Military Acute Concussion Evaluation 2 (MACE 2) — Questions and Answers

Question 1: What cognitive function is tested by asking the patient to follow multi-step commands?

Executive function (Correct answer)
Muscle coordination
Visual processing
Respiratory function

Correct answer: Executive function

Multi-step commands require the patient to understand, remember, sequence, and execute several actions in a specific order. These abilities are core components of executive function, which encompasses planning, working memory, and problem-solving. Therefore, struggling with such tasks can indicate an impairment in these higher-level cognitive processes.

Question 2: What is the Blast Exposure and Concussion Incident Report (BECIR)?

A request form for explosive ordnance
A standardized military form documenting blast exposure details, symptoms, and clinical findings for all service members involved in blast events (Correct answer)
A financial claim form for combat injuries
A report on damaged equipment

Correct answer: A standardized military form documenting blast exposure details, symptoms, and clinical findings for all service members involved in blast events

The BECIR documents blast event details (distance, type, orientation), immediate symptoms, MACE results, and clinical findings, creating a record for medical tracking and potential future disability claims.

Question 3: What is the normal recovery timeline for concussion?

Exactly 30 days for everyone
24 hours
Most service members recover within 7-14 days, though some may take several weeks; symptoms persisting beyond 3 months may indicate post-concussion syndrome (Correct answer)
Recovery from concussion takes at least 1 year

Correct answer: Most service members recover within 7-14 days, though some may take several weeks; symptoms persisting beyond 3 months may indicate post-concussion syndrome

The majority of concussions resolve within 1-2 weeks with proper management. However, approximately 10-20% of individuals experience prolonged symptoms. Recovery timelines vary based on injury severity, history, and individual factors.

Question 4: What is the most commonly reported symptom of concussion?

Seizures
Headache (Correct answer)
Loss of consciousness
Paralysis

Correct answer: Headache

Headache is reported in approximately 90% of concussions, making it the most common symptom. Loss of consciousness occurs in less than 10% of concussions, contrary to popular belief.

Question 5: When should the MACE be administered after a potential concussive event?

As soon as possible after the event, ideally within the first 24 hours, and before the service member returns to duty (Correct answer)
Only during annual physical examinations
Only when the service member requests it
Only after 7 days have passed

Correct answer: As soon as possible after the event, ideally within the first 24 hours, and before the service member returns to duty

Early administration of the MACE captures the acute cognitive effects of concussion. The initial assessment serves as a baseline against which subsequent assessments can be compared to track recovery.

Question 6: How does exertional testing factor into return-to-duty decisions?

Service members must demonstrate they can perform physical exertion without symptom recurrence before returning to full duty (Correct answer)
Physical exertion is never tested
Only desk-duty positions require exertion testing
Exertional testing is optional

Correct answer: Service members must demonstrate they can perform physical exertion without symptom recurrence before returning to full duty

Exertional testing is critical because concussion symptoms often recur with physical and cognitive stress. Service members must tolerate progressively increasing activity levels without symptom exacerbation before returning to duty.

Question 7: What criteria must be met before a concussed service member can return to full duty?

Only the service member's desire to return
One week of rest regardless of symptoms
Passing a physical fitness test
Symptom-free at rest and during exertion, normal MACE scores, normal neurological examination, and completion of the progressive return-to-activity protocol (Correct answer)

Correct answer: Symptom-free at rest and during exertion, normal MACE scores, normal neurological examination, and completion of the progressive return-to-activity protocol

Return to full duty requires: complete symptom resolution at rest and during progressive exertion, normalized cognitive testing, normal neurological exam, and successful completion of all stages of the graded activity protocol.

Question 8: What distinguishes combat-related TBI from sports concussion?

Combat TBI often involves blast mechanisms, polytrauma, comorbid PTSD, delayed presentation, and austere treatment environments (Correct answer)
Sports concussion is never serious
There is no difference
Combat TBI is always more severe

Correct answer: Combat TBI often involves blast mechanisms, polytrauma, comorbid PTSD, delayed presentation, and austere treatment environments

Combat TBI differs from sports concussion in mechanism (blast vs. impact), comorbidities (PTSD, pain, polytrauma), diagnostic challenges (delayed presentation, overlapping symptoms), and treatment context (operational environment vs. clinic).

Question 9: What does the concentration subtest of the MACE assess?

