Addressing Shortfalls of the Current American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury in the Context of Intimate Partner Violence: A Commentary

Abstract

Intimate partner violence (IPV) is a global public health issue worldwide characterized by physical, sexual, psychological, and/or emotional aggression by a current or former intimate partner. It is the most common form of violence against women. Moreover, a large proportion of survivors experience repeated IPV incidents from their abusers. Brain injury is often a critical consequence of IPV. IPV-caused brain injuries (IPV-BI) are often mild (termed IPV-mBI) and repeated in nature, which ultimately impacts quality of life (QoL) of survivors. It is critical to confirm whether or not an mBI has occurred in survivors of physical IPV in order to help both survivors and clinicians navigate through an effective care pathway. Existing tools that are currently being used in the IPV-mBI-specific context are explicitly screening and/or research based. The current American Congress of Rehabilitation Medicine (ACRM) diagnostic criteria are intended to diagnose traumatic brain injury resulting from head impacts through various causes. However, IPV-mBI also includes nonfatal strangulation as a distinct mechanism of injury, and its multifactorial nature is often combined with coexisting and co-occurring emotional and psychological distress. Thus, both IPV and IPV-mBI have unique, parallel influences, both simultaneously impacting QoL. Consequently, given the unique characteristics of IPV-mBI, the mechanisms of injury, the presence of additional coexisting and co-occurring comorbidities, and distinct impacts on QoL, the current ACRM diagnostic criteria would likely lead to low degree of diagnostic certainty in survivors of IPV-mBI. Therefore, a clinical decision-making process that is IPV context-specific is justified.

Keywords

American Congress of Rehabilitation Medicine Diagnostic Criteria clinical decision-making pathways intimate partner violence strangulation traumatic brain injury

The Clinical Manifestations of Physical Intimate Partner Violence-Caused Mild Brain Injury

The American Congress of Rehabilitation Medicine (ACRM) outlines a diagnostic criterion for mild traumatic brain injury (mTBI) as a traumatically induced physiological disruption of brain function that is manifested by loss of consciousness for 30 min or less and altered mental state and/or post-traumatic amnesia no longer than 24 h after the injury.¹ Brain injury (BI) due to intimate partner violence (IPV) is a global concern, with prevalence estimates amongst those experiencing physical IPV for multiple BIs up to 75% and a single BI up to 100%.^2–4 IPV-caused brain injury (IPV-BI) results from two mechanisms: (1) brain damage caused by external mechanical forces such as blows to the head/face, falls/pushes causing “whiplash,” penetrating injuries, and/or impacts to the head, which is referred to as IPV-caused traumatic brain injury (IPV-TBI), and (2) brain damage caused by reduced oxygen (hypoxia) and/or blood flow (ischemia) that typically occurs through nonfatal strangulation (NFS), referred to as IPV-caused hypoxic-ischemic brain injury (IPV-HIBI).^2,4–8 Thus, IPV-BI includes IPV-TBI and/or IPV-HIBI. To maintain consistency, we will refer hereafter to the brain injury from either head impacts and/or NFS in IPV as IPV-BI in this paper. IPV-BIs from the above-mentioned mechanisms in survivors of IPV tend to be mild (referred to as IPV-mBI), often occurring repetitively over the course of months or years.

Furthermore, IPV-mBI can lead to significant short and/or long-term consequences including cognitive impairments (e.g., deficits in memory, attention, reasoning, planning and executive functioning), psychological or emotional disturbances (e.g., depression, anxiety, fatigue and post-traumatic stress disorders [PTSD]), and/or sensorimotor problems (e.g., paralysis or paresis of facial or extremity muscles, numbness, loss of sensation, muscle spasms, facial droop, and unilateral weakness).^2,9–11 Similar to mTBIs from causes other than IPV, it is critical to confirm whether or not an IPV-mBI has occurred in survivors of physical IPV in order to help survivors and clinicians navigate through effective care pathways.

