Journal of Clinical and Experimental Neuropsychology, 27:334-351, 2005 \ T J Psycholoqv PreSS

Copyright © Taylor & Francis Ltd. I raytottfnrobcroup

ISSN: 1380-3395
DOI: 10.1080/13803390490520328

Neuropsychological Studies of Mild

Traumatic Brain Injury: A Meta-Analytic
Review of Research Since 1995

KATHERINE A. R. FRENCHAM,' ALLISON M. EOX,''^

AND MURRAY T. M A Y B E R Y '
'School of Psychology, University of Western Australia, Crawley, Australia
^Private Practice, Perth, Western Australia

A meta-analysis conducted by Binder, Rohling and Larrabee (1997) established a rela-

tionship between mild traumatic brain injury (TBI) and small reductions in cognitive
functioning in individuals assessed more than 3 months post-injury. As a follow-up,
this study summarized similar research that (1) was published since the previous meta-
analysis, and (2) included data collected at any stage post-injury. An extensive litera-
ture search revealed J 7 suitable studies from which effect sizes were aggregated. The
overall effect size was g = 0.32, p < .001. Speed of processing measures had the larg-
est effect, g = 0.47, p < .001. The merging ofpost-acute effect sizes with those reported
in Binder et al. 's review yielded a nonsignificant result, g = 0.11. Time since injury
was found to be a significant moderator variable, with effect sizes tending to zero with
increasing time post injury.

Introduction
This article describes a meta-analysis of recent literature addressing the effects of mild
traumatic brain injury (TBI) on neuropsychological functioning in adults. The main inten-
tion was to follow on from Binder, Rohling and Larrabee's (1997) oft-cited meta-analysis
and to report current findings in the field by summarizing research conducted between
1995 and 2003. Since the focus of Binder et al.'s study was the chronicity of cognitive
deficits after mTBI, they excluded research addressing outcome less than 3 months post-
trauma. In contrast, the present analysis included studies conducted at any stage post
injury to address the influence of time since injury on neuropsychological outcome. This
relationship has not previously been addressed meta-analytically in mTBI research.
In 1997, Binder et al. summarized all suitable literature published at that time to
obtain an overall effect size for the influence of mTBI on neuropsychological functioning
in the post-acute phase (more than 3 months post-injury, with the acute phase accordingly
encompassing the first 3 months after TBI). According to their criteria, suitable studies
were those that involved prospective, or at least 'quasi-prospective', recruitment of partic-
ipants, as opposed to recruitment through referral for clinical intervention due to persistent

Received 22 December 2003; accepted 15 April 2004.

Thanks go to the authors of papers included in this analysis who willingly provided additional
data and information to assist in the completion of this meta-analysis. This study was supported by
an Australian Postgraduate Award provided to K. Frencham.
Address correspondence to: K Frencham, School of Psychology, University of Western Australia,
35 Stirling Highway, Crawley, 6009, Australia. Email: katef@graduate.uwa.edu.au
334
 mTBI Research: Meta-Analysis Since 1995 335

symptomatology post-TBI (e.g., via neuropsychological assessment or rehabilitation).

Prospective samples, such as consecutive mTBI admissions to an Emergency Department,
are chosen on the basis of the head injury only, and are therefore argued to provide a rela-
tively unbiased representation of outcome post-injury. 'Clinical' samples, such as those
seen later post-injury due to ongoing difficulties (e.g., through rehabilitation clinics) are
more likely to represent complicated rather than standard recoveries, leading to an over-
estimate of morbidity (Dikmen & Levin, 1993). Reitan and Wolfson (1999) highlighted
the effect of sample selection method on neuropsychological outcome in their comparison
of neuropsychological performance by prospective and clinical samples to that of matched
controls, citing poorer outcome for the clinical group.
By summating results from 11 prospective post-acute studies. Binder et al. (1997)
obtained general and more specific neuropsychological outcome measures. Overall, a
small positive effect of mTBI was found {d-0.\2), however, more conservative analysis
using the g statistic failed to reach significance {g = 0.07). After sorting results into neu-
ropsychological domains, they also reported a significant but small effect in the area of
attention and concentration (g = 0.17), leading to their suggestion that attention measures
might be the most sensitive to persistent neuropsychological dysfunction after mTBI. It
was concluded that neuropsychological performance was reduced by less than 5% in asso-
ciation with a mTBI, an amount, they argued, that was smaller than the measurement error
associated with commonly used tests. They cautioned that the association between the
incidence of mTBI and subtle neuropsychological deficits did not provide evidence that
the head injury caused these deficits.
While numerous studies have adopted longitudinal designs and tested individuals at
different times post-injury, methodological inconsistencies often make the task of inter-
preting and consolidating such findings difficult and confusing for the reader. One diffi-
culty consistently highlighted in mTBI reviews, is that disparate outcome results may
largely reflect variability in recruitment approaches and tasks employed to measure per-
formance (Bernstein, 1999; Binder, 1986; Binder, 1997; Binder et al., 1997; Dikmen &
Levin, 1993; Dikmen, Machamer, & Temkin, 2001). Despite the impact of these issues on
results, general trends are evident in the literature relating to neuropsychological outcome
in the acute and post-acute phase, both on a general and domain specific level.
There is a common consensus that while mild cognitive impairment may be evident
immediately following mTBI (i.e., during the first week), this resolves within the first 1-3
months for the 'typical' patient (Alexander, 1995; Dikmen, McLean, & Temkin, 1986;
Macchiocci, Barth, Wayne, Rimel, & Jane, 1996; McLean, Temkin, Dikmen, & Wyler, 1983;
Ponsford et al., 2000; Reitan & Wolfson, 1999; Stewart, Kaylor, & Koutanis, 1996; Voller et
al., 1999). In the acute phase, specific deficits have been noted in the areas of working mem-
ory, attention and memory in general (Alexander, 1995), however there is some variability
in this pattem, which seems to depend upon the tasks employed to measure functioning in
each domain. In general, tasks that are sufficiently cognitively demanding have been
suggested to have increased sensitivity to mTBI (Raskin, Mateer, & Tweeten, 1998).
Speed of processing tasks often reflect difficulties after mTBI (Bleiberg, Kane, Reeves,
Garmoe, & Halpem, 2000). For example, even after mild concussion, individuals have been
shown to be impaired on both simple and more complex reaction time tasks during the first
few months post injury (Hugenholtz, Stuss, Stetham, & Richard, 1988). Other studies have
demonstrated intact speed of processing and attention, but acute difficulties with recall that
resolve by three months post-injury (Stuss, Stetham, Hugenholtz, & Richard, 1989). Mild
to moderate deficits have been demonstrated more generally when a standard neuropsycho-
logical battery is administered one week post-injury (Stewart et al., 1996).
336 K. A. R. Frencham et al.