Sustained attention and working memory through reverse digit recall and months backward tasks (Correct answer)
Emotional stability
Physical endurance
Visual acuity

Correct answer: Sustained attention and working memory through reverse digit recall and months backward tasks

The concentration subtest uses reverse digit span (repeating numbers backward) and months backward tasks to evaluate attention, concentration, and working memory—cognitive functions commonly disrupted by concussion.

Question 10: How does body armor affect blast-related brain injury?

Armor has no effect on blast injuries
Body armor completely prevents blast TBI
Helmets eliminate all concussion risk
Body armor protects the torso but does not prevent blast wave transmission to the brain; helmet protection against blast overpressure is limited (Correct answer)

Correct answer: Body armor protects the torso but does not prevent blast wave transmission to the brain; helmet protection against blast overpressure is limited

While helmets protect against secondary (fragment) and tertiary (impact) blast injuries, they provide limited protection against the primary blast wave, which can still cause brain injury through pressure transmission.

Question 11: What emotional and behavioral changes should be monitored after concussion?

Only anger is an emotional symptom
Emotional changes only occur with severe TBI
No emotional changes occur with concussion
Irritability, mood swings, anxiety, depression, decreased frustration tolerance, and personality changes (Correct answer)

Correct answer: Irritability, mood swings, anxiety, depression, decreased frustration tolerance, and personality changes

Concussion commonly affects emotional regulation through disruption of prefrontal cortex function and limbic system connections. Irritability, anxiety, depression, and reduced emotional control are common and often distressing symptoms.

Question 12: How soon after a suspected concussion should the MACE be administered?

After one month
After one week
Within 24 hours
Immediately (Correct answer)

Correct answer: Immediately

The MACE is designed for acute assessment, meaning it should be administered as soon as possible after a suspected concussion. Immediate evaluation is crucial for establishing baseline symptoms, identifying any red flag signs, and initiating appropriate medical management and removal from activity to prevent further injury.

Question 13: Which component is NOT part of the MACE neurological examination?

Physical endurance test (Correct answer)
Cognitive screening
Neurological screening
Symptom evaluation

Correct answer: Physical endurance test

The MACE focuses on neurological and cognitive assessments relevant to concussion, such as symptom evaluation, cognitive screening (memory, orientation), and neurological screening (balance, coordination). A physical endurance test, which measures stamina and physical exertion, is not a component of the MACE neurological examination as it does not directly assess concussion-related brain function.

Question 14: What symptom tracking tools are used to monitor concussion recovery?

Only brain imaging
Standardized symptom checklists (like the RPQ, NSI, or PCSS) that rate symptom severity on numeric scales over time (Correct answer)
Only verbal questioning
No standardized tools exist

Correct answer: Standardized symptom checklists (like the RPQ, NSI, or PCSS) that rate symptom severity on numeric scales over time

Validated symptom checklists (Neurobehavioral Symptom Inventory, Rivermead Post-Concussion Symptoms Questionnaire, Post-Concussion Symptom Scale) quantify symptom severity and track changes over time to guide clinical decisions.

Question 15: What is the total maximum score possible on the MACE cognitive (SAC) assessment?

30 (Correct answer)
20
25
40

Correct answer: 30

The MACE cognitive assessment (based on the SAC) has a maximum total score of 30 points across orientation, immediate memory, concentration, and delayed recall.

Question 16: What is the primary purpose of the Military Acute Concussion Evaluation (MACE)?

To assess chronic traumatic brain injury
To measure physical fitness
To evaluate acute concussions (Correct answer)
To diagnose mental health disorders

Correct answer: To evaluate acute concussions

The Military Acute Concussion Evaluation (MACE) is specifically designed as a standardized tool for healthcare providers to assess service members immediately following a suspected concussion. Its primary purpose is to identify and evaluate the acute symptoms and cognitive deficits associated with a recent mild traumatic brain injury. This allows for timely diagnosis and appropriate management.

Question 17: Which symptom might indicate the need for immediate medical attention during a MACE evaluation?

Mild dizziness
Slight nausea
Mild fatigue
Severe headache (Correct answer)

Correct answer: Severe headache

While mild symptoms are common with concussions, a severe headache, especially one that worsens, can be a "red flag" symptom indicating a more serious brain injury, such as an intracranial hemorrhage. The MACE protocol emphasizes identifying such severe symptoms that warrant immediate advanced medical evaluation.