An Overview of the 2023 ACRM Diagnostic Criteria

The ACRM diagnostic criteria for mTBI were most recently updated in 2023 (referred to as ACRM 2023) and are intended to diagnose mTBI in clinical practice and identify cases in research.¹ The ACRM 2023 guideline consists of six criteria: mechanisms of injury, clinical signs, acute symptoms, clinical examination and laboratory findings, and neuroimaging abnormality. An additional criterion—that the observed signs and symptoms and the findings from the clinical examinations and laboratory findings are not better accounted for by confounding factors¹—is used to rule out mTBI. In the 2023 ACRM criteria, mTBI is diagnosed when, one or more of the criteria listed below is met following a plausible mechanism of injury:

One or more clinical signs attributable to TBI.

At least two acute symptoms and at least one clinical or laboratory finding attributable to TBI.

Neuroimaging evidence of TBI, such as unambiguous trauma-related intracranial abnormalities on computed tomography (CT scan) or structural magnetic resonance imaging (MRI).

By contrast, an mTBI is suspected when one or more of the criteria listed below is met following a plausible mechanism of injury:¹

At least two acute symptoms.

At least two clinical examination or laboratory findings.

It is unclear if criterion 6 (i.e. not better accounted for by confounding factors) is met.

Current ACRM Diagnostic Processes Can Lead to Low Degree of Diagnostic Certainty in IPV-mBI

Survivors of physical IPV may acquire mBI from a broader array of mechanisms other than those listed in the ACRM 2023 diagnostic criteria,¹ such as HIBI from NFS.^2,4–6,12 Mild IPV-BI from direct hits to the head, face, and/or neck and from episodes of NFS co-occur in the majority of survivors of physical IPV.⁸ In addition, psychological distress (e.g., depression, anxiety, suicidality, insomnia, PTSD, and existential threats) is one of the major presentations in survivors of IPV-mBI, more so than what is typically observed in survivors of mTBI from other causes.^6,8,13–15 Psychological symptoms may be modulated by substance use and/or a history of adverse childhood events.¹⁶ As such, rejecting the final criterion of the ACRM 2023 guidelines—that other factors may better account for the patient’s experience—is challenging because: (1) IPV-mBI is multifactorial (i.e., biological, behavioral, structural, social, and environmental) and varies greatly across the population;² (2) IPV-mBI is often combined with coexisting and co-occurring polytrauma such as emotional abuse and psychological distress like PTSD;¹² and (3) survivors of IPV-mBI may initially report substance use and/or mental health comorbidities, potentially masking mBI symptoms.⁴ Consequently, given the characteristics of IPV-mBI, the mechanisms of injury, the presence of additional coexisting and co-occurring comorbidities, and their distinct impacts on quality of life (QoL), the ACRM 2023 diagnostic criteria would likely lead to a low degree of diagnostic certainty in survivors of IPV-mBI. Therefore, a tool with a classification system or specific criteria that are clinically validated, relatively short (since lengthy tools limit feasibility for use in clinical practice), and IPV context-specific is justified so IPV-mBI can be accurately diagnosed and appropriate follow-up care provided.¹²

