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Table of Contents
Background
A traumatic brain injury (TBI) is defined as a blow or jolt to the head or a penetrating head injury that disrupts the function of the brain. Concussions, also called “closed head injuries”, are a type of TBI. Not all blows or jolts to the head result in a TBI. The severity of such an injury may range from “mild”, i.e., a brief change in mental status or consciousness to “severe”, i.e., an extended period of unconsciousness or amnesia after the injury. TBI can cause a wide range of functional changes which can affect thinking, sensation, movement, language, and/or emotions. Some symptoms may appear immediately after the injury and other symptoms may not appear for days or weeks. Because of the nature of the injury and the symptoms, sometimes people may not recognize or admit that they have a problem. In post-concussion/mild TBI patients, recovery time is within weeks/months, but a small percentage have persistent symptoms. Patients with moderate to severe TBI may never fully recover their pre-injury function.
The rate of combat-related brain injuries in servicemembers returning from the current conflicts in Iraq and Afghanistan is higher than in previous conflicts. Blast injuries are a significant cause of TBIs. TBI is often associated with severe multiple trauma, post traumatic stress disorder (PTSD) or undiagnosed concussions. Screening patients who are at risk for a TBI is important in order to ensure that TBIs are identified and appropriately treated.
Below, we have provided information on TBI, including clinical guidance, policies and directives, training material, and other resources to assist healthcare providers and Service members and their families.
Clinical Guidance
DoD/VA Clinical Guidance
- Clinical Practice Guidelines – Non-Deployed Setting
- VA/DoD Management of Concussion/mild Traumatic Brain Injury Clinical Practice Guideline, Apr 09
This Evidence Based Guideline applies to adult patients (18 years or older) who are diagnosed with concussion/mTBI and complain of symptoms related to the injury and who are treated in VA/DoD clinical settings for these symptoms at least 7 days after the initial head injury. The guideline is relevant to all healthcare professionals providing or directing treatment services to patients with concussion/mTBI in any VA/DoD healthcare setting, including both primary and specialty care. It does not address: management of concussion/mTBI in the acute phase ( 7 days post injury ), management of moderate or severe TBI, mTBI presented as polytrauma and managed in an inpatient setting, or mTBI in children .
- Clinical Practice Guidelines – Deployed Setting
- Other Clinical Guidance
- Assessment and Management of Dizziness Associated with Mild TBI Clinical
Recommendation, Sep 12, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) (This clinical
recommendation provides the primary care provider an approach to evaluating dizziness
following mTBI and guidance regarding referral for further vestibular evaluation and care.)
- Indications and Conditions for Neuroendocrine Dysfunction Screening Post Mild Traumatic Brain Injury Clinical Recommendations, Aug 12, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) (This Clinical Recommendation is intended to offer the health care provider an approach to identify-ing patients with mTBI who may benefit from further endocrine evaluation and care and is specifically intended to support the primary care provider.)
- Cognitive Rehabilitation Therapy, Military Health System (MHS) Web Page (An informational web page designed to educate stakeholders and service members about Cognitive Rehabilitation Therapy (CRT), a series of techniques and exercises designed to assist persons who have suffered cognitive defects as a result of injury or illness recover such skills.)
- Case Management for Concussion/Mild Traumatic Brain Injury Guidance Document, 8 Nov 10, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE)
(The purpose of this Guidance Document is to provide guidance for case management of Service members who have sustained concussion/mild traumatic brain injury (mTBI).)
- Traumatic Brain Injury Care in the Department of Defense, Sep 09
This report summarizes the significant strides DoD, through the Services, delivering care to its injured Service members, ranging from immediate battlefield to long-term care at the home front.
- Acute Clinical Care and Care Coordination for Traumatic Brain Injury within Department of Defense, Journal of Rehabilitation Research and Development, Vol 46, No 6, 2009
This article summarizes the care systems available for the acute management of TBI from point of injury to stateside military treatment facilities.
