Investigating the Variability in Mild Traumatic Brain Injury Definitions: A Prospective Cohort Study

Published:February 04, 2018DOI:



      To prospectively compare the proportion of traumatic brain injuries (TBIs) that would be classified as mild by applying different published definitions of mild TBI to a large prospectively collected dataset, and to examine the variability in the proportions included by various definitions.


      Prospective observational study.


      Hospital emergency departments.


      Children (N=11,907) aged 3 to 16 years (mean age, 8.2±3.9y). Of the participants, 3868 (32.5%) were girls, and 7374 (61.9%) of the TBIs were the result of a fall. Median Glasgow Coma Scale score was 15.

      Main Outcome Measures

      We applied 17 different definitions of mild TBI, identified through a published systematic review, to children aged 3 to 16 years. Adjustments and clarifications were made to some definitions. The number and percentage identified for each definition is presented.


      Adjustments had to be made to the 17 definitions to apply to the dataset: none in 7, minor to substantial in 10. The percentage classified as mild TBI across definitions varied from 7.1% (n=841) to 98.7% (n=11,756) and varied by age group.


      When applying the 17 definitions of mild TBI to a large prospective multicenter dataset of TBI, there was wide variability in the number of cases classified. Clinicians and researchers need to be aware of this variability when examining literature concerning children with mild TBI.


      List of abbreviations:

      ACRM (American Congress of Rehabilitation Medicine), APHIRST (Australian Paediatric Head Injury Rules Study), GCS (Glasgow Coma Scale), LOC (loss of consciousness), PTA (posttraumatic amnesia), TBI (traumatic brain injury), WHO (World Health Organization)
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        • Crowe L.
        • Babl F.
        • Anderson V.
        • Catroppa C.
        The epidemiology of paediatric head injuries: data from a referral centre in Victoria, Australia.
        J Paediatr Child Health. 2009; 45: 346-350
        • Emery C.
        • Barlow K.
        • Brooks B.
        • et al.
        A systematic review of psychiatric, psychological, and behavioural outcomes following mild traumatic brain injury in children and adolescents.
        Can J Psychiatry. 2016; 61: 259-269
        • Rivara F.
        • Koepsell T.
        • Wang J.
        • et al.
        Incidence of disability among children 12 months after traumatic brain injury.
        Am J Public Health. 2012; 102: 2074-2079
        • Lloyd J.
        • Wilson M.
        • Tenovuo O.
        • Saarijärvi S.
        Outcomes from mild and moderate traumatic brain injuries among children and adolescents: a systematic review of studies from 2008-2013.
        Brain Inj. 2015; 29: 539-549
        • Satz P.
        • Zaucha K.
        • McClearly C.
        • Light R.
        • Asarnow R.
        • Becker D.
        Mild head injury in children and adolescents: a review of studies.
        Psychol Bull. 1997; 122: 107-131
        • Carroll L.
        • Cassidy D.
        • Holm L.
        • Kraus J.
        • Coronado V.G.
        • WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury
        Methodological issues and research recommendations for mild traumatic brain injury: the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury.
        J Rehabil Med. 2004; : 113-125
        • The Mild Traumatic Brain Injury Committee of the Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine
        Definition of mild traumatic brain injury.
        J Head Trauma Rehabil. 1993; 8: 86-87
        • Teasdale G.
        • Jennett B.
        Assessment of coma and impaired consciousness.
        Lancet. 1974; 2: 81-84
        • Kristman V.
        • Borg J.
        • Godbolt A.
        • et al.
        Methodological issues and research recommendations for prognosis after mild traumatic brain injury: results of the International Collaboration of Mild Traumatic Brain Injury Prognosis.
        Arch Phys Med Rehabil. 2014; 95: S265-S277
        • Cancelliere C.
        • Cassidy J.D.
        • Li A.
        • Donovan J.
        • Côté P.
        • Hincapié C.A.
        Systematic search and review procedures: results of the international collaboration on mild traumatic brain injury prognosis.
        Arch Phys Med Rehabil. 2014; 95: S101-S131
        • Babl F.
        • Borland M.
        • Ngo P.
        • Acworth J.
        • Krieser D.
        • Pandit S.
        • et al.
        Paediatric Research in Emergency Departments International Collaborative (PREDICT): first steps towards the development of an Australian and New Zealand research network.
        Emerg Med Australas. 2006; 18: 143-147
        • Babl F.
        • Lyttle M.
        • Bressan S.
        • Borland M.
        • Phillips N.
        • Kochar A.
        • et al.
        A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST).
        BMC Pediatr. 2014; 14: 148
        • Babl F.
        • Borland M.
        • Phillips N.
        • Kochar A.
        • Dalton S.
        • McCaskill M.
        • et al.
        Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study.
        Lancet. 2017; 17: 2393-2402
        • Barlow K.
        • Crawford S.
        • Stevenson A.
        • Sandhu S.S.
        • Belanger F.
        • Dewey D.
        Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury.
        Pediatrics. 2010; 126: e374-e381
        • Nielsen A.
        • Mortensen P.
        • O'Callaghan E.
        • Mors O.
        • Ewald H.
        Is head injury a risk factor for schizophrenia?.
        Schizophr Res. 2002; 55: 93-98
        • Selassie A.
        • Fakhry S.
        • Ford D.
        Population-based study of the risk of in-hospital death after traumatic brain injury: the role of sepsis.
        J Trauma. 2011; 71: 1226-1234
        • Heitger M.
        • Jones R.
        • Dalrymple-Alford J.
        • Frampton C.M.
        • Ardagh M.W.
        • Anderson T.J.
        Motor deficits and recovery during the first year following mild closed head injury.
        Brain Inj. 2006; 20: 807-824
        • Heitger M.
        • Macaskill M.
        • Jones R.
        • Anderson T.J.
        The effect of mild closed head injury on involuntary saccadic adaptation: evidence for the preservation of implicit motor learning.
        Brain Inj. 2005; 19: 109-117
        • de Kruijk J.
        • Leffers P.
        • Meerhoff S.
        • Rutten J.
        • Twijnstra A.
        Effectiveness of bed rest after mild traumatic brain injury: a randomised trial of no versus six days of bed rest.
        J Neurol Neurosurg Soc. 2002; 73: 167-172