Question 18: What is assessed during the neurological screening portion of the MACE?

Respiratory rate
Muscle strength and coordination (Correct answer)
Liver function
Blood oxygen levels

Correct answer: Muscle strength and coordination

The neurological screening portion of the MACE assesses various aspects of neurological function that can be affected by a concussion. This includes evaluating muscle strength, coordination, balance, and gait to identify any motor deficits or neurological impairments resulting from the head injury.

Question 19: What is the Warfighter Brain Health Initiative?

A recruitment marketing campaign
A veterans' employment program
A military fitness challenge
A DoD program focused on protecting service members' brain health through education, exposure monitoring, treatment advances, and policy development (Correct answer)

Correct answer: A DoD program focused on protecting service members' brain health through education, exposure monitoring, treatment advances, and policy development

The Warfighter Brain Health Initiative addresses the full spectrum of brain health: blast exposure monitoring, concussion prevention and treatment, mental health, sleep optimization, and long-term brain health for military personnel.

Question 20: What documentation is required throughout the concussion recovery process?

Documentation is optional during recovery
Only the initial assessment needs documentation
Initial MACE scores, serial symptom checklists, follow-up MACE scores, activity progression notes, and final return-to-duty clearance documentation (Correct answer)
Only the final clearance needs to be documented

Correct answer: Initial MACE scores, serial symptom checklists, follow-up MACE scores, activity progression notes, and final return-to-duty clearance documentation

Comprehensive documentation tracks the entire recovery: initial assessment, serial symptom monitoring, repeat cognitive testing, progressive activity tolerance, and final clearance. This record supports medical decisions and disability claims if needed.

Question 21: What is a key symptom evaluated in the MACE neurological examination?

Abdominal pain
Skin rash
Headache (Correct answer)
Fever

Correct answer: Headache

Headache is one of the most common and prominent symptoms experienced after a concussion, often appearing immediately or shortly after the injury. The MACE specifically includes a symptom checklist where individuals are asked to report the presence and severity of various symptoms, with headache being a key indicator of a potential concussion.

Question 22: What should be done if a patient shows significant cognitive impairment during the MACE?

They should be sent for immediate advanced medical evaluation (Correct answer)
They should be given painkillers and monitored
They should rest and re-test after 24 hours
They should continue with normal activities

Correct answer: They should be sent for immediate advanced medical evaluation

Significant cognitive impairment identified during the MACE, especially if severe or worsening, indicates a potentially more serious brain injury or complication. In such cases, the protocol mandates immediate referral for advanced medical evaluation (e.g., neuroimaging, specialist consultation) to rule out conditions like intracranial bleeding.

Question 23: What cognitive rehabilitation strategies are used for concussion recovery?

No cognitive rehabilitation exists for concussion
Only medication is used
Graduated cognitive loading, compensatory strategy training, attention and memory exercises, and psychoeducation about expected recovery (Correct answer)
Cognitive rehabilitation is only for severe TBI

Correct answer: Graduated cognitive loading, compensatory strategy training, attention and memory exercises, and psychoeducation about expected recovery

Cognitive rehabilitation may include progressive cognitive loading (reading, problem-solving), compensatory strategies (note-taking, checklists), targeted attention/memory training, and education about normal recovery expectations.

Question 24: What research is being conducted on military blast-related TBI?

Studies on blast physics, biomarkers, neuroimaging, blast exposure thresholds, protective equipment, and long-term outcomes of repeated blast exposure (Correct answer)
Only animal studies are conducted
Research was completed decades ago
No research exists on blast TBI

Correct answer: Studies on blast physics, biomarkers, neuroimaging, blast exposure thresholds, protective equipment, and long-term outcomes of repeated blast exposure

Active research areas include blast wave modeling, blood-based biomarkers for rapid diagnosis, advanced neuroimaging (DTI, fMRI), blast exposure monitoring devices, improved helmet design, and longitudinal studies of blast-exposed veterans.

Question 25: During the MACE, which cognitive function is commonly tested?

Heart rate
Memory recall (Correct answer)
Blood pressure
Reflexes

Correct answer: Memory recall

Concussions frequently impair cognitive functions, particularly memory. The MACE includes specific tasks, such as word list recall, to assess both immediate and delayed memory. This helps identify any short-term memory deficits, which are a common sign of acute concussion.

