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Updated tools and training improve TBI and concussion recovery

A group of military personnel wearing face mask working on laptop computers Air National Guard service members from the 119th Civil Engineer Squadron take a baseline neuro-cognitive assessment known as an Automated Neuropsychological Assessment Metric as part of their pre-deployment training at the North Dakota Air National Guard Base, Fargo North Dakota, Feb. 6, 2021. This assessment can be repeated and used by medical professionals in the event of a suspected traumatic brain injury or concussion (Photo by: Air National Guard Tech. Sgt. Nathanael Baardson).

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Up-to-date clinical tools help military health care providers diagnose and manage traumatic brain injury (TBI) on and off the battlefield. And an increased focus on training providers to use these tools is improving patient outcomes and mission readiness, according to research by the Traumatic Brain Injury Center of Excellence.

TBICoE recently conducted research on the Department of Defense Progressive Return to Activity Following Acute Concussion/Mild Traumatic Brain Injury clinical recommendations for managing headaches, as well as the Military Acute Concussion Evaluation 2, known as MACE 2.

TBICoE assessed the effectiveness of the return-to-activity guidelines after offering on-site training to providers. Using a similar study design, TBICoE also reported on the effectiveness of a post-traumatic headache management clinical recommendation. At the end of 2020, TBICoE published results of a study on the usability and utility of its MACE 2 screening tool when used in the field.

"We are applying what began with the (return to activity guidelines) a few years back to other TBICoE products," said TBICoE Division Chief, Navy Capt. (Dr.) Scott Pyne. "By training providers in how to use our state-of-the science tools and rehabilitation strategies, patients get better faster, and this contributes to our mission goals of better health and readiness."

TBICoE is a division of the Defense Health Agency Research and Development Directorate.

Based on a study at Army, Navy, and Marine installations, TBICoE researchers found training providers on the return-to-activity guidelines expanded their knowledge, leading to changes in concussion management, and in turn, a positive impact on patient outcomes. The researchers gave providers standardized training on the content and how to clinically apply return-to-activity guidelines for service members with acute concussion. The clinical recommendation describes how to gradually increase patient activity through six stages. The study assessed providers' approach to patient progression through the stages before and after the training.

“Providers who are directly trained in return-to-activity guidelines are more likely to provide effective patient education, ultimately helping their patients to recover more rapidly,” wrote Mark Ettenhofer, a TBICoE research neuropsychologist at Naval Medical Center San Diego, in an article authored with TBICoE colleagues at Fort Bragg, North Carolina; Camp Pendleton, California; and TBICoE headquarters in Silver Spring, Maryland. Recently, TBICoE revised the return-to-activity recommendations to align with the latest scientific literature findings.

TBICoE also assessed the effectiveness of its headache management clinical recommendation, and found instructing providers in its use also improved outcomes. Like the return-to-activity study, providers learned about the headache management clinical recommendation, which provides tools for assessing post-traumatic headaches and contains both drug and non-drug interventions for decreasing their frequency, severity, and duration. The researchers assessed the providers’ treatment approaches before and after instruction, and found, after training, providers scheduled follow-up visits more frequently, which led to better patient monitoring.

"The results presented in this study demonstrate the potential of the Management of Headache Following Concussion (Clinical Recommendation) to promote provider knowledge and confidence in treating (post-traumatic headaches) in a military setting. This in turn may translate to timely return to duty," wrote Camp Pendleton Research Scientist Rosemay Remigio-Baker and colleagues.

In another study published in 2020, TBICoE researchers showed primary care managers and medics could use the MACE 2 screening tool effectively. Designed by TBICoE in conjunction with the TBI Advisory Committee and the military services, the MACE 2 enables users in the field to screen for common symptoms, cognitive deficits, and neurological signs following concussion. Revised in 2018 to improve accuracy, the newer tool now assesses balance and eye motion, increasing screening time.

Bilal Khokhar, an epidemiologist at TBICoE, and his colleagues surveyed 28 active duty primary care managers and 22 Army combat medics. They were asked to rate, on a scale from strongly disagree to strongly agree, whether they could use the tool, whether various tests were helpful, and whether they were confident about those tests.  When the individual responses were averaged by category of question, the response was positive, and no overall average score fell below the neutral rating.

"Despite the increased complexity and duration of the MACE 2 compared with the previous version of this tool, military providers and Army medics found the new MACE 2 very useable and had a high degree of confidence in its performance," wrote Khokhar and colleagues. However, the researchers cautioned that future studies may result in additional revisions.

"Work must be performed in perpetuity to deliver a product usable by clinicians that offers the greatest validity," said Seth Kiser, the study's senior author and a research scientist at TBICoE.

All these studies demonstrate how TBICoE draws on its expertise in research, clinical affairs, and education to continually update its products and facilitate training, so providers will always "Be TBI ready," based on the latest science. Providers can get the most current information on these tools from TBICoE’s publications, and obtain training on their use from regional education coordinators.

To learn more about Brain Injury Awareness Month, check out the BIAM page on Health.mil.

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In this lesson we review the six major changes in the TBICoE's revised 2021 Progressive Return to Activity (PRA) Clinical Recommendation that differ from the original recommendation. The changes reflect the latest TBI research, and will make it easier for providers to manage the recovery process and return service members with concussion to full duty as quickly and safely as possible. Each video in the PRA training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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PRA Training Video 3: Understanding Relative Rest

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PRA Training Video 1: PRA Overview

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In the first of TBICoE's Progressive Return to Activity (PRA) video training series, you will learn about the reasons for using a progressive return to activity process and receive an overview of the 2021 PRA algorithm and its associated tools. By the end of lesson one, providers will better understand the PRA process, and explain that process to service members diagnosed with concussion. Each video in the PRA training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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In this lesson, we review the criteria for advancing through the stages of the Progressive Return to Activity (PRA) Clinical Recommendation. Each video in the PRA training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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In this lesson, we cover how to perform the Return to Duty, or RTD screening, which now includes both vestibular/physical and neurocognitive examinations. The purpose of the RTD screening is to objectively measure whether a service member is ready for return to full duty. Each video in the Progressive Return to Activity training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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This lesson covers how to use the Progressive Return to Activity, or PRA's Symptom-Guided Management and Specialty Referral Guidance tables. This lesson also details primary care management strategies for service members who are not progressing as expected in the PRA. Each video in the Progressive Return to Activity training series is designed to support primary care providers' ability to manage concussion/traumatic brain injury (TBI).

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