Challenges in Detecting IPV-mBI

Based on our earlier work,¹¹ approximately 49–57% survivors of IPV reported external injuries to head, face and/or neck in an acute/subacute setting. That means greater than 43% of survivors of physical IPV did not present obvious external injuries to the head, face and/or neck. At the chronic stage, the percentage of survivors of IPV not reporting obvious external injuries to the head, face and/or neck would be much higher since most external injuries (e.g., scratches, bruises, and petechiae) would have healed with time. Unfortunately, routinely used neuroimaging tools are insufficiently sensitive to detect structural abnormalities that result from mBI secondary to physical IPV at either acute or chronic stages.¹⁷ Moreover, tools currently being used in the context of IPV-mBI—including the brain injury severity assessment (BISA) interview,⁵ brain injury screening questionnaire with IPV module (BISQ-IPV),¹⁸ Boston assessment of TBI-lifetime for female survivors of IPV (BAT-L/IPV),¹⁹ Ohio State University TBI identification method (OSU TBI-ID),²⁰ HELPS/HELPS-adaptations,^21,22 and CHATS²³—are explicitly screening tools. Screening tools and diagnostic tools serve distinct roles in health care. Screening tools are designed to identify potential health conditions or risk factors in large, generally asymptomatic populations, enabling early detection and preventive measures. In contrast, diagnostic tools are used to confirm or rule out a specific disease in individuals who present symptoms or have tested positive during screening.²⁴ Clarke et al.,²⁵ recently compared various assessment tools used in the context of IPV-mBI. The BISA, BISQ, BAT-L/IPV and HELPS-IPV adaptations have been feasibly implemented to screen for probable IPV-mBI.^{5,8,10,18,22,26–28} Among them, the HELPS-adaptation and CHATS are relatively short tools designed to flag the possibility of IPV-mBI in non-research/clinical settings (e.g., women’s shelters), whereas the BISQ, BISA, and BAT-L/IPV are more comprehensive. However, the BISA, BISQ-IPV, BAT-L/IPV, and OSU-TBI-ID were developed specifically for use in research.¹² Furthermore, as all these IPV-mBI screening tools are subjective in nature, there is a lack of objective measures, such as blood biomarkers or neuroimaging investigations, to rule out IPV-mBI.^3,12,29 Finally, clinical examination findings are not integrated into these tools, which is one of the components in the ACRM 2023 diagnostic criteria.¹ Moreover, different studies have reported sensorimotor and vestibular impairments resulting in dizziness, imbalance, incoordination etc.,^30–33 and ocular deficits^11,33,34 due to IPV-mBI. Finally, Hicks et al.,³⁴ reported about 45% IPV-related injuries involve one or both eyes, which is a significantly large number, indicating how important it is to include an ocular examination as a part of the IPV-mBI assessment. In effect, the existing tools are helpful in characterizing suspected/probable exposure to IPV-mBI rather than diagnosing it, and limiting determination to a “suspected” or “probable” IPV-mBI potentially compromises clinical care and management.

Avenues to Enhance ACRM Criteria to Improve Diagnostic Certainty in Survivors of IPV-mBI

Loss of consciousness or an alteration of consciousness may indicate the presence of TBI, particularly at the acute stage. However, dependence on such clinical signs is challenging in the context of IPV-mBI due to its unique characteristics (e.g., multifactorial causation and co-occurring injuries) described elsewhere.^2,12 It is also important to note many incidents of IPV-mBI do not occur in the presence of a witness (except perhaps children and the perpetrator), and survivors do not routinely know if, or for how long, they lost consciousness.

Fluid (blood, saliva, etc.) biomarkers may provide a potential objective measure to improve diagnostic certainty in IPV-mBI.^12,35,36 A growing number of studies have now shown blood biomarkers reflective of neuroaxonal and glial injury, such as Ubiquitin Carboxy-terminal Hydrolase L1 (UCH-L1), tau, Neurofilament Light (NfL), S100B, and Glial Fibrillary Acidic Protein (GFAP), may aid in diagnosing individuals within the first week after IPV-mBI depending on the marker, with the vast majority of studies focused on mTBI caused by mechanical trauma.^37–42 Reyes et al.,³⁸ identified the effectiveness of UCH-L1, GFAP, and NfL in discriminating individuals with and without mTBI. GFAP levels were elevated at 6 h post-injury (acute injury), whereas NfL levels were elevated at 7 days post-injury (subacute injury) compared with individuals with orthopedic trauma. UCH-L1 levels were elevated compared with controls at both time points. In addition, the authors compared the diagnostic accuracy of these biomarkers using Area Under the Curve (AUC) analysis. The diagnostic accuracy of UCH-L1 and GFAP was higher at 6 days whereas that of NfL was higher at 7 days (AUC at 6 days: UCH-L1 = 0.79, GFAP = 0.85, AUC at 7 days: NfL = 0.81). These findings were found in participants who did not exhibit abnormalities on their CT scan, indicating the blood biomarkers have considerable clinical ability (AUC ≥ 0.8)⁴³ to discriminate CT-negative mBI patients from that of controls.