Addressing recovery over a one year interval, Dikmen et al. (1986) demonstrated that
impairments in cognitive functioning "largely disappeared" by one month post injury,
apart from subtle deficits on memory and attention tasks (p. 1231). By one year follow-up,
these subtle deficits had also resolved, with mTBI individuals performing comparably to
controls. While they concluded that there was no evidence of clinical impainnent, they
and other researchers have noted a trend that mTBI individuals generally score slightly
lower than controls (Dikmen et al. 1986; Stuss et al., 1989).
In their review, Dikmen and Levin (1993) concluded that while few would dispute the
early effects of mTBI, the area of recovery and long-term effects was more controversial.
In terms of post-acute outcome, the general view is that any long-term deficits will be
minor. Perhaps the most influential post-acute research to date is that conducted by
Dikmen, Machamer, Winn, & Temkin (1995) incorporating a large, prospectively
recruited sample of mTBI cases (A' = 161). At one year follow-up, neuropsychological
results in the patient group were found to be comparable to controls, leading to the conclu-
sion that mTBI was not associated with persisting deficits. However, other smaller scale
studies have noted long-term impairments after mTBI in the areas of speed of processing
(Bernstein, 2002; Sangal & Sangal, 1996), sustained attention (Bohnen, Jolles, Twijnstra,
Mellink, & Wijnen, 1995), divided attention, and rapid processing (Cicerone, 1997;
Mangels, Craik, Levine, Schwartz, & Stuss, 2002), generally in the context of intact per-
formance on other tasks.
While there is no consensus as to which specific tasks, if any, will detect long-term
deficits, there is agreement regarding the areas of cognition that will not be affected by
mTBI. Overall, gross deficits in intelligence and memory are not associated with mTBI
(Bohnen et al., 1995; Fisher, Ledbetter, Cohen, Marmor, & Tulsky, 2000; Raskin et al.,
1998). Simpler attention and working memory tasks such as Digit Span have also been
found to be insensitive to long-term deficits, again supporting the view that tasks are
required to be sufficiently cognitively demanding to demonstrate the subtle impairment
of attention and speed of processing that may follow mTBI (Cicerone, 1997). As men-
tioned, no systematic reviews or meta-analyses addressing either the effect of time
since injury on neuropsychological functioning or general functioning in the acute
phase have been undertaken in the mTBI literature to date. Despite the need for meta-
analytic studies being highlighted as an important area for further research in a recent
review of the literature (Bernstein, 1999), Binder et al.'s (1997) publication represents
the only meta-analysis that bas been conducted on neuropsychological outcome in this
population. The aim of this study was to address overall outcome and outcome in seven
specific domains, similar to those classified by Binder et al. (1997). The effect of stage
of recovery on these potential deficits was also a focus with a view to determining
whether specific neuropsychological domains may have different trajectories of recov-
ery post-injury.

