Mild Traumatic Brain Injury (mTBI)

By Michael J. Doria, Ph.D.
Neuropsychologist / MACE Program Manager


Mild Traumatic Brain Injury (mTBI) has been labeled the “signature injury” of the wars in Iraq and Afghanistan and has thrust the identification and treatment of mTBIs to the vanguard of concerns for the military healthcare community.  However, the epidemiology of combat-related mTBI remains poorly understood despite the potential deleterious effects for service member and service alike.

Brain injury, interchangeable with the term concussion, is typically used in reference to moderate or severe TBI. In the operational theatres of Iraq and Afghanistan, most cases of mTBI (up to 80%) are due to patient exposure to the concussive shock wave of an IED blast.  Motor vehicle accidents causing contra-coup head injuries are also common within the combat zones of both wars. Additionally, advancements in medical technique and technology have allowed for greater survival rates from major injuries than in times past, with the unintended effect of leaving more survivors suffering the lingering effects of concussive brain injury.

Historically, military medicine has relied heavily on the sports medicine world for research and information regarding mTBIs and their treatment. However, the amount of occurred injuries in the two ongoing theatres has allowed for both the academic and medical communities to more consistently and succinctly devise and define the differences between acute, moderate, and mild TBI. In terms of treatment, the military community has come to more formally recognize that immediate patient rest and restriction of duty for the 24-hour period following incidence of mTBI can be beneficial in promoting the resolution of symptoms which may subsequently emerge.

Successful management of post-concussive symptoms is crucial to maintaining military personnel in their functional deployed status. Current DOD guidelines require that all military personnel not in a vehicle and within 50 meters of an IED blast point require a concussion evaluation and the mandated follow-up management as necessary. If any Service member in a vehicle that was in any degree exposed to a blast or roll over exhibits mTBI symptoms then ALL Service members in that vehicle will be required to have an evaluation. Service members experiencing three concussions in one deployment are now removed from active combat duty. A Significant Action (SIGACT) is generated for each concussive event documented by field and/or medical personnel. This requires command personnel to respond to the event within 24 hours.

A focus on promoting positive expectations for recovery is also supported at this time. Research suggests that 90% of all individuals suffering a concussion resulting from a mTBI see full resolution of symptoms within one week. Communicating this fact to an affected service member can greatly aid in their recovery. Promoting accurate symptom reporting and active management of persistent symptoms can lead to a quick and complete return to duty for affected personnel.

Advances in military medicine have also resulted in a more clear understanding of why symptoms of a concussion may persist beyond a month or two. It is commonly accepted that post-concussive symptoms persist when there is co-occurring Post-traumatic Stress Disorder (PTSD) or other mood disturbance or AXIS I/II psychopathology. The presence of PTSD is highly correlated with the DSM IV diagnostic criteria for post-concussive disorder. Resulting post traumatic headaches and migraines, sleep disturbance and cognitive fatigue can frequently become genuinely debilitating if not treated.

The Military Acute Concussion Evaluation (MACE) is a screening and documentation measure which is used to gauge the severity of symptoms and cognitive deficits after a diagnosis of a concussion has been made. Taking less than 15 minutes to administer, it involves collecting a history of the injury event and the symptoms experienced at that time, followed by a brief neurological screening, and a similarly short cognitive test.  The score is presented with a listing of symptoms endorsed and a red or green light regarding the neurological screen. All cases of a concussion result in mandatory restricted duty for 24 hours followed by immediate reevaluation via the MACE.  Similarly, the MACE is most effective if given within 24 hours of the injury event to fully gauge the level of possible brain injury.