Doctors and other health-care providers have a new standard for diagnosing mild traumatic brain injury (TBI), thanks to a thorough process led by researchers from the University of B.C. and Harvard-affiliated Spaulding Rehabilitation Hospital.
“We’ve achieved consensus across a diverse range of experts in developing these new diagnostic criteria,” said Dr. Noah Silverberg, associate professor in UBC’s department of psychology, member of the Djavad Mowafaghian Centre for Brain Health and Centre for Aging SMART at Vancouver Coastal Health, and co-lead of the project. “Our hope is that this strong consensus will drive a global shift towards adopting these criteria, ultimately improving patient care and research consistency in the field.”
Mild traumatic brain injuries—or concussions, as most people call them—are notoriously tricky to diagnose because they usually aren’t detectable by brain scans and symptoms can be diverse, subtle, and overlap with other conditions.
Criteria used to diagnose such injuries have become wildly inconsistent. A definition published by the American Congress of Rehabilitation Medicine (ACRM) in 1993 has spawned so many offshoots as research has evolved over the past 30 years that a patient’s diagnosis now really depends on the criteria being used.
One study applied various sets of criteria to 12,000 pediatric cases and found that the proportion of children diagnosed with mild TBI could be anywhere from seven to 99 per cent.
For patients, this inconsistency leads to inequities in injury management and care, accessing health insurance, and compensation.
For researchers, it has been a huge barrier to harmonizing findings from different TBI studies, because datasets using different criteria can’t be used for apples-to-apples comparisons.
The work undertaken by Dr. Silverberg and Dr. Grant Iverson of Spaulding Rehabilitation Hospital on behalf of ACRM and published on Friday in Archives of Physical Medicine and Rehabilitation aims to establish a new global standard that can be applied across age groups, health systems and injury circumstances.
The researchers convened a working group of 17 ACRM Mild TBI Task Force members and an external interdisciplinary expert panel of 32 clinician-scientists from seven countries and various fields such as sports, civilian trauma, and military settings. Their criteria were based on syntheses of current research evidence and went through several rounds of revision until more than 90 per cent of the expert panel agreed with what they were proposing.
The new criteria are designed to be applicable across a range of injury circumstances, including civilian trauma, sports-related injuries and military contexts. They take into account blood tests and tests of thinking skills, balance, and vision that can contribute to the diagnosis of TBI, which hasn’t been a feature of previous criteria.
“While we’ve made significant progress in creating these diagnostic criteria for mild TBI, the task ahead is to ensure their widespread adoption,” said Dr. Silverberg. “It’s a challenging journey, but one we’re committed to, as it will pave the way for standardized care and research in this crucial area of health.”
The researchers will be presenting the new criteria at international conferences attended by scientists and health-care professionals, and collaborating with other important partners like the international Concussion in Sport Group and the U.S. Department of Defense. The goal is to have the criteria incorporated into clinical practice guidelines and accreditation standards for health-care facilities in the U.S. and Canada, and eventually be integrated into electronic medical records.
The diagnostic criteria will need to undergo review and updating as scientific knowledge of mild TBI advances.
Interview language(s): English
Archives of Physical Medicine and Rehabilitation
Method of Research
Subject of Research
The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury
Article Publication Date
Dr. Arciniegas receives royalties and fees from American Psychiatric Association Publishing for services as a book and journal editor, and from Springer Publishing and Cambridge University Press for service as a book editor. Dr. Bayley reports research funding from Canadian institutes of Health research and Brain Canada. He has an employment relationship with UHN-Toronto Rehabilitation Institute as Medical Director. Dr. Bazarian reports grants from BrainScope LLC, personal fees from Abbott, personal fees from Q30 Innovations. Dr Broglio has current or past research funding from the National Institutes of Health; Centers for Disease Control and Prevention; Department of Defense – USA Medical Research Acquisition Activity, National Collegiate Athletic Association; National Athletic Trainers’ Association Foundation; National Football League/Under Armour/GE; Simbex; and ElmindA. He has consulted for US Soccer (paid), US Cycling (unpaid), University of Calgary SHRed Concussions external advisory board (unpaid), medico-legal litigation, and received speaker honorarium and travel reimbursements for talks given. He is co-author of “Biomechanics of Injury (3rd edition)” and has a patent pending on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” (U.S. Application No. 17/164,490). Dr. Davis is a member of the Scientific Committee of the 6th International Consensus Conference on Concussion in Sport; an honorary member of the AFL Concussion Scientific Committee; Section Editor, Sport and Rehabilitation, NEUROSURGERY; and has attended meetings organised by sporting organisations including the NFL, NRL, IIHF, IOC and FIFA; however, has not received any payment, research funding, or other monies from these groups other than for travel costs. Dr. Echemendia reports grants from NFL/Boston Children’s Hospital, clinical consulting fees from the National Hockey League, Major League Soccer, US Soccer Federation and expert testimony fees. Dr. Gioia reports royalties from Psychological Assessment Resources, Inc. He is on the Medical Advisory Panel and Board of Directors of USA Football for which he receives no payment. Dr. Giza reports past financial relationships with Avanir and Neural Analytics Inc. Dr. Hinds reports consulting fees from