In a group of patients who had experienced IPV-mBI, Sun and colleagues (2025)³⁷ observed elevated levels of plasma NfL compared with healthy controls, orthopedic trauma controls, as well as non-IPV-mTBI groups.³⁷ These results are promising and demonstrate that blood biomarker studies in the acute setting after IPV are feasible. In our previous study of IPV, we found IPV-mTBI (due to direct head impacts) and IPV-HIBI due to NFS often co-occur,⁸ which may result in different psychopathological consequences, and therefore blood-biomarker signatures, compared with mBI from head impacts or NFS alone. Another study found elevated S100B (an astrocyte-enriched protein), which has been linked to recent consensual sexual strangulation in 15 females compared with 17 who have never engaged in partnered sexual strangulation.⁴⁴ Thus, blood biomarkers have potential to improve diagnostic certainty in survivors of IPV in whom neuroimaging findings are normal or neuroimaging investigations are not completed.^36–38,40 A summary of candidate biomarkers, their diagnostic windows, and proposed clinical relevance is included in Table 1.

Table 1.

Comparison Between the Updated ACRM Diagnostic Criteria and the Clinical Decision-Making Process in IPV-mBI for Identifying Mild BI, Including Modifications

ACRM criteria for mTBI	IPV-mBI specific criteria	Modifications
Criterion 1: Mechanism of injury (MOI)	Criterion 1: Mechanism of injury (MOI)	1. Additional details in the context of IPV-mBI: Occurrence of one or multiple MOI indicated by the IPV survivor or a scenario where an IPV survivor comes to the clinic in acute distress but is unwilling or unable to share details regarding the MOI. 2. Additional MOI: Non-fatal strangulation, suffocation, smothered.
Criterion 2: Clinical signs	Criterion 2: Clinical signs and/or symptoms	Drawing from the clinical experience of practitioners who work with survivors of IPV-mBI and insights from our ongoing research, it can be challenging to distinguish between signs and symptoms in this group. Thus, they were merged.
Criterion 3: Acute symptoms	Criterion 2: Clinical signs and/or symptoms
Criterion 4: Clinical examination and laboratory findings	Criterion 3: Abnormal findings on clinical examination	Clinical examination and blood biomarker investigation constitute two distinct criteria in context of IPV-mBI, as the growing body of literature on IPV-mBI highlights the critical role of both assessments in identifying IPV-mBI.
	Criterion 4: Abnormal findings on blood biomarker investigation	Candidate biomarkers	Diagnostic windows	Proposed clinical relevance
		NfL	Up to 180 days post mTBI (peak 7 days)	Subacute to chronic detection of mild, moderate and severe TBI
		GFAP	30 min to 7 days post mTBI (peak 20 h)	Acute detection of mild, moderate and severe TBI
		UCH L1	Raises rapidly (peak 8 h post injury), declines over the following 48 h	Acute detection of mild, moderate and severe TBI
		BD-Tau	Within 24 h post injury	Acute diagnosis of TBI
		S100B	>6 h up to 30 days post NFS	To rule out test for intracranial pathology & NFS-caused BI
		NSE	48 h post HIBI	Prognostication of HIBI
		IL-6, IL-1b, MCP-2, IL-1RA, IFN-y	At <24 h	TBI diagnosis and prognosis
		IL-6, IL-1β and MCP-1	Within a week	TBI diagnosis and prognosis
		Ptau-181, Ptau-217	Elevated up to 18 h post mTBI	Detection of Alzheimer’s pathology
		Aß42/Aß40	Decreased in years following TBI	Detection of Alzheimer’s pathology
Criterion 5: Neuroimaging abnormality (if completed)	—	Neuroimaging, if obtained, can show intracranial abnormalities suggestive of TBI. The magnetic resonance/computed tomography angiography may be useful in cases of suspected/confirmed NFS for detecting potential carotid artery dissection. However, routinely used neuroimaging often do not detect mBI. Therefore, the clinical decision-making process for IPV-mBI was created to identify IPV-mBI in survivors with normal neuroimaging results or those who haven’t undergone neuroimaging assessments. Therefore, the ACRM-neuroimaging criterion was excluded in the IPV-mBI identification process.
Criterion 6: Not better accounted for by confounding factors	—	The criterion 6 of the ACRM 2023 guidelines was excluded in the IPV-mBI context because it is challenging in these survivors since IPV-mBI: (1) is multifactorial and varies greatly across the population; (2) is often combined with coexisting and co-occurring polytrauma such as emotional abuse and psychological distress; and (3) may initially report substance use and/or mental health comorbidities potentially masking BI symptoms.