- Report of Consensus Conference on Cognitive Rehabilitation for Mild Traumatic Brain Injury 27 and 28 April 2009, Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE) and Defense and Veterans Brain Injury Center (DVBIC)
This report describes a consensus conference of subject matter experts convened to develop a guidance document for the assessment, intervention, programs, and outcomes/efficacy as they relate to cognitive rehabilitation of chronic post-concussive symptoms in service members and veterans receiving treatment within military medical settings.
- Driving Following Traumatic Brain Injury - Clinical Recommendations, 28 Jul 09, DCOE
Report of DCoE Driving Evaluations after Traumatic Brain Injury Conference which provides clinical recommendations to healthcare professionals within the Military Health System regarding the assessment of the ability to drive following traumatic brain injury, regardless of severity.
- Coding
- Tips for Treating Chronic Symptomatic Mild Traumatic Brain Injury and Post-Traumatic Stress Disorder for Civilian Health Care Professionals, DCoE Web Page
This DCoE Web Page contains tips, resources and educational information for civilian health care professionals about TBI and PTSD and how to approach military patients.)
- Fact Sheets
- Veterans Health Administration Materials for Health Care Providers on Traumatic Brain Injury
- Implementation Tools
- Web Pages
Non-DoD/VA Clinical Guidance
- Clinical Practice Guidelines
- Care of the Patient with Mild Traumatic Brain Injury, American Association of Neuroscience Nurses (AANN) and American Rehabilitation Nurses (ARN) Clinical Practice Guideline Series, 2011. This Guideline provides recommendations based on current evidence that will help registered nurses, advanced practice nurses, and institutions provide safe and effective care to injured patients with a mild traumatic brain injury (MTBI). The goal of this guideline is to offer evidence-based recommendations on nursing activities that have the potential to maximize outcomes for persons following MTBI.
- Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting, American College of Emergency Physicians (ACEP), Annals of Emergency Medicine Vol 52 No 6, Dec 08 This clinical policy provides evidence-based recommendations on select issues in the management of adult patients with mild traumatic brain injury (TBI) in the acute setting. It is the result of joint efforts between the ACEP and the Centers for Disease Control and Prevention.
- Nursing Management of Adults with Severe Traumatic Brain Injury, American Association of Neuroscience Nurses (AANN) Clinical Practice Guideline Series, 2008
This Guideline provides recommendations based on current evidence designed to help registered nurses, intensive care unit personnel, and institutions provide safe and effective care to severely injured patients with traumatic brain injury (TBI).
- TBI Treatment Guidelines, Brain Trauma Foundation
- Guidelines for the Management of Severe Traumatic Brain Injury, 3rd edition, 2007
- Guidelines for Prehospital Management of Traumatic Brain Injury, 2nd edition, 2007
- Guidelines for the Surgical Management of Traumatic Brain Injury, 2006
- Guidelines for Field Management of Combat-Related Head Trauma, 2005
- Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescents, July 2003
- Other Clinical Guidance
Policies and Directives
DoD/Joint Forces
Air Force
Army
Navy/Marines
- NAVMED Policy 11-004, Navy Medicine Training Requirements for Health Care Professionals in Traumatic Brain Injury, 9 Sep 11
- BUMEDINST 6310.12, Traumatic Brain Injury Care in Navy Medical Treatment Facilites, 18 Jul 11
- NAVMED Policy 11-001, Implementing Required Medical Exam Before Administrative Separation for Post Traumatic Stress Disorder (PTSD) or Traumatic Brain Injury (TBI), 9 Feb 11
- BUMEDNOTE 6310, Guidance for Conducting Baseline Pre-Deployment Neurocognitive Functional Assessments and Revision to NAVMED 63 10/6, 15 Oct 10
- NAVMED Policy 07-021, Policy Guidance for Traumatic Brain Injury (TBI): Definition and Reporting, 13 Dec 07
VA (Department Of Veterans Affairs)
- VHA Directive 2010-012, Screening and Evaluation of Possible Traumatic Brain Injury in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans, 8 Mar 10
- VHA Directive 2009-028, Polytrauma-Traumatic Brain Injury (TBI) System of Care, 9 Jun 09
- Department of Veteran Affairs. 38 CFR Part 4, Schedule for Rating Disabilities: Evaluation of Residuals of Traumatic Brain Injury (TBI). Federal Register, 73(2). Washington D.C., January 3, 2008, Amendment (final): Federal Register 73(185), September 23, 2008: 54693-54708. (This document amends the Department of Veterans Affairs (VA) Schedule for Rating Disabilities by revising the portion of the Schedule that addresses neurological conditions and convulsive disorders. The effect of this action is to provide detailed and updated criteria for evaluating residuals of traumatic brain injury (TBI).)