Hypotheses
In line with Binder et al.'s (1997) findings, it was hypothesised that overall, mTBI would
have an effect significantly greater than zero in the direction that performance would be
poorer for individuals with a mTBI compared to controls. Likewise, effect sizes were
expected to be larger in domains reportedly more susceptible to the effects of TBI, such as
speed of processing and attention. It was also hypothesized that there would be a moderat-
ing effect of time since injury, such that the size of neuropsychological deficits would be
inversely related to time since injury.
 mTBI Research: Meta-Analysis Since 1995 337

Method

Sample of Studies
Studies to be included in the meta-analysis were identified using the PsycINFO computer-
ized system. The key words used for the search were mild head injury, mild traumatic
brain injury, minor head injury or concussion and neuropsychology, assessment or cogni-
tive. A search was also conducted for recent reviews and meta-analyses in the area, and
relevant studies were gathered by systematically reviewing the reference lists of these
papers (e.g., Dikmen et al., 2001; Lees-Haley, Green, Rohling, Fox, & Allen, 2003;
McAllister & Arciniegas, 2002; Mittenberg, Canyock, Condit, & Patton, 2001; Mittenberg
& Strauman, 2000; Satz et al., 1999). Additionally, studies were collected by searching for
those that had cited Binder et al.'s (1997) paper using the online Institute for Scientific
Information (ISI) Web of Science, which exhaustively searches citation databases within
the fields of Science, Social Science and Arts and Humanities.
Strict criteria were imposed for inclusion and exclusion of studies, many of which
were adopted from those used by Binder et al. (1997). While their report was published in
1997, the most recent paper they included in their analysis was published in 1995. To
ensure inclusion of all suitable studies published since Binder et al.'s study, papers pub-
lished during and since 1995 were reviewed. Thus, criteria for inclusion were that the
study (1) was published in a joumal during or since 1995, (2) was written in the English
language, (3) involved comparison of a control group to a group of individuals who had
sustained a mTBI, and (4) reported data that had not been analyzed in part or full in the
context of both the present and Binder et al.'s previous meta-analyses.
Studies were excluded if (1) they reported on child mTBI research, (2) severity of
head injury was not differentiated and data from mild cases were embedded within data
from TBI groups of greater severity, preventing calculation of effect sizes for mTBI,
(3) participant inclusion was dependant on the presence of symptomatology, (4) individu-
als obtained a Glasgow Coma Scale score less than 13, (5) participants had incurred whip-
lash or other non-impact head injuries, and (6) attrition rates were higher than 50% (in the
case of follow-up studies). As mentioned, there were no exclusion criteria relating to time
post-injury.

Design
A between-groups design was adopted, where presence of mTBI was the independent
variable. Dependent variables included neuropsychological measures and time since
injury, analysed as a continuous variable.

Results
Sample Characteristics
Seventeen studies were identified as being suitable for analysis, involving a total of 634 mTBI
and 485 control individuals. Based on all available data, the mean age of mTBI individuals was
28.46 years {SD = 10.38; 71.75% male, 28.25% female) and for controls it was 29.31 years
{SD - 11.51; 66.27% male, 33.73% female). Length of education in years was similar across
groups (mTBI: M - 12.23, SD = 1.49; controls: M = 12.29,5D = 1.56). Combining the average
time post-injury for each study, the mean time since mTBI was 1.13 years {SD = 2.44).
338 K. A. R. Frencham et al.

With regard to the nature of the mTBI samples, ten studies involved samples of individ-
uals recruited as consecutive admissions to Emergency Departments. Inclusion in three stud-
ies was based on a self-reported history of mTBI, and four studies involved sportspeople
(e.g., American College Football and Australian Rules Football players) who had incurred
in-season concussions whilst being followed through prospective studies. There was some
variability in terms of which criteria were imposed to determine whether a mTBI had been
incurred. The most liberal of these was a self-reported "blow to the head causing the individ-
ual to stop what they were doing due to a loss of consciousness." Two studies relied on self-
report for the duration of loss of consciousness and post-traumatic amnesia. However, all
samples included were considered to be representative of the wider mTBI population.
Control and mTBI groups were matched at least in terms of age and years of educa-
tion. Most control groups (85.35%) comprised healthy community samples. Only three
studies incorporated control groups of patients consecutively recruited through Emergency
Departments with non-head injuries.
Twelve studies involved single session testing and five incorporated longitudinal
designs, where the same subjects were tested on more than one occasion to address the
effects of time since injury on neuropsychological performance. Of the longitudinal stud-
ies, two studies involved two sessions, one study involved three sessions and the remain-
ing two studies involved four sessions.

Analysis
Each paper was reviewed to check whether data were presented for all measures that had
been administered. While this was the case for the majority of studies, some had used
blanket comments such as "there was no significant difference on any neuropsychological
measure administered" in place of presenting data that could be used to calculate an effect
size or reported statistics for the significant, but not the nonsignificant, measures. In an
effort to include as much relevant data as possible, authors of papers that met criteria but
required further information before effect sizes could be calculated were contacted via
email and invited to provide the relevant data. If made available, these results were
included in the meta-analysis. If the authors failed to reply or were unable to provide such
data, effect sizes of zero were entered for the measures in question so as to not overesti-
mate the overall effect size. However, when using this technique, the final result may
slightly underestimate the effect being calculated (Rosenthal & Dimatteo, 2001).
There was some variability with regard to how results were presented in the 17
selected studies, however in most cases, means and standard deviations for both mTBI and
controls groups were available for the calculation of effect sizes. When only F or t values
were presented, transformation equations were used to calculate the associated effect size
(Rosenthal, 1991, p. 19). While the majority of results were presented as raw scores, some
were standardized (e.g., measures taken from the Wechsler scales) or were adjusted to
reflect change since baseline (pre-injury) testing. In the latter case, the adjusted scores
were used to calculate effect sizes as they still yielded difference scores between control
and mTBI groups.
Binder et al. (1997) calculated effect sizes in two ways, using either the standard
deviation of the control group or the pooled standard deviation as the denominator.'