On the table: ACRM, The American Congress of Rehabilitation Medicine; MOI, mechanism of injury; mTBI, mild traumatic brain injury; IPV, intimate partner violence; IPV-mBI, intimate partner violence-caused mild brain injury; CBIV, Clinical decision-making tool for Brain Injury from intimate partner Violence; GFAP, glial fibrillary acidic protein; HIBI: hypoxic-ischemic brain injury; NfL, Neurofilament Light; NFS: non-fatal strangulation.

Clinical Decision-Making in IPV-mBI with the ACRM 2023 Diagnostic Criteria as a Foundation

To address the shortfalls of ACRM 2023 criteria for identifying IPV-mBI, we proposed the algorithm outlined in Figure 1. Consistent with the ACRM diagnostic criteria,¹ the clinical decision-making process in IPV-mBI was fundamentally based on the following four major criteria: (1) mechanism of injury (MOI); (2) signs and symptoms (S/S); (3) clinical examination; and (4) blood biomarkers. Table 1 presents a comparison of the ACRM 2023 diagnostic criteria and the clinical decision-making process in IPV-mBI for identifying mBI, along with the justifications for the changes made. These changes were based on the following evidence.

FIG. 1.

The clinical decision-making processes in intimate partner violence-caused mild brain injury (IPV-mBI), based on the revised ACRM 2023 diagnostic criteria as the foundation. The clinical decision-making framework has been described for identifying IPV-mBI in survivors where neuroimaging results are normal or where neuroimaging tests have not been completed. Solid lines indicate routes to diagnosed IPV-mBI, dashed lines represent routes to probable/suspected IPV-mBI, and the dotted line shows the route to unlikely IPV-mBI. ACRM, American Congress of Rehabilitation Medicine.

As indicated in the ACRM diagnostic criteria, any abnormality detected using neuroimaging in survivors of physical IPV would confirm the diagnosis of IPV-mBI. Magnetic resonance angiography or CT angiography of the brain and neck may be useful in cases of suspected/confirmed NFS to detect potential carotid artery dissection.⁴⁵ However, routine neuroimaging techniques like CT or MRI often do not identify structural abnormalities that result from IPV-mBI. Therefore, the clinical decision-making process would particularly be useful in detection of IPV-mBI in those survivors in whom neuroimaging findings are normal or neuroimaging investigations are not completed (because they are either not available/feasible and/or contraindicated). Furthermore, criterion 6 (i.e., not better accounted for by confounding factors) of the ACRM 2023 guidelines is challenging in the context of IPV-mBI as described above. Therefore, criteria 5 and 6 of the guidelines were not included in the IPV-mBI clinical decision-making process.

Findings from pilot data showed that over 80% (37 out of 46) of participants reported experiencing one or more MOIs that had the potential to result in BI. Of the participants who reported one or more MOIs, approximately 87% (38 out of 46) exhibited various S/S that align with those observed in BI (# of S/S: average: 5.56, range: 1–13). These pilot data align with the findings of one of our previous studies (single MOI: reported by 91%, multiple MOI: reported by 89%, and S/S: reported by 32% participants)¹¹ and other published literature.^3,6,33 Given that MOI and S/S are prevalent subjective traits in this population, they were considered as criteria 1 and 2, respectively.