- Veterans Health Administration, Under Secretary for Health's Information Letter (IL 10-2006-004), Screening and Clinical Management of Traumatic Brain Injury, 25 Jan 06
Forms and Measures
- Automated Neuropsychological Assessment Metrics (ANAM) (ANAM is a computer-based tool designed to detect speed and accuracy of attention, memory, and thinking ability. It does not diagnose any medical condition. The results may help healthcare staff compare a Service Member's speed and accuracy of attention, memory, and thinking ability before and after an injury.)
- Military Acute Concussion Evaluation (MACE) is DoD's standard concussion screening tool for the acute clinical assessment of service members involved in a
potentially concussive event.
- VA Traumatic Brain Injury Disability Evaluation Worksheet
Other Related Information
Reports
- TMA Report to Congress, National Defense Authorization Act Fiscal Year 2012, Section 724 Report on Memorandum Regarding Traumatic Brain Injuries, 2 Aug 12 (Report is on the implementation of the DoD policy related to the management of concussion and mild traumatic brain injury (mTBI) in the deployed setting, the effectiveness of such policy with respect to identifying and treating blast-related injuries, and the effect of such policy on operational effectiveness in theater.)
- Defense Health Board Report 2012-04, Management of Traumatic Brain Injury in Tactical Combat Casualty Care, 26 Jul 12 (The DHB reviewed the current Tactical Combat Casualty Care Guidelines and recommended amending them to include guidance for the treatment of casualties with suspected moderate/severe TBI.)
- ST 4-02.52, Mild Traumatic Brain Injury/Concussion, Mar 12 (This Special Text provides information and guidance on mild TBI including the continuum of care from the point of injury through continued care provided by the Department of Veterans Affairs. It is for use by training developers and medical and nonmedical commanders and their staff for information and planning purposes.) (Requires access to Army Knowledge on Line (AKO).)
- Under Secretary of Defense (P&R) Report to Congress, Comparative Effectiveness of Neuroimaging Modalities on the Detection of Traumatic Brain Injury, 20 Mar 12 (This report concludes that there is no single imaging modality in clinical use that can be universally applied to all patients who experience a TBI. The report concludes that there is a need for more validation or exploration of nearly every technique in the clinical and research disciplines, as well as consideration of the fact that each modality assesses different aspects of anatomy and/or physiology and that future research efforts must concentrate on addressing these limitations to improve TBI care.)
- Congressional Budget Office (CBO) Study,The Veterans Health Administration's Treatment of PTSD and Traumatic Brain Injury Among Recent Combat Veterans, Feb 12
- RAND Corporation Technical Report, Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Servicemembers and Their Families, 2011 (First comprehensive catalog of programs sponsored or funded by the Department of Defense to aid military members and their families with psychological health or traumatic brain injury issues.)
