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A Commentary on Silverberg and the Many Expert Panel Definitions of Mild Head Injury

  • Andrew R. Mayer
    Affiliations
    The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, MN
    Neurology, Psychiatry, and Psychology Departments, University of New Mexico School of Medicine, Albuquerque, NM
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      Public awareness of mild traumatic brain injury (mTBI) has never been higher. As noted by Silverberg et al
      • Silverberg ND
      • Iverson GL
      • Arciniegas DB
      • et al.
      Expert panel survey to update the American Congress of Rehabilitation Medicine definition of mild traumatic brain injury.
      and in other reviews,
      • Mayer AR
      • Quinn DK
      • Master CL.
      The spectrum of mild traumatic brain injury: a review.
      different expert panels have developed different criteria for defining “mTBI,” “concussion,” “complicated mTBI,” and even “moderate TBI.” The terms concussion and mTBI cause particular confusion. Silverberg notes (italics added; see also discussion starting on page 82 of that article), “These 2 labels are sometimes considered synonymous or as subordinate or superordinate terms, with concussion representing a subset of mild TBI without structural brain injury.”
      • Silverberg ND
      • Iverson GL
      • Arciniegas DB
      • et al.
      Expert panel survey to update the American Congress of Rehabilitation Medicine definition of mild traumatic brain injury.
      (p77) However, as demonstrated in Silverberg's own table 2, expert consensus panels differentiate concussion from mTBI both on clinical symptoms and imaging findings.
      • Silverberg ND
      • Iverson GL
      • Arciniegas DB
      • et al.
      Expert panel survey to update the American Congress of Rehabilitation Medicine definition of mild traumatic brain injury.
      Therefore, table 1 presents 4 clinical scenarios in which a patient with postconcussive symptoms and clear evidence of a blow to the head presents for care with or without an alteration in mental status and with or without imaging findings.
      Table 1Contingency table for diagnosis based on clinical presentation and structural imaging findings
      Clinical Scenario Altered Mental Status Present “Lesion” Present Meets Criteria for “mTBI” (eg, ACRM)
      Criteria from ACRM, World Health Organization, Centers for Disease Control, and so on.
      Meets Criteria for “Concussion” (eg, CISG)
      Criteria from International Conference of CISG, American Medical Society for Sports Medicine, Ontario Neurotrauma Foundation.
      1 No No No Yes
      2 Yes No Yes Yes
      3 No Yes Yes
      Opinion not always explicitly denoted (ACRM) and/or varies by expert consensus panel (Department of Defense and Ontario Neurotrauma Foundation).
      No
      4 Yes Yes Yes
      Opinion not always explicitly denoted (ACRM) and/or varies by expert consensus panel (Department of Defense and Ontario Neurotrauma Foundation).
      No
      Abbreviations: ACRM, American Congress of Rehabilitation Medicine; CISG, Concussion in Sport Group.
      low asterisk Criteria from ACRM, World Health Organization, Centers for Disease Control, and so on.
      Criteria from International Conference of CISG, American Medical Society for Sports Medicine, Ontario Neurotrauma Foundation.
      Opinion not always explicitly denoted (ACRM) and/or varies by expert consensus panel (Department of Defense and Ontario Neurotrauma Foundation).
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      References

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        • Iverson GL
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        Expert panel survey to update the American Congress of Rehabilitation Medicine definition of mild traumatic brain injury.
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        • Mayer AR
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        • Master CL.
        The spectrum of mild traumatic brain injury: a review.
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      1. Lexico. Definition of subset in English. Available at: https://www.lexico.com/en/definition/subset/. Accessed April 27, 2021.

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