' Note that Binder et al. (1997) used the labels d for the effect-size statistic calculated using the
standard deviation of the control group, and g for the statistic calculated using the pooled standard
deviation. Our use of the labels d and g is different, but arguably more consistent with the meta-
analysis literature (e.g. see Rosenthal and Dimatteo, 2002).
 mTBI Research: Meta-Analysis Since 1995 339

The former technique has been criticized in the context of neuropsychological research
since control group variance tends to be smaller than that of experimental groups, leading
to an overestimation of effect (Zakzanis, 2001). To evaluate the potential impact of this
issue, the standard deviations were compared for the two sets of samples, and indeed the
mean of the standard deviations was larger for the mTBI samples (13.37) than for the con-
trol samples (10.09). Therefore we used the pooled standard deviation equation suggested
by Hedges and Olkin (1985, p. 79), which is used in calculating Cohen's d.
However, Cohen's d has been reported to be subject to bias that leads to an inflation
of effect sizes when smaller samples are used. Estimated effect sizes were calculated by
incorporating a sample size "bias correction factor" (Hedges & Olkin, 1985, p. 80) and the
resultant corrected effect-size estimate is labeled g. The resultant g statistic should result in
effect sizes marginally lower than the uncorrected measure of effect size reported in
Binder et al.'s study. The sample-size bias-corrected effect size, g, was calculated both to
reflect overall neuropsychological outcome, and outcome in specific neuropsychological
domains. In all cases, the positive direction of an effect size value indicates poorer perform-
ance by the mTBI group.

Choice of Neuropsychological Domains. The domains employed were generally consis-

tent with those used in Binder et al's (1997) study; our perceptual organization, verbal
comprehension, motor skills and executive functioning factors corresponded with their
performance skills, verbal skills, manual dexterity and cognitive flexibility and abstraction
domains. However some domains were modified to both accommodate tasks that had been
developed and used since publication of their study, and to provide a more suitable group-
ing system on the basis of the tasks used in the samples analyzed presently. However, it is
acknowledged that the practice of clustering neuropsychological data into domains can be
controversial due to the fact that very few tasks can be labeled "process pure."
Several studies employed measures that were introduced since the previous meta-
analysis, such as subtests from the third editions of the Wechsler Adult Intelligence and
Memory Scales (WAIS-III, Wechsler, 1997b; WMS-III, Wechsler, 1997a). Supported
by factor analytic research, one main difference between the revised (Wechsler, 1981;
Wechsler, 1987) and third editions of these measures is that the third editions provide esti-
mates of Working Memory and Speed of Processing Index scores (see e.g., Tulsky &
Price, 2003; van der Heidjen «fe Donders, 2003). With regard to processing speed, there
has been a trend that recent studies include measures of reaction time and general speed of
processing. In line with recent research into the nature of speed of processing (O'Connor
& Bums, 2003), variables such as simple psychomotor speed and reaction time were
included in this factor. Thus, the domain that Binder et al. (1997) had labeled 'attention
and concentration' was classified as two domains in the present study: working memory/
attention and speed of processing.
In the original meta-analysis, memory was split into two factors, memory acquisition
and delayed recall, however these have been collapsed into a single factor for the purposes
of this study. While memory has been previously treated both as separate auditory and
visual components or learning and delayed components, factor analytic research does not
conclusively support either approach, and results seem to differ based on the measures
used in each factor analysis. For example, studies involving the WMS-III have been
unsuccessful in breaking memory into learning and delayed components, and report
instead that it should be broken into auditory and visual factors (Bowden, Carstairs, &
Shores, 1999; Burton, Ryan, Axelrod, Schellenberger, & Richards, 2003). Studies
addressing the factor structure of a more comprehensive neuropsychological battery have
340 K. A. R. Frencham et al.

claimed that memory is best represented as a single factor (Ardila, Glaeaon, & Rosselli,
1998; Miller & Rohling, 2001), and it has been previously treated this way in a large scale
prospective study incorporating a TBI population, (Dikmen et al., 1995).
Accordingly, the seven-factor structure adopted in this study included (1) working
memory /attention, (2) perceptual organization, (3) verbal comprehension, (4) motor skills,
(5) memory, (6) executive functioning, and (7) speed of processing. Examples of the tasks
most frequently included to calculate effect sizes for each factor are presented in Table 1.