- GAO-12-27R, Department of Defense: Use of Neurocognitive Assessment Tools in Post-Deployment Identification of Mild Traumatic Brain Injury, 24 Oct 11
- Institute of Medicine (IOM) Report, Nutrition and Traumatic Brain Injury: Improving Acute and Sub-acute Health Outcomes in Military Personnel, 2011
- Military Health System, Department of Defense Numbers for Traumatic Brain Injury Web Page
- Department of Veterans Affairs Office of Inspector General Follow-Up Healthcare Inspection, VA's Role in Ensuring Services for Operation Enduring Freedom/Operation Iraqi Freedom Veterans after Traumatic Brain Injury Rehabilitation, 1 May 08
- Public Law 110-206 - Traumatic Brain Injury Act of 2008, 28 Apr 08
- GAO Report 08-615, Mental Health and Traumatic Brain Injury Screening Efforts Implemented, but Consistent Pre-Deployment Medical Record Review Policies Needed. May 08
- GAO Report, VA Health Care Mild Traumatic Brain Injury Screening and Evaluation Implemented for OEF/OIF Veterans, but Challenges Remain, Feb 08
- The Army Surgeon General Traumatic Brain Injury (TBI) Task Force (includes Report 17 May 07 and Summary of Recommendations 17 Jan 08)
- Armed Forces Epidemiological Board (AFEB) Recommendation 2006-02: Traumatic Brain Injury in Military Service Members, 11 Aug 06
Articles
Education and Training
Healthcare Professionals Education and Training Material
- DoD/VA Sources
- Presentations
- DotMil Docs (Military Health System audio broadcasts)
- Dot Mil Docs 101: Brain Injury in Theater, 9 Mar 10 (Director of the Defense and Veterans Brain Injury Center (DVBC) talks about a new policy for the management of concussion in theater, and gives an update on DoD TBI research and education programs.)
- Dot Mil Docs100: Concussions, 4 Mar 10 (An Director of the National Intrepid Center of Excellence, discusses concussions: their signs and symptoms, treatment methods, and how the DoD screens service members for them.)
- Training Material
- DVBIC TBI Courses for Civilian Providers (Courses produced by the Defense and Veterans Brain Injury Center (DVBIC) for civilian healthcare providers on treating combat-related TBI symptoms and co-occurring conditions.)
- Complementary and Alternative Medicines (CAM), Modalities and Interventions Fact Sheet, 4 Feb 13 (This fact sheet, which was prepared by the Defense Centers of Excellence for
Psychological Health and Traumatic Brain Injury (DCoE), educates providers on the clinical use of CAM modalities in Veterans Affairs and the Military Health System.)
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Mild TBI Web-Based Case Studies (A series of 12 modules using actual patient vignettes to assist health care professionals understand mild TBI,
including screening, diagnosis, and management of symptoms in the non-deployed setting. Offers one free CEU/CME per module. Produced by the
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE).
- TRICARE Pilot Education Program for Civilian Providers on PTSD and TBI (Offers 17 Continuing Education Units. Direct care providers can take advantage of this CME educational opportunity through their existing MHS Learn accounts.)
- TBI Training on MHS Learn (Series of videos about TBI ranging from a simple introduction to provider level instruction. Must register with MHS Learn and log in to view them - Select MHS Staff Training. - Log in - Search for TBI)
- Indications and Conditions for Neuroendocrine Dysfunction Screening Post Mild Traumatic Brain Injury Training Slides, DCoE (This educational module is relevant to all health care professionals conducting screening for patients with mild TBI in any Defense Department (DoD) health care setting, including both primary and specialty care.)
- Treating the Invisible Wounds of War Online Course Series, Citizen-Soldier Support Program (CSSP), University of North Carolina (To prepare civilian providers to address post-deployment issues facing OIF/OEF veterans and their families, CSSP has partnered with the Veterans Integrated Service Network 6, Mental Illness Research Education and Clinical Center (VISN 6 MIRECC) and the North Carolina Area Health Education Centers (AHEC) to create these online courses for PTSD & TBI. Each course offers continuing education credits, depending upon course material.)
- VA, Veterans Health Initiative Independent Study Course, Traumatic Brain Injury, Apr 10
- Reference Web Pages
- Non-DoD/VA Sources
- Training Material
- Reference Web Pages
Service Members and Families Information and Training Material
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