TABLE C-1 The Number of DoD Service Members (All Armed Forces) Diagnosed with TBI, 2000–2010a

Year

Number of Service Members

2000

10,963

2001

11,830

2002

12,470

2003

12,898

2004

13,312

2005

12,192

2006

16,946

2007

23,160

2008

28,555

2009

29,252

2010b

30,703

Total

202,281

aAvailable online: http://www.dvbic.org/TBI-Numbers.aspx (accessed March 25, 2011).

bAs of quarter 4 of 2010, as of February 17, 2011.

evaluation when an individual presented to medical care with symptoms concerning for TBI. An in-theater assessment of TBI care sponsored by the Joint Chiefs of Staff, however, found that individuals at risk for TBI failed to seek medical evaluation; consequently, mandatory event-based screening protocols were implemented in July 2010. These protocols include obligatory medical evaluations for all individuals within 50 meters of a blast, those who were located in a building or vehicle damaged by a blast, and those with certain other indications like blunt trauma to the head.

The Military Acute Concussion Evaluation (MACE) is the tool used in acute TBI screening (Figure C-1). The MACE tool was instituted in 2006 and assesses the following four domains: history of the traumatic event, including presence or absence of changes in consciousness; current symptoms; neurological exam; and, if indicated, a brief cognitive appraisal. The MACE tool is based on the Standardized Assessment of Concussion used for sports-related injuries where scores of 25 or less are indicative of cognitive impairment (McCrea et al., 2000). A validation study of MACE use in an austere environment is currently under way. Preliminary evidence suggests cognitive scores slightly less than 25 in a deployed setting may be normal because simple orientation may be affected by lack of differentiation during daily routines. Further validation testing is ongoing to optimize the use of this cognitive evaluation in theater.

Initially, the only documentation required when utilizing MACE was the numeric score associated with the cognitive assessment, which led to incomplete capture of the TBI exposure and an immediate written record in a member’s medical history. Subsequently, documentation requirements were modified and the following were added: cognitive score, neurological assessment, and current symptoms (CNS). Using this additional documentation facilitates the identification of a temporal relationship between the traumatic event and symptom onset in addition to changes in symptom profiles over time. Although MACE is not a definitive diagnostic tool for TBI, positive screens trigger a detailed clinical exam to confirm the diagnosis or determine the differential diagnosis for ongoing symptoms.

Service members evacuated to Landstuhl Regional Medical Center (LRMC) for any injury or illness undergo additional screening using the MACE tool. From May 2006 to October 2008, approximately 18,000 patients (approximately 12,200 inpatients and 5,800



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