National Football League Players Association, Major League Soccer Players Association, NanoDX, Gryphon Bio, CONNECT-TBI, Prevent Biometrics, and Synaptek via SCS Consulting LLC. Dr. Hinds is a non-paid co-PI for LIMBIC-CENC, non-paid advisory board member for Project Enlist/Concussion Legacy Foundation, and serves on Congressionally Directed Medical Research Program review panels. Dr. Iaccarino reports research funding from the Wounded Warrior Project. She is a consultant for the National Football League (NFL). Dr. Iverson serves as a scientific advisor for NanoDX®, Sway Operations, LLC, and Highmark, Inc. He has a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild TBIs. He has received past research support or funding from several test publishing companies, including ImPACT Applications, Inc., CNS Vital Signs, and Psychological Assessment Resources (PAR, Inc.). He has received research funding as a principal investigator from the National Football League, and subcontract grant funding as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members. He has received research funding from the Wounded Warrior Project™. He acknowledges unrestricted philanthropic support from ImPACT Applications, Inc., the Mooney-Reed Charitable Foundation, the National Rugby League, Boston Bolts, and the Schoen Adams Research Institute at Spaulding Rehabilitation. Dr. Leddy reports that he is on the Scientific Advisory Boards of Neuronasal, Quadrant Biosciences, and Highmark Innovations, is a minority shareholder in Highmark Innovations and in 360 Concussion Care, an interdisciplinary concussion clinic, and receives expert testimony fees. Dr. Le Sage reports grants as a principal investigator from Canadian Institutes of Health Research (CIHR) and from Fonds de recherche du Québec en Santé (FRQ-S). She is a consultant for the Institut National d’Excellence en santé et en services sociaux (INESSS) and for the Quebec Ministry of Health and Social Services (MSSS). Dr. Manley reports research funding from the Department of Defense, NIH, National Footbal League (NFL), Abbott Laboratories, and grateful patients. Dr. Mass declares grant funding from the Framework 7 program of the European Union (Grant 602150), and consulting fees from PresSura Neuro, Integra Life Sciences, and NeuroTrauma Sciences. Dr. Menon reports grants, personal fees, and non-financial support from GlaxoSmithKline; personal fees from Neurotrauma Sciences, Lantmaanen AB, Pressura, and Pfizer, outside of the submitted work. Dr. McCrea reports research grants from the NIH, Department of Defense, Center for Disease Control and Prevention (CDC), Department of Veterans Affairs, Abbott Laboratories, National Football League (NFL), and National Collegiate Athletic Association (NCAA), and consultancy with the Green Bay Packers and Neurotrauma Sciences, Inc. Dr Ponsford reports grants from the Victorian Transport Accident Commission and National Health and Medical Research Council and provides expert testimony for cases involving mild TBI. Dr. Putukian is a paid consultant for Major League Soccer, and serves on several committees including the NFL Head, Neck & Spine Committee, the Football Association (FA) Research Task Force, the US Soccer Medical Advisory Committee and the NOCSAE Scientific Advisory Committee. She has assisted with the United Kingdom Concussion Foundation Forum, received funding for research from the NCAA-CARE-DoD 2.0 (ended 2020), and has received honoraria and reimbursement for travel for speaking and conferences attended, received royalties for the Netter’s Sports Medicine textbook, and received compensation for work as an expert for cases involving concussion, team physician and other sports medicine topics. Dr. Reed reports grants from the Canadian Institutes of Health Research and Special Olympics Canada, and holds a Canada Research Chair (Tier 2) in Pediatric Concussion. He is a co-investigator in a multicentre study funded by the National Football League (NFL) Scientific Advisory Board but does not receive financial support. He is an Executive Board Member for the International Paediatric Brain Injury Society. He is a minority shareholder in 360 Concussion Care, an interdisciplinary concussion clinic. Dr. Silverberg reports grants from the Canadian Institutes of Health Research, Canadian Foundation for Innovation, VGH+UBC Hospital Foundation, and WorkSafeBC, and clinical consulting fees from the National Hockey League and Major League Soccer, and expert testimony fees. Dr. Wethe reports a financial relationship with King-Devick technologies and a financial interest in Mayo Clinic Concussion Check. Dr. Yeates is the recipient of the Ronald and Irene Ward Chair in Pediatric Brain Injury, funded by the Alberta Children’s Hospital Foundation. He receives an editorial stipend from the American Psychological Association and book royalties from Guilford Press and Cambridge University Press. He is the Chair of the Canadian Concussion Network, which is funded by a grant from the Canadian Institutes of Health Research. He is a co-investigator in a multicentre study funded by the National Football League (NFL) Scientific Advisory Board but does not receive financial support. He is a member of the Scientific Advisory Committee for Brain Injury Canada and of the National Research Advisory Council for the National Pediatric Rehabilitation Resource Center. Dr. Zafonte receives royalties from Springer/Demos publishing for serving as co- editor of the text Brain Injury Medicine. Dr. Zafonte serves on the Scientific Advisory Board of Kisbee Nanodiagnostics, and Myomo. He also evaluates patients in the MGH Brain and Body-TRUST Program which is funded by the NFL Players Association. Dr Zafonte also serves on the Mackey White health committee. Dr. Zafonte serves as PI for the Football Players Health Study at Harvard. Dr. Zasler is the sole shareholder in Concussion Care Center of Virginia, LTD. He has a clinical and forensic consulting practice in brain injury medicine. Dr. Zemek reports being a co-investigator in a multicentre study competitively funded by the National Football League (NFL) Scientific Advisory Board; he is a minority shareholder in 360 Concussion Care, an interdisciplinary concussion clinic.