Question 26: What cognitive symptoms should be monitored after concussion?

Only spelling errors
Cognitive symptoms do not occur with concussion
Slowed processing speed, difficulty concentrating, memory problems, confusion, and difficulty finding words (Correct answer)
Only mathematical ability

Correct answer: Slowed processing speed, difficulty concentrating, memory problems, confusion, and difficulty finding words

Concussion commonly impairs processing speed, attention/concentration, working memory, executive function, and verbal fluency. These deficits are detected by the MACE and affect the service member's ability to perform duty tasks.

Question 27: How can concussion symptoms be differentiated from combat stress reactions?

Combat stress always involves loss of consciousness
They cannot be differentiated
Through timing relative to injury, specific cognitive deficits on MACE, neurological findings, and the pattern of symptom onset and resolution (Correct answer)
Only brain imaging can distinguish them

Correct answer: Through timing relative to injury, specific cognitive deficits on MACE, neurological findings, and the pattern of symptom onset and resolution

Concussion symptoms are temporally linked to an injury event and include specific cognitive deficits. Combat stress reactions are related to psychological stressors and may not involve cognitive impairment on testing, though significant overlap exists.

Question 28: What type of task might be used to assess orientation in the MACE cognitive testing?

Asking the patient to identify different colors
Asking the patient to run a short distance
Asking the patient to state the current date and location (Correct answer)
Asking the patient to solve a puzzle

Correct answer: Asking the patient to state the current date and location

Orientation questions, such as asking for the current date, day of the week, month, year, and location, are used in the MACE to assess a patient's awareness of their surroundings and temporal context. Disorientation can be a significant sign of cognitive impairment following a concussion.

Question 29: What is the significance of repeated low-level blast exposure?

Blast exposure only affects hearing
Only single large blasts cause injury
Low-level blasts have no health effects
Cumulative subconcussive blast exposure may cause progressive brain injury even without diagnosable concussions, similar to repeated head impacts in contact sports (Correct answer)

Correct answer: Cumulative subconcussive blast exposure may cause progressive brain injury even without diagnosable concussions, similar to repeated head impacts in contact sports

Research suggests that repeated exposure to blast overpressure during training (breaching, artillery, heavy weapons) may cause subclinical brain changes over time, leading to concerns about occupational exposure limits.

Question 30: How should the MACE be documented and reported?

Documentation is optional
Only abnormal results need documentation
Results are verbal only
Results must be recorded on the official MACE form, included in the service member's medical record, and reported through the chain of command per service policy (Correct answer)

Correct answer: Results must be recorded on the official MACE form, included in the service member's medical record, and reported through the chain of command per service policy

Complete MACE documentation includes the date, time, mechanism of injury, all subtest scores, neurological screening results, and clinical recommendations. This documentation supports medical tracking and return-to-duty decisions.

Question 31: What aspect of neurological function is assessed with balance tests in the MACE?

Hearing ability
Coordination and equilibrium (Correct answer)
Cognitive ability
Visual acuity

Correct answer: Coordination and equilibrium

Balance tests, such as tandem gait or standing on one leg, are included in the MACE to assess an individual's coordination and equilibrium. Concussions can disrupt the brain's ability to process sensory information and control motor movements, leading to impaired balance and an increased risk of falls.

Question 32: What balance and vestibular symptoms are associated with concussion?

Dizziness, vertigo, balance problems, motion sensitivity, and difficulty with rapid head movements (Correct answer)
Balance problems only occur in elderly patients
Concussion does not affect balance
Only severe TBI causes dizziness

Correct answer: Dizziness, vertigo, balance problems, motion sensitivity, and difficulty with rapid head movements

The vestibular system is commonly disrupted by concussion, causing dizziness, balance impairment, and motion sensitivity. These symptoms are assessed through balance testing (BESS) and may require vestibular rehabilitation.

Question 33: What is the neurometabolic cascade following concussion?

A series of cellular and metabolic changes including ionic flux, energy crisis, axonal injury, and neuroinflammation that impair brain function (Correct answer)
Bleeding inside the skull
The physical impact of the skull hitting the brain
Swelling of the brain stem

Correct answer: A series of cellular and metabolic changes including ionic flux, energy crisis, axonal injury, and neuroinflammation that impair brain function

After concussion, potassium floods out of cells while calcium rushes in, creating an energy crisis. Mitochondrial dysfunction, oxidative stress, and neuroinflammation follow, explaining symptoms even without visible structural damage.

