Special communication
Methodological Issues and Research Recommendations for Prognosis After Mild Traumatic Brain Injury: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis

https://doi.org/10.1016/j.apmr.2013.04.026Get rights and content

Abstract

The International Collaboration on Mild Traumatic Brain Injury (MTBI) Prognosis performed a comprehensive search and critical review of the literature from 2001 to 2012 to update the 2002 best-evidence synthesis conducted by the World Health Organization Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation Task Force on the prognosis of MTBI. Of 299 relevant studies, 101 were accepted as scientifically admissible. The methodological quality of the research literature on MTBI prognosis has not improved since the 2002 Task Force report. There are still many methodological concerns and knowledge gaps in the literature. Here we report and make recommendations on how to avoid methodological flaws found in prognostic studies of MTBI. Additionally, we discuss issues of MTBI definition and identify topic areas in need of further research to advance the understanding of prognosis after MTBI. Priority research areas include but are not limited to the use of confirmatory designs, studies of measurement validity, focus on the elderly, attention to litigation/compensation issues, the development of validated clinical prediction rules, the use of MTBI populations other than hospital admissions, continued research on the effects of repeated concussions, longer follow-up times with more measurement periods in longitudinal studies, an assessment of the differences between adults and children, and an account for reverse causality and differential recall bias. Well-conducted studies in these areas will aid our understanding of MTBI prognosis and assist clinicians in educating and treating their patients with MTBI.

Section snippets

Definition of MTBI

The WHO Task Force report tabled 38 definitions from studies included in their best evidence synthesis.1 Although many definitions had overlapping criteria, they also exhibited considerable differences and used varying terms for the condition including MTBI, concussion, and minor head injury. Most definitions (62%) included Glasgow Coma Scale (GCS) scores as one or the only criterion, but not all applied the same GCS spectrum to define MTBI. Others (38%) used varying criteria for loss of

Quality of Existing Research

We found important biases and methodological flaws in the design and conduct of MTBI prognosis studies (table 2). The most common reasons for nonacceptance or exclusion in the ICoMP review are highlighted in this section.

Methodological issues

Even among accepted studies, nonfatal methodological issues existed. Table 3 summarizes some of the main issues and highlights practical recommendations to assist clinical researchers in addressing them.

Research Priorities

According to the findings of the ICoMP, the field of MTBI prognosis research has advanced slowly. In 2004, the WHO Task Force listed 5 research priority areas: (1) the use of confirmatory designs; (2) the influence of pain, psychological distress, and alcohol or drug abuse on recovery; (3) studies in the elderly; (4) exploration of the role of compensation/litigation issues; and (5) further examination of the long-term consequences of MTBI in very young children.1 Most of these are still

Conclusions

Future research on MTBI prognosis needs to address the issues highlighted in this review. Standard criteria for defining MTBI would improve the comparability of studies, but since this currently does not exist, authors need to clearly describe their MTBI criteria. Potential biases, including issues of confounding, information, and selection bias, should be considered in the design phase of a research study. Research designs should be selected as appropriate for the research question, and

Acknowledgments

We thank the other members of ICoMP: Jean-Luc af Geijerstam, MD, PhD; Eleanor Boyle, PhD; Victor G. Coronado, MD, MPH; Pierre Côté, DC, PhD; Cesar A. Hincapié, DC, MHSc; Ryan Hung, MD, MSc; Michelle Keightley, PhD; Alvin Li, BHSc; Connie Marras, MD, PhD; Peter Rumney, MD; and Britt-Marie Stålnacke, MD, PhD; Panos Lambiris, MSc, Information Scientist, University Health Network, for assisting in developing, testing, and updating the search strategies; and Meijia Zhou, BSc, for assistance with

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    Supported by the Ontario Neurotrauma Foundation (grant no. 2010-ABI-MTBIWHO-871). The funder was not involved in the design or preparation of the study protocol, or in the management of the project, analysis or interpretation of data, or the preparation of the final article.

    No commercial party having a direct financial interest in the results of the research supporting this article has conferred or will confer a benefit on the authors or on any organization with which the authors are associated.

    The findings and conclusions in this research are those of the authors alone and do not necessarily represent the official views or policies of the Centers for Disease Control and Prevention or any agency of the United States government. Inclusion of individuals, programs, or organizations in this article does not constitute endorsement by the United States government.

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