Combination of Effect Sizes. For each study, effect sizes were calculated separately for all
measures and were then pooled to detennine an average effect size (see Table 2). Before
subsequently pooling data from all studies to calculate an overall estimate of effect of
mTBI, the homogeneity of the effect sizes was assessed. One method for testing whether
at least one effect size differs from the others is by calculating the test statistic Q (see
Hedges & Olkin, 1985, p. 123). Using the chi-square distribution, the hypothesis that the
effect sizes were estimates of the same parameter was accepted (g^bt 13.14 < x\^, 26.30
with 16 df and a = .05). Due to the variation in sample size across these studies, effect
sizes were weighted according to sample size. The underlying rationale is that the variance
associated with each effect size estimate depends on sample size, such that studies with
larger sample sizes will produce more precise estimates (Hedges & Olkin, 1985). By
weighting studies, those with larger sample sizes will have more influence on the final

Table 1
Tasks Representative of Those Included in Each Cognitive Factor used to
Calculate Effect Sizes

Factor Examples of Tasks Included Under Each Factor

Working memory and attention Trail Making Test
Digit Span
PASAT
Stroop
Perceptual organization Performance IQ and substituent subscales
(Wechsler scales)
Verbal comprehension Verbal IQ and substituent subscales
(Wechsler scales)
Motor skills Grooved Pegboard
Finger Tapping
Memory Rey Auditory / California Verbal
Leaming Tests
Paired Associate Learning
Hopkins Verbal Leaming Test
Rey Complex Figure Test
Executive functioning Controlled Oral Word Association Test
Wisconsin Card Sorting Test
Speed of processing Symbol Digit Modalities Test
Reaction Time
Digit Symbol (Wechsler scales)
 mTBI Research: Meta-Analysis Since 1995 341

Table 2
Details of Neuropsychological Studies of Mild Traumatic Braiti Itijury
Included iti the Meta-Analysis

Author/s N N Mean N Chronicity

(Year of Publication) tnTBI Control g sessions (at each session)
Batcheloretal. (1995) 35 35 0.60 1 2 weeks
Macciocchi et al. (1996) 183 48 0.26 3 1 day; 5 days; 10 days
Hinton-Bayre et al. (1997) 10 10 0.82 1 2 days
Bazarianetal. (1999) 71 60 0.24 1 1 day
Collins et al. (1999) 16 10 0.27 4 1 day; 3 days; 5 days;
7 days
Mathias and Coats (1999) 27 27 0.31 1 Between 1 and 4 months
Volleretal. (1999) 12 14 0.44 2 1 day, 6 weeks
Ponsford et al. (2000) 84 53 0.02 2 1 week, 3 months
Reitan and Wolfson (2000) 18 41 0.07 1 2 weeks
Echemendiaetal. (2001) 29 20 0.51 4 2 hours, 2 days, 1 week.
1 month
Goldstein et al. (2001) 13 14 0.31 1 Within 2 months
McAllister etal. (2001) 18 12 0.17 1 1 month
Potteretal. (2001) 24 24 0.45 1 Within 5 years
Segalowitzetal. (2001) 10 12 0.04 1 6.4 years (average)
Bernstein (2002) 13 10 0.22 1 Within 8 years
Comerford et al. (2002) 56 85 0.68 1 1 day
Mangels et al. (2002) 11 10 0.22 1 Within 3 years

effect size estimate, thus increasing accuracy. The method employed for weighting studies
was based on that described by Hedges and Olkin, where for each study, the product of
experimental and control sample sizes is divided by the sum of the group sizes, and the
result for each study is then divided by the sum of these ratios taken across all of the stud-
ies. Accordingly, these linear combinations of weights 'sum to unity' (1985, p. 10).
Weighted effect sizes were then summed to provide a weighted estimate, g = 0.32 {SD =
0.26). A single-sample, one-tailed t test indicated that the overall effect size was signifi-
cantly greater than zero (see Table 3 for details).
The effect sizes for each neuropsychological domain were also calculated. After
weighting for sample size, single-sample, one-tailed t tests were performed on thexstatis-
tic for each domain. As can be seen in Table 3, four domains; speed of processing, work-
ing memory/attention, memory and executive function; were found to have significant
positive effect sizes, the largest being g - 0.47 {SD - 0.25) for the speed of processing
domain. There were no significant effects in the perceptual organization, verbal compre-
hension or motor skills domains. See Figure 1 for graphical representation of these effect
sizes. According to guidelines suggested by Cohen (1992, Table 1) the size of these
effects ranged from small to moderate.

Time since injury. The effect of time post-injury was addressed (1) on a gross level by
addressing acute and post-acute phase results separately, (2) by pooling Binder et al.'s
(1997) data with the post-acute data here described, and (3) by addressing the relationship
between neuropsychological performance and time since injury as a continuous variable.
 022
052
data
022
CN
o 00
0 0 0
c

, inclludi
ex
ra
!£! vn en
CS

o d d d 3
o

^. p
CS CS en
60

00

•s **
*
* *
*
*
IBID

* * * * *
CX
*00 0 CS 0 vo 0 •n en CS >>

I
O 00 in VO Tl- CS 00
c ra
C/5
ra
^H p-H
en en CS vo
CJ it
'E "eb c
> 60
cJ5

-i^
E T3
O !> r - VO en VO
en en en en en en CN

Ti
CS
(N
0 0 0 0 0 0 0 0 0 0

-= ^
O CM '
en
en
0
00
(N
0 0
?^ iri in
<N (N

?
s 0 0en 0en
Tl-
0 0
Tt

'^ I c
« U O
a
Ii -H 00

•a

o ^
T3 ra
CS en 00 "o O U-) IT) —< ON O oo
o 00 en 00 O\ r-~ 00 >o CS - ^ en
Ti- en en '—^ en