        • de Boussard C.
        • Lundin A.
        • Karlstedt D.
        • Edman G.
        • Bartfai A.
        • Borg J.
        S100 and cognitive impairment after mild traumatic brain injury.
        J Rehabil Med. 2005; 37: 53-57
        • Lau B.
        • Collins M.
        • Lovell M.
        Sensitivity and specificity of subacute computerized neurocognitive testing and symptom evaluation in predicting outcomes after sports-related concussion.
        Am J Sports Med. 2011; 39: 1209-1216
        • Covassin T.
        • Elbin R.
        • Nakayama Y.
        Tracking neurocognitive performance following concussion in high school athletes.
        Phys Sportsmed. 2010; 38: 87-93
        • Lovell M.
        • Collins M.
        • Iverson G.
        • et al.
        Recovery from mild concussion in high school athletes.
        J Neurosurg. 2003; 98: 296-301
        • Pellman E.
        • Lovell M.
        • Viano D.
        • Casson I.R.
        Concussion in professional football: recovery of NFL and high school athletes assessed by computerized neuropsychological testing- part 12.
        Neurosurgery. 2006; 58: 263-274
        • Field M.
        • Collins M.
        • Lovell M.
        • Maroon J.
        Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes.
        J Pediatr. 2003; 142: 546-553
        • Iverson G.
        • Lovell M.
        • Collins M.
        Interpreting change on ImPACT following sport concussion.
        Clin Neuropsychol. 2003; 17: 460-467
        • Erlanger D.
        • Kaushik T.
        • Cantu R.
        • et al.
        Symptom-based assessment of the severity of a concussion.
        J Neurosurg. 2003; 98: 477-484
        • Lau B.C.
        • Kontos A.P.
        • Collins M.
        • Mucha A.
        • Lovell M.R.
        Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players?.
        Am J Sports Med. 2011; 39: 2311-2318
        • Da Dalt L.
        • Andreola B.
        • Facchin P.
        • Gregolin M.
        • Vianello A.
        • Battistella P.A.
        Characteristics of children with vomiting after minor head trauma: a case-control study.
        J Pediatr. 2007; 150: 274-278
        • Hollingsworth W.
        • Vavilala M.
        • Jarvick J.
        The use of repeated head computed tomography in pediatric blunt head trauma: factors predicting new and worsening brain injury.
        Pediatr Crit Care Med. 2007; 8: 348-356
        • Pentland B.
        • Hutton L.
        • Jones P.
        Late mortality after head injury.
        J Neurol Neurosurg Psychiatry. 2005; 76: 395-400
        • Levin H.S.
        • Hanten G.
        • Roberson G.
        • et al.
        Prediction of cognitive sequelae based on abnormal computed tomography findings in children following mild traumatic brain injury.
        J Neurosurg Pediatr. 2008; 1: 461-470
        • Hawley C.
        • Ward A.
        • Magnay A.
        • Long J.
        Outcomes following childhood head injury: a population study.
        J Neurol Neurosurg Psychiatry. 2004; 75: 737-742
        • British Society of Rehabilitation Medicine
        Rehabilitation after traumatic brain injury. A working party report of the British Society of Rehabilitation Medicine.
        BSRM, London1998
        • Halley M.
        • Silva P.
        • Foley J.
        • Rodarte A.
        Loss of consciousness: when to perform computed tomography?.
        Pediatr Crit Care Med. 2004; 5: 230-233
        • Babikan T.
        • Satz P.
        • Zaucha K.
        • Light R.
        • Lewis R.S.
        • Asarnow R.F.
        The UCLA longitudinal study of neurocognitive outcomes following mild pediatric traumatic brain injury.
        J Int Neuropsychol Soc. 2011; 17: 886-895
        • Greenspan L.
        • McLellan B.
        • Greig H.
        Abbreviated Injury Scale and Injury Severity Score: a scoring chart.
        J Trauma. 1985; 25: 60-64
        • Grubenhoff J.A.
        • Kirkwood M.
        • Deakyne S.
        • Wathen J.
        Detailed concussion symptom analysis in paediatric ED population.
        Brain Inj. 2011; 25: 943-949
        • Fay T.
        • Yeates K.O.
        • Taylor H.G.
        • et al.
        Cognitive reserve as a moderator of postconcussive symptoms in children with complicated and uncomplicated mild traumatic brain injury.
        J Int Neuropsychol Soc. 2010; 20: 94-105
        • Taylor H.G.
        • Dietrich A.
        • Nuss K.
        • et al.
        Post-concussive symptoms in children with mild traumatic brain injury.
        Neuropsychology. 2010; 24: 148-159
        • Woodrome S.
        • Yeates K.O.
        • Taylor H.G.
        • et al.
        Coping strategies as a predictor of post-concussive symptoms in children with mild traumatic brain injury versus mild orthopedic injury.
        J Int Neuropsychol Soc. 2011; 17: 317-326
        • Yeates K.O.
        • Taylor H.G.
        • Rusin J.
        • et al.
        Longitudinal trajectories of postconcussive symptoms in children with mild traumatic brain injuries and their relationship to acute clinical status.
        Pediatrics. 2009; 123: 735-743
        • Hajek C.
