: Defense and Veterans Brain Rehab PRA: RehabilitationProgressive Return to ActivityInjury CenterTCCC: Tactical Combat Casualty CareDoD: Department of DefenseFDA: Food and Drug Administration VOMS: Vestibular-Ocular MotorMACE 2: Military Acute Concussion ScreeningEvaluation 2PUID 4899.1.1.15Released: August 2012 Revised: March 2019by Defense and Veterans Brain Injury Center.This product is reviewed annually and is current until superseded.800-870-9244 dvbic.dcoe.mil
Neuro-ophthalmology: Anxiety/ Mood (MACE 2: Q4C) Identify: acute stress reaction, neuroendocrine dysfunction: Consider: Providing the Acute Concussion . 2015 DoD Definition of Traumatic Brain Injury: A traumatically induced structural injury or physiological disruption : of brain function, as a result of an external force, that is indicated .