E „-

CS CS en •* in en o
00 00 r- vo t-- en vo en o
>o en —I >r)
15
g gV
a
c 0 c
ts ra
0
60
Is*
'— N o (u *
M 3
ra
-a
0
'c
ra
.2 '^ 3 CP
e £0? 1
1 I 1"-
ual

a
Acu

60
kin

60 •ra ^
U U 0
II
 mTBI Research: Meta-Analysis Since 1995 343

To compare perfonnance between the acute and post-acute phases after mTBI, sup-
plementary analyses of overall effect size were conducted by parceling the data into two
phases post-injury. For the acute data, including all data collected up to 3 months post-injury, a
moderate effect size was obtained: weighted g- 0.33 (5D= 0.24). A one sample, one-tailed
/ test indicated that the overall acute effect size was significandy greater than zero. While
the weighted effect size for the post-acute phase was slightly lower, g = 0.28 {SD = 0.34),
the t test result was nonsignificant (see Table 3 for details).
Since only five suitable post-acute studies had been published since Binder et al.'s
(1997) study, data from the currently reported samples and the 11 samples reported in the
previous meta-analysis were pooled, using details provided in Table 1 of their paper. The
resultant effect size would reflect all post-acute phase research on mTBI conducted to
date, with the shared exclusion and inclusion parameters. Prior to pooling results, the data
from both studies had to be rendered compatible. Thus, their effect-size estimates were
corrected using the aforementioned technique (see the introduction to this section), to
minimize any bias related to sample size. A small positive effect size was generated, g =
0.11 {SD - 0.30). However, using a single-sample, one-tailed t test, significance of the
difference between this result and a 'no effect' result failed to reach criterion, / (16) =
1.52, p > .05, with the 95% confidence interval fractionally crossing the ^ = 0 demarcation
(see Figure 1).
The moderating effect of time (as a continuous variable) on neuropsychological out-
come was investigated. This was done for the overall estimate, and also for those domains
in which the effect had been significant: speed of processing, working memory/attention,
memory and executive function. For the latter comparison, data were compared across
samples (A'^ 27), instead of studies, since as mentioned, several studies included longitudinal

1 1

0.8 H

!> 0.4 j
I 0.2 \
u o4-

< -0.4 -j
-0.6 ]
-0.8 ^
u o
2 U

I
1 1
Neuropsychological Domain

Figure 1. Mean Weighted Effect Sizes of Mild TBI on Neuropsychological Functioning, both
Overall (in Acute and Post-Acute Phases) and in Specific Domains (95% Confidence Intervals
Displayed as Error Bars).
Note. WM/Att: Working memory/attention; PO: Perceptual organisation; VC; Verbal comprehen-
sion; Mot: Motor skills; Mem: memory; EF: Executive functioning; SoP: Speed of processing.
*Overall post-acute combined effect size is a combination of all available post-acute data on the
neuropsychological sequelae of mTBI, including data used in the preceding meta-analysis.
344 K. A. R. Frencham et al.

data for the same group of individuals, which permitted the calculation of effect sizes at
different times post injury. The moderating effect of time since injury was addressed by
observing the level of correlation between this variable and the magnitude of effect sizes
(Rosenthal, 1991; Zakzanis, 1998; Zakzanis, Graham, & Campbell, 2003). Addressing the
normality of the distributions of time since injury and effect size, we found the distribution
of effect sizes to be relatively normal, while time since injury was significantly positively
skewed. Non-parametric techniques were therefore chosen to address the relationship
between these factors.'^ Using Spearman's rank order correlation coefficient rho, there was
a significant correlation between time since injury and g, rJ^N = 27) - -0.47, p- .012, thus
time accounted for approximately 22% of the variance in the effect of mTBI. The pattern
of the relationship was such that effect size tended toward zero with increased time since
injury. Correlations were also calculated between time since injury and specific neuro-
psychological domains with significant effect sizes. While there were no significant
correlations involving working memory/attention, executive function, or speed of process-
ing, there was a significant correlation between time since injury and memory, rJ^N- 19) =
-0.60, p = .007.
Adopting a finer focus still on the moderating effect of time since injury on neuropsy-
chological performance, we addressed correlations within both the acute and post-acute
phases, to address whether the relationship was different between phases. A significant
correlation was shown for the acute phase, r^{N= 21) = -0.63, p = .002. Again, when bro-
ken down into specific neuropsychological domains, only memory revealed a significant
relationship with time since injury, r^{N =15) = - 0 . 6 4 , p - .O\.ln the post-acute phase, the
relationship between time since injury and effect size failed to reach significance, r^{N = 6) =
—0.26, p = .62, however this was likely reflective of the small number of samples available
for analysis.
Since the majority of samples related to the acute phase post-injury, we addressed
whether the relationship between time since injury and effect size could be further defined
within the first month post-injury. Again, effect size was found to tend towards zero with
increased days post-injury r^{N= 20) = -0.52, p = .020, with memory results also revealing a
significant result, rg{N = 14) = -0.72, p = .004. There were a limited number of samples
for data collected after one month (A^ = 7), and no significant relationship with time post
injury was found, r^ - -0.14, p - .76.
Finally, using the combination of data included in this and Binder et al.'s study, the
moderating effect of time since injury in the post-acute phase was examined. There was no
overall effect of time since injury on neuropsychological outcome in the post-acute phase.