        • Yeates K.O.
        • Taylor H.G.
        • et al.
        Relationship among post-concussive symptoms and symptoms of PTSD in children following mild traumatic brain injury.
        Brain Inj. 2010; 24: 100-109
        • Tham S.
        • Palermo T.
        • Vavilala M.
        • et al.
        The longitudinal course, risk factors, and impact of sleep disturbances in children with traumatic brain injury.
        J Neurotrauma. 2012; 29: 154-161
        • Gagnon I.
        • Swaine B.
        • Friedman D.
        • Forget R.
        Children show decreased dynamic balance after mild traumatic brain injury.
        Arch Phys Med Rehabil. 2004; 85: 444-452
        • Gagnon I.
        • Swaine B.
        • Friedman D.
        • Forget R.
        Visuomotor response time in children with a mild traumatic brain injury.
        J Head Trauma Rehabil. 2004; 19: 391-404
        • Gagnon I.
        • Swaine B.
        • Friedman D.
        • Forget R.
        Exploring children's self-efficacy related to physical activity performance after a mild traumatic brain injury.
        J Head Trauma Rehabil. 2005; 20: 436-449
        • Roncadin C.
        • Guger S.
        • Archibald J.
        • Barnes M.
        • Dennis M.
        Working memory after mild, moderate, or severe childhood closed head injury.
        Dev Neuropsychol. 2004; 25: 21-36
        • Anderson V.
        • LeBrocque R.
        • Iselin G.
        • et al.
        Adaptive ability, behavior and quality of life pre and posttraumatic brain injury in childhood.
        Disabil Rehabil. 2012; 34: 1639-1647
        • Anderson V.
        • Catroppa C.
        • Haritou F.
        • Morse S.
        • Rosenfeld J.V.
        Identifying factors contributing to child and family outcome 30 months after traumatic brain injury in children.
        J Neurol Neurosurg Psychiatry. 2005; 76: 401-408
        • Anderson V.
        • Catroppa C.
        • Morse S.
        • Haritou F.
        • Rosenfeld J.
        Functional plasticity or vulnerability after early brain injury?.
        Pediatrics. 2005; 116: 1374-1382
        • Kenardy J.
        • LeBrocque R.
        • Hendrikz J.
        • Iselin G.
        • Anderson V.
        • McKinlay A.
        Impact of posttraumatic stress disorder and injury severity on recovery in children with traumatic brain injury.
        J Clin Child Adolesc Psychol. 2012; 41: 5-14
        • Blinman T.
        • Houseknecht E.
        • Snyder C.
        • Wiebe D.J.
        • Nance M.L.
        Postconcussive symptoms in hospitalized pediatric patients after mild traumatic brain injury.
        J Pediatr Surg. 2009; 44: 1223-1228
        • Spencer M.T.
        • Baron B.J.
        • Sinert R.
        • Mahmoud G.
        • Punzalan C.
        • Tintinalli A.
        Necessity of hospital admission for pediatric minor head injury.
        Am J Emerg Med. 2003; 21: 111-114
        • Luis C.
        • Mittenberg W.
        Mood and anxiety disorders following pediatric traumatic brain injury: a prospective study.
        J Clin Exp Neuropsychol. 2002; 24: 270-279
        • AbdelMalik P.
        • Husted J.
        • Chow E.
        • Bassett A.S.
        Childhood head injury and expression of schizophrenia in multiply affected families.
        Arch Gen Psychiatry. 2003; 60: 231-236
        • Gedye A.
        • Beattie B.
        • Tuokko H.
        • Horton A.
        • Korsarek E.
        Severe head injury hastens age of onset of Alzheimer's disease.
        J Am Geriatr Soc. 1989; 37: 970-973
        • Korinthenberg R.
        • Schreck J.
        • Weser J.
        • Lehmkuhl G.
        Post-traumatic syndrome after minor head injury cannot be predicted by neurological investigations.
        Brain Dev. 2004; 26: 113-117
        • Lee L.K.
        • Monroe D.
        • Bachman M.C.
        • et al.
        Isolated loss of consciousness in children with minor blunt head trauma.
        JAMA Pediatr. 2014; 168: 837-843
        • Yeates K.O.
        • Taylor H.G.
        • Rusin J.
        • et al.
        Premorbid child and family functioning as predictors of post-concussive symptoms in children with mild traumatic brain injuries.
        Int J Dev Neurosci. 2012; 30: 231-237
        • Eisenberg M.
        • Meehan W.
        • Mannix R.
        Duration and course of post-concussive symptoms.
        Pediatrics. 2014; 133: 999-1006
        • Centers for Disease Control and Prevention
        Updated mild traumatic brain injury guideline for adults.
        Centers for Disease Control and Prevention, Atlanta, GA2016
        • Zemek R.
        • Barrowman N.
        • Freedman S.
        • et al.
        Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED.
        JAMA. 2016; 8: 1014-1025
        • Khetani A.
        • Brooks B.
        • Mikrogianakis A.
        • Barlow K.
        Incorporating a computerized cognitive battery into the emergency department care of pediatric mild traumatic brain injuries- it is feasible?.
        Pediatr Emerg Care. 2016 Dec 28; ([Epub ahead of print])
        • NINDS Common Data Elements
        Traumatic brain injury.
        (Available at:)