Question 34: During the MACE cognitive testing, how is immediate memory tested?

By testing the patient's reaction time
By asking the patient to recall a list of words immediately after hearing them (Correct answer)
By measuring the patient's heart rate
By asking the patient to spell words backward

Correct answer: By asking the patient to recall a list of words immediately after hearing them

Immediate memory is tested in the MACE by presenting a short list of words (typically 5) and then asking the patient to repeat them back right away. This assesses the brain's ability to register and temporarily hold new information, which can be impaired by a concussion.

Question 35: What are the visual symptoms of concussion?

Only color blindness occurs
Concussion never affects vision
Only complete vision loss
Blurred vision, double vision (diplopia), light sensitivity (photophobia), difficulty tracking moving objects, and visual field deficits (Correct answer)

Correct answer: Blurred vision, double vision (diplopia), light sensitivity (photophobia), difficulty tracking moving objects, and visual field deficits

Visual disturbances are common after concussion because multiple brain areas involved in visual processing are vulnerable to injury. Convergence insufficiency, accommodation dysfunction, and saccadic eye movement abnormalities are frequently observed.

Question 36: What are the four cognitive subtests of the MACE?

Vision, hearing, balance, and coordination
Reading, writing, arithmetic, and spelling
Running, swimming, marching, and shooting
Orientation, immediate memory, concentration, and delayed recall (Correct answer)

Correct answer: Orientation, immediate memory, concentration, and delayed recall

The MACE evaluates: Orientation (time, place, situation), Immediate Memory (word list recall), Concentration (reverse digits and months backward), and Delayed Recall (previously learned word list after a delay).

Question 37: What is the dual diagnosis challenge of TBI and PTSD in military populations?

Only one condition can be diagnosed
TBI and PTSD never co-occur
TBI and PTSD share overlapping symptoms (sleep disturbance, concentration problems, irritability), making differential diagnosis and treatment complex (Correct answer)
Treatment for one always cures the other

Correct answer: TBI and PTSD share overlapping symptoms (sleep disturbance, concentration problems, irritability), making differential diagnosis and treatment complex

TBI and PTSD frequently co-occur in combat veterans and share symptoms including concentration difficulty, irritability, sleep disruption, and memory problems. Accurate diagnosis requires careful evaluation of symptom onset, mechanism, and course.

Question 38: How should pain management be approached in service members with concussion?

Pain management is not necessary for concussion
Immediately prescribe strong opioid medications
Use non-opioid approaches first (rest, ice, acetaminophen), avoid NSAIDs acutely due to bleeding risk, and avoid medications that may mask neurological changes (Correct answer)
Only ice should be used, never medication

Correct answer: Use non-opioid approaches first (rest, ice, acetaminophen), avoid NSAIDs acutely due to bleeding risk, and avoid medications that may mask neurological changes

Pain management after concussion prioritizes non-pharmacological approaches and non-opioid analgesics. NSAIDs may be avoided acutely (theoretical bleeding risk), and sedating medications that could mask neurological deterioration should be used cautiously.

Question 39: Which section of the MACE gathers information about the circumstances of the potential injury event?

History (Correct answer)
Delayed Recall
Cognitive Assessment
Neurological Exam

Correct answer: History

The History section of the MACE documents the mechanism of injury, LOC, amnesia, and other event-related details that contextualize the injury.

Question 40: Which of the following tests is typically included in the MACE neurological examination?

Lung capacity test
MRI scan
Verbal memory test (Correct answer)
Blood glucose level

Correct answer: Verbal memory test

The MACE neurological examination includes a cognitive screening component, and a verbal memory test is a standard part of this. This typically involves asking the individual to recall a list of words, which helps assess their immediate and delayed verbal memory, a key indicator of cognitive function post-concussion.

Military Acute Concussion Evaluation 2 (MACE 2)

The MACE 2 is a standardized, multimodal tool used by military healthcare providers to evaluate concussion in service members, covering history and screening, symptom reporting, neurological examination, cognitive assessment, and vestibular/ocular-motor screening.

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