Prevalence of neuropsychological Impairment. As in Binder et al.'s (1997) study, effect

size estimates were calculated to detennine the prevalence of neuropsychological impair-
ment that could be inferred to exist in the mTBI population. Results were transformed to
provide both the degree to which the control and rr\TBI populations would not overlap,
using Cohen's nonoverlap statistic, U, and the proportion of total variance in neuro-
psychological results that could be accounted for by group membership (control or mTBI),
using r^.

^To simplify interpretation, non-parametric statistics are reported for all relationships with time
since injury. However, time since injury was also transformed into a logarithmic function to counter-
act the strong positive skew of the distribution. All correlations using transformed data were found
to be comparable to the non-parametdc analyses reported in the body of this report.
 mTBI Research: Meta-Analysis Since 1995 345

Using Cohen's idealized distributions to estimate the U statistic (Cohen, 1988 p. 22),
it was demonstrated that in terms of an overall effect of mTBI on neuropsychological
functioning (and also for neuropsychological functioning in the acute phase post-injury)
21.3% of the mTBI distribution fell below the control distribution, or conversely 78.7% of
the mTBI distribution was shared with that of healthy controls, thus indicating a small
degree of discriminability between groups. Of the neuropsychological domains, the largest
degree of nonoverlap occurred with speed of processing measures, with the U statistic
indicating that 33% of the scores obtained by individuals with mTBI would not be
obtained by control individuals. Since this statistic is based on Cohen's d, and we used a
bias corrected version of d {g), the amount of nonoverlap may be a slight underestimate,
when directly compared to the results provided by Binder et al. (1997).
Bias corrected effect sizes were also converted into correlation coefficients, as they
were in the previous meta-analysis. As shown in Table 3, the overall r = 0.16, which trans-
lates to indicating that 16% of individuals had cognitive deficits in association with mTBI.
Addressing variance, r^, it is evident that group membership, of either the mTBI or control
group, accounts for 2.70% of the overall variance in neuropsychological results (2.50% of
the acute phase results), and approximately 5.20% of speed of processing results. See
Table 3 for further details regarding these calculations.

Discussion
The aim of this study was to follow-on from Binder et al.'s (1997) meta-analysis of the
neuropsychological effects of mild traumatic brain injury, and provide an indication of the
current state of research in the field, not only for the post-acute phase after injury, but for
all stages post-injury. Subsequent analysis included data from 17 publications. In line with
our hypotheses, we found that there was a small positive effect of mTBI on neuropsycho-
logical performance across all stages post-injury. In line with Binder et al.'s findings, we
also noted a significant effect in the area of working memory/attention and speed of pro-
cessing, domains combined under their attention and concentration label. Additionally, we
demonstrated small effects in the areas of memory and executive function. There was a
trend that these effects were larger than those reported in the previous meta-analysis, even
taking into account the differences in the statistics that were employed {d versus g). How-
ever, this likely reflects the influence of recent data collected in the extremely acute phase
(i.e., within the first 24 hours post-injury).
With respect to time post-injury, we found significant positive effects during the acute
phase, however while the effect size relating to the post-acute phase was positive, it failed to
reach significance. Likewise, the combination of our post-acute data with that reported by
Binder et al. (1997) yielded a small, nonsignificant effect. This effect (g = 0.11) was larger
than the previous (non bias-corrected) estimate (g = 0.07), however the associated error
meant that we were still unable to reject the null hypothesis of an effect size of zero.
In line with these results (and our hypotheses) we found that there was a significant
moderating effect of time post-injury on neuropsychological performance, such that the
effect of mTBI attenuated over time, and tended towards zero. Addressing neuropsychologi-
cal domains separately, this relationship was evident only for memory within the acute
phase. The correlation of combined effect sizes from this and the previous meta-analysis
with time post-injury revealed no significant relationship, supporting the view of previous
research that the main part of recovery after mTBI occurs within the first three months, with
any subsequent changes in performance being of limited statistical and clinical significance
(Binder et al., 1997; Dikmen et al., 1985; Dikmen et al., 1995; Ponsford et al., 2000).
346 K. A. R. Frencham et al.