Similarly, our team has shown that IPV-mBI affects cognitive-motor and balance functions, resulting in diminished cognitive abilities and reduced motor performance, respectively.^10,46 Cognitive impairments and balance deficits are frequently noted in other IPV-mBI research as well.^31,47–49 This evidence, combined with clinical practitioners’ experiences with survivors, strongly supported the inclusion of a neurological examination in survivors of IPV-mBI, making it a third criterion.

Likewise, evaluating blood biomarkers in survivors with normal or incomplete neuroimaging results is an important factor. The results from the preliminary study conducted in one of our labs noted above³⁷ are very encouraging and align with the findings of numerous biomarker-based studies.^38–42 Consequently, the findings from biomarker investigations were regarded as a fourth criterion in the clinical decision-making process for IPV-mBI.

Thus, inclusion of both subjective and objective measures in the clinical decision-making process would better differentiate among diagnosed mBI vs. probable/suspected mBI vs. unlikely mBI from IPV.

Moving Ahead: Development of a Clinical Decision-Making Tool for IPV-mBI

Moving forward, in accordance with the clinical decision-making process for IPV-mBI illustrated in Figure 1, we proposed to develop a Clinical decision-making tool for Brain Injury from physical Violence (CBIV), using the 2023 ACRM diagnostic criteria to form the foundation to develop the CBIV. The CBIV development and validation will have two phases:

Phase I: Development phase: This phase includes

Designing the CBIV: An initial draft of the CBIV has been developed, based on a literature review, examples of other TBI-specific clinical diagnostic tools, discussion with the research team, knowledge users, clinical collaborators, and patients with lived experience of IPV-mBI, and preliminary data collected from patients recruited in our larger study.

Refining the CBIV: With the basic draft of the CBIV in place, we will use it to collect preliminary data in survivors of physical IPV. At the same time, we will establish an expert advisory group comprised of IPV-BI researchers, clinical practitioners who work with survivors of IPV-BI, knowledge users, and patients with lived experience of IPV-BI to provide advice and feedback on potential refinements to the CBIV.

Piloting: A pilot study will be conducted.

Advisory group feedback: Prior to, midway through, and after the pilot data collection period, we will seek advice and feedback from the advisory group to iteratively refine the CBIV.

Phase II: Validation phase

We will establish the feasibility, reliability (inter- and intra-rater reliability), validity (criterion and construct), sensitivity, and specificity of the CBIV during the validation phase of the study. In addition, the predictive value (either positive or negative) will be tested for inclusion/exclusion of blood biomarkers against a measure of QoL. Phase II activities will yield a refined, reliable, and valid CBIV available to use in routine clinical practice for accurate identification of IPV-mBI. Afterward, we will engage with our network of clinician collaborators to promote use of the CBIV and, with subsequent funding, undertake broader implementation and evaluation studies.

The CBIV is currently undergoing refinement. After validation, we anticipate it could serve as an essential clinical adjunct to the ACRM diagnostic criteria, enabling clinicians and researchers to distinguish between diagnosed IPV-mBI, probable/suspected IPV-mBI, and unlikely IPV-mBI in survivors of IPV. Moreover, the CBIV will likely also be applicable to individuals who have experienced other types of physical violence, such as family violence, non-partner-related abuse, and stranger violence.

Conclusion

The proposed clinical decision-making tool has the potential to have a substantial impact in that it will address specific deficiencies of the ACRM 2023 diagnostic criteria in the context of IPV-mBI and will also address a major gap in care for survivors who have experienced mBI from IPV—a significantly underserved population. In particular, improving the ability to determine whether an mBI has occurred in survivors of IPV will open doors to an mBI clinical care pathway that, until recently, has not been typically considered for this population.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work is supported by a grant from the Canadian Institutes of Health Research National Women’s Health Research Initiative Innovation Fund (029689).

Authors’ Contribution

S.P.A.: Conceptualization, writing (original draft), and writing (review and editing), P.V.D. and S.R.S.: Conceptualization and writing (review and editing); M.G., G.F.S., M.I.H., K.M.K., C.M.L., K.M., H.V., C.E., and C.L.W.: Writing (review and editing).

Abbreviations

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