• MACE 2
• Vestibular/Ocular-Motor Screening for Concussion

MACE 2 References

1. McCrea, M. (2001). Standardized mental status testing on the sideline after sport-related concussion. Journal of Athletic Training, 36(3), 274–279.
2. McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S.,… Vos, P. E. (2017). Consensus statement on concussion in sport—The 5th international conference on concussion in sport held in Berlin, British Journal of Sports Medicine.
3. Mucha, A., Collins, M. W., Elbin, R., Furman, J. M., Troutman-Enseki, C., DeWolf, R. M., Kontos, A. P. (2014). A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions preliminary findings. American Journal of Sports Medicine, 40(10), 2479-2486.

The PRA is a six-step approach that begins after the provider performs the MACE 2 and diagnoses the patient with a concussion, or mild TBI. The PRA stages start with relative rest and allow service members to gradually increase activities until they receive clearance for return to full duty or activity. In each stage, the PRA offers general and military specific activities and options to help providers manage their patients' primary symptom clusters. The PRA also offers recommendations on specialty referrals and handouts are available in the appendix for providers to give patients and leadership.

• Clinical Recommendation
• Patient and Leadership Guide
• References and Acknowledgements

*NEW* Progressive Return to Activity Provider Training, DHA LMS Course #DHA-US1226 (CAC authentication required) 
TBICoE has developed and launched the Progressive Return to Activity Provider Training on the Defense Health Agency Learning Management System (hosted by Joint Knowledge Online). The PRA DHA LMS training is a convenient, detailed course that breaks down key concepts of the PRA clinical recommendation. This training includes periodic knowledge checks, interactive content, and a case study to test the learner’s understanding of the content. There is a one-hour continuing education credit attached through DHA’s Continuing Education Program Office. 

Additional provider education for the PRA include:

• PRA Video
• PRA Patient-focused Infographic
• PRA Training Slides
• PRA Training Video Series and workbook can be found on the Provider Education page.

The Recurrent Concussion Evaluation Card is designed to guide providers in the management of patients with a history of three or more documented concussions within a 12-month span.

TBICoE developed this quick reference ICD-10 for TBI based on the latest coding guidance and the Military Health System Professional Services and Specialty Medical Coding Guidelines Version 5.0, to facilitate consistent and accurate coding for TBI diagnoses and related symptoms and conditions.

The Neuroendocrine Dysfunction Following Concussion/Mild TBI Provider Fact Sheet is a one page document that gives primary care managers an overview of neuroendocrine dysfunction that can occur after concussion, or mild TBI. It highlights conditions with overlapping symptoms, screening and treatment considerations, risk factors, and referral guidance for suspected NED.

The Neuroimaging Following Concussion/Mild TBI clinical recommendation is a concise and interactive clinical algorithm with guidance on imaging modalities in the acute (≤ 7 days post-injury) and post-acute (>7 days post-injury) timeframes. This clinical recommendation allows primary care managers to make an informed, evidenced-based decision regarding whether or not imaging is indicated following a concussion.

• Clinical Recommendation
• References and Acknowledgements

This clinical recommendation provides medical staff with a single, comprehensive reference for the assessment and management of dizziness and visual disturbances following mild TBI. Dizziness and visual disturbances often present with overlapping symptoms and should prompt a provider to perform a visual and dizziness—or vestibular—assessment.

• Clinical Recommendation
• References and Acknowledgements
• Managing Dizziness Changes Following Concussion Fact Sheet
• Managing Vision Changes Following Concussion Fact Sheet

Provides step-by-step guidance to help primary care managers assess and manage sleep disturbances associated with mild TBI. The 2020 update includes dosing recommendations for relevant medications, clearer specialty referral timelines, and a more comprehensive coverage of sleep disturbances that include restless legs syndrome, insufficient sleep syndrome, and parasomnias.

• Clinical Recommendation
• References and Acknowledgements
• Patient Fact Sheet
• Sleep after Concussion for Patients Infographic: "Sleep After Concussion" is intended for patients and caregivers of those who have sustained a TBI. The infographic reviews general information of sleep-related concerns and points towards additional educational resources.

As headache is the most common symptom reported following a concussion, also known as a mild TBI, this clinical recommendation and supporting tools are intended to guide health care providers in the diagnosis, evaluation and treatment of post-traumatic headache.

• Clinical Recommendation 
• Clinical Support Tool
• Patient Fact Sheet
• "Management of Headache Following Concussion (Course #US-1112)" provider training course is now available on Joint Knowledge Online, MHS' enterprise learning management system. Visit our Provider Education page for more information about the course, or go directly to the training on JKO (CAC required).

Helps providers treating service members and veterans with persistent cognitive challenges after traumatic brain injury. The clinical suite consists of full clinical recommendations, a short version of the recommendations, a referring provider resource, and appendices.

• Clinical Recommendation
• Short Version
• Referring Provider Resource
• Appendices
• SCORE Study
• Online training via VHA Train

This clinical recommendation provides background on pre-deployment neurocognitive testing and the use of automated neuropsychological assessment metrics following a concussion in the deployed setting.

• Clinical Recommendation

ICD-10 Coding Guidance for TBI

TBICoE developed this resource based on the latest coding guidance and the Military Health System Professional Services and Specialty Medical Coding Guidelines Version 5.0, to facilitate consistent and accurate coding for TBI diagnoses and related symptoms and conditions.

Epworth Sleepiness Scale (ESS)

The ESS is widely used in the field of sleep medicine as a subjective measure of a patient's sleepiness. The test is a list of eight situations in which you rate your tendency to become sleepy on a scale of 0 - no chance of dozing, to 3 - high chance of dozing.

Dizziness Handicap Inventory (DHI)

The 25-item self-assessment evaluates the impact of dizziness on daily life imposed by vestibular system disease.

Glasgow Coma Scale (GCS)

The GCS is used to assess the consciousness and neurological functioning of a person who has just received a TBI. The total score is the sum of the scores in three categories: eye-opening response, verbal response and motor response.

Headache Impact Test (HIT-6)

The six-item HIT-6 provides a global measure of adverse headache impact and is used to screen and monitor patients with headaches in both clinical practice and clinical research. The HIT-6 items measure the severity of headache pain and the adverse impact of headache on social functioning, role functioning, vitality, cognitive functioning and psychological distress. (Source: NIH)

Insomnia Severity Index (ISI)

The ISI is a brief, validated, seven-item self-report questionnaire useful for the initial assessment of insomnia symptom severity and ongoing monitoring of treatment response.

Neurobehavioral Symptom Inventory (NSI)

The NSI is used as a subjective measure for symptom reporting. The NSI is a 22-item symptom inventory of non-specific but common mild TBI symptoms.

Patient Global Impression of Change (PGIC)

The PGIC captures clinically meaningful change that makes a difference to the patient. Consisting of one question rated on a seven-point Likert scale, the PGIC offers a quick and simple method of quantifying clinical progress. The patient is asked to describe the change in activity limitations, symptoms, emotions and overall quality of life related to the concussion.

Patient Health Questionnaire (PHQ-9)

The PHQ-9 is a nine-item tool commonly used in the primary care setting to assess the presence and severity of depression symptoms.

Posttraumatic Stress Disorder Checklist -5 (PCL-5)

The PCL-5 is a 20-item self-report measure that assesses the 20 DSM-5 symptoms of PTSD. The PCL-5 has a variety of purposes, including: monitoring symptom change during and after treatment, screening individuals for PTSD and making a provisional PTSD diagnosis.