Addressing the nature of the 17 studies included in this analysis, while they all
adhered to strict inclusion and exclusion criteria, they varied somewhat in many areas
including the types of mTBI and control groups that were used. In studies of long-term
impairment after mTBI, the reliance on self-report for injury details in the context of hos-
pital records being unavailable is not ideal, and may increase variability in neuropsycho-
logical results. Despite this, such studies have been viewed as vital to this research, in the
context of the low research output in this area (Bernstein, 1999).
Of course, poor methodology can cloud the interpretation of neuropsychological
results, making it difficult to state the role of head injury in any subsequent cognitive def-
icit (Binder, 1997). Non-head injury variables can lead to discrepancies in neuropsycho-
logical outcome during the post-acute phase. Recent research has shown that (1) the
effects of age and gender can mimic or mask the effects of TBI, and (2) the stringency of
exclusion criteria can affect neuropsychological effect sizes. For example, Dikmen eV al.
(2001) found that while individuals selected solely on the basis of a Glasgow Coma Scale
score of 13-15 had residual memory difficulties at one year post-mTBI, those selected
using more stringent criteria (which also specified normal imaging results, post traumatic
amnesia <24 hr, and time to follow commands <1 hr) performed comparably to controls.
Also, mTBI risk factors such as previous substance usage or previous head injuries can
also influence results. Thus, the use of poorly matched experimental and control groups
increases the likelihood that neuropsychological group differences will refiect premorbid
group differences rather than the effect of mTBI. All studies presently analyzed involved
control groups that were at least matched in terms of age and education, with the majority
also matched in terms of gender. The use of orthopedic control groups is also becoming
more common. As future studies continue in this vein, heeding the calls for improved
methodological control, it may become viable for subsequent meta-analyses to weight
studies in terms of quality, and assess the influence of these factors meta-analytically.
Our literature search spanning 8 years yielded only five studies that addressed the
post-acute phase. It appears that since Dikmen et al.'s (1995) well-designed study with its
large sample size, similar research has attenuated. While subsequent reviews have called
for further research into this area, little has been forthcoming (Bernstein, 1999). In the area
of long-term research, studies addressing outcome post 6 months have been noted to be
lacking with even fewer addressing outcome post one year. This lack of recent published
research on the post-acute effects of mTBI may also relate to the so-called 'file drawer'
problem, which refers to the tendency that papers reporting nonsignificant findings are
less likely to be published (see Rosenthal & Dimatteo, 2002). While the main contribution
of Dikmen et al.'s paper was a nonsignificant result for mTBI individuals, this was pre-
sented in the context of other significant results relating to a continuum of head injury
severity. It is possible that in this area of research many nonsignificant differences may be
unpublished.
While the inclusion of studies that reported on prospectively recruited participants
arguably reduced the bias in effect size, it also limited the number of studies available for
analysis, for example, all published studies that had used retrospective selection of partic-
ipants who were referred for neuropsychological assessment were excluded. When neu-
ropsychological data was addressed across cognitive domains, cumulative sample sizes
were quite substantial (A^> 330). However, since meta-analysis uses the study, rather than
the participant, as the unit of analysis, the number of cases was sometimes insufficient to
facilitate meaningful analyses, with associated large estimated errors of measurement.
Therefore, it is not clear whether Binder et al.'s (1997) findings of nonsignificant effects
in the areas of delayed recall and cognitive fiexibility, for example, refiect the absence of a
 mTBI Research: Meta-Analysis Since 1995 347

persistent deficit, or relate to sampling issues, since three or less studies were included in
these calculations. With further research in the field, including both individual and meta-
analytic studies, the effects of mTBI in specific domains could be clarified.
Another effect of pooling results to obtain an overall estimate, is that within domains,
significant results from tasks more sensitive to impairment post mTBI may be masked by
nonsignificant results from tasks less sensitive. For example, a significant effect of mTBI
on a demanding task such as the PASAT may be muted by nonsignificant results on digit
span, a task already mentioned as being insensitive to mTBI. Also, some studies employed
a general neuropsychological battery approach as opposed to administering measures
hypothesised to have optimal sensitivity to mTBI.
Bernstein (1999) reported that many long-term and follow-up studies use general neu-
ropsychological measures, which while they may be valid measures of attention and recall
for example, may not be sensitive to the subtle deficits that may persist. He called for the
development, standardization and evaluation of more demanding measures in the areas of
divided attention and infonnation processing speed. The continual use of insensitive mea-
sures (e.g., using digit span in the attention and concentration domain) may result in a high
number of false negative results (Cicerone, 1997), although the sensitivity is often unknown.
Future meta-analyses could address the effect of mTBI on widely used tasks, and provide a
guide to help researchers and clinicians choose tasks with optimal sensitivity to mTBI.
With regard to the fact that memory was the only neuropsychological domain that
was associated with time since injury, the contribution of early effects such as the "tempo-
rary amnesia" that can occur after mTBI must be considered (Binder, 1986). Standard
classification of mTBI includes the criterion that post-traumatic amnesia (PTA) cannot
exceed 24 hours (Mild Traumatic Brain Injury Committee, 1993). However, one study in
this review involved testing at 2 hours post injury, and numerous others involved testing at
1 day post injury (see Table 2). Given that many studies in the acute phase were conducted
within 24 hours of the injury, it is possible that the poor memory results for this phase, and
subsequent recovery may reflect a resolution of PTA in part.
Determination of period of PTA is also largely dependant on the measure that is used,
and certain measures wouJd assess that the end of PTA was earlier than others (Stuss et al.,
2000). Stuss et al. found that TBI individuals, who were classified as mild according to a
Glasgow Coma Scale score of 13-15, were actually more severe, as some of them did not
regain continuous memory until 15 days post-injury as measured by one PTA measure. In
these cases, poor memory performance within the first two weeks would arguably reflect
PTA, rather than residual memory deficits.
While our results reflect a small effect of mTBI in the acute phase, and a smaller non-
significant effect in the post-acute phase, it is possible that a sub-sample in the studies
summarized did have more severe cognitive deficits, and that the effect of their results has
been lost (in terms of statistical significance) by the pooling of data. While cognitive
recovery in the majority of patients does probably follow the pattern suggested by the
effect sizes reported, research suggests that