Concussion/mTBI Screening

Introduction

A concussion or mild traumatic brain injury (mTBI) may not be readily identified unlike a more serious closed or penetrating head injury. 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 earliest opportunity and through all levels 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 a loss of consciousness (LOC), an alteration of consciousness (AOC), post-traumatic amnesia (PTA) associated with the injury or traumatic event, or if the event resulted in any neurologic changes or symptoms.

Pre-Deployment

The current war in Afghanistan has made the assessment of cognitive deficits associated with concussion/mTBI an important focus of medical care. Starting in 2008, service members have been required to take baseline computerized neurocognitive evaluations — using the Automated Neuropsychological Assessment Metric (ANAM) — before they deploy. The Defense and Veterans Brain Injury Center has been designated as the Office of Responsibility for this DoD-wide program, referred to as the Neurocognitive Assessment Tool (NCAT) program.

The goals of the NCAT program are to assure implementation of the system-wide pre-deployment testing program, to help facilitate the assessment of service members after they have had a concussion, and assist with the build-out of the NCAT Release 2 ANAM system. To help with the collection of test data — no matter where a service member receives medical care — the Defense Health Information Management System is developing capabilities for NCAT Release 2 to become part of the medical record and to be accessible worldwide.

The NCAT is used in conjunction with clinical practice guidelines for evaluating concussion and is one of many tools for health care providers to assess concussion/mTBI. Although the DoD is required to use ANAM, other federal agencies have expressed interest. Currently, the Coast Guard — which is a part of the Department of Homeland Security — is participating in this NCAT program.

To schedule ANAM testing: Please email usarmy.jbsa.medcom.mbx.otsg-anam-operations@mail.mil

Obtaining NCAT baselines for treatment: If you are a provider in need of an individual’s baseline NCAT scores to compare with a post-injury assessment, please request this information via usarmy.jbsa.medcom.mbx.otsg--anam-baselines@mail.mil

If you have questions about NCAT or need to speak with someone, please call 855-630-7849.

In-Theater

Ideally, screening should occur immediately following the injury event or as soon as possible. The Military Acute Concussion Evaluation (MACE) is a screening tool for assessing concussion in the deployed setting.1 This assessment takes approximately 10 minutes to administer by a skilled medic/corpsman or a provider.

The MACE alone does not diagnose concussion/mTBI. When administered properly, it assists in obtaining the event history that later helps providers determine how to proceed with the cognitive screening, symptom screening and neurological evaluation. The Policy Guidance for Management of mTBI/Concussion was developed in June 2011 and is a product used with the MACE for in- theater assessment.

1 Per the Policy Guidance for Management of mTBI/Concussion in the Deployed Setting.

Landstuhl Regional Medical Center (LRMC)

LRMC is a unique medical center as it is the initial stop for service members coming from the field. Service members with significant injuries or non-combat-related medical conditions that require evacuation from theater undergo screening for concussion/mTBI at LRMC. Center staff members aim to screen all patients (using their standard form and MACE) unless it is not medically possible. This screening identifies any history of TBI (combat or non-combat related) and 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. Service members also are referred to LRMC2 if further evaluation is warranted beyond a Level III facility, i.e., Combat Support Hospital. These symptomatic patients are managed in the clinic with the expectation of returning to duty.

2 Per the Policy Guidance for Management of mTBI/Concussion in the Deployed Setting.

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). Included in the PDHA, there are questions about the occurrence of a head injury event, alteration of consciousness as a result of that event, concussion-related symptoms immediately after the event, and the presence of current concussion-related symptoms. Positive responses on these questions should prompt a clinician interview to more fully evaluate for concussion/mTBI. Following the PDHA, a service member will also complete a post-deployment health reassessment (PDHRA) to ensure that he/she is not still experiencing symptoms that would require further evaluation.

Veterans

Screening for concussion/mTBI of veterans occurs upon entry into the Veterans Health Administration system, using a TBI Clinical Reminder tracking system. The first step of the reminder is to identify possible Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) participants based on whether their date of separation from military duty or active-duty status occurred after Sept. 11, 2001. The screening for concussion/mTBI is done once for all individuals who report OEF/OIF/OND deployments. For those who confirm these deployments and do not have a prior diagnosis of concussion/mTBI, the screening continues with four sequential sets of questions. Arrangements for further evaluation are offered for those who screen positive for concussion/mTBI.

Conclusion

It is important to realize that not all individuals who screen 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.

Screening serves two main purposes even if the service member or veteran is asymptomatic:

  1. It identifies those individuals who might have a concussion/mTBI.
  2. It establishes 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: headache, dizziness, nausea, 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. Please email us to contact one of our subject matter experts.

Additional Resources

References

Kelly MP, Coldren RL, Parish RV, Dretsch MN, Russell ML. Assessment of Acute Concussion in the Combat Environment. Arch Clin Neuropsychol. 2012 Apr 3. [Epub ahead of print]

Sayer NA, Nelson D, Nugent S (2011). Evaluation of the Veterans Health Administration traumatic brain injury screening program in the upper Midwest. J Head Trauma Rehabil. 2011 Nov-Dec;26(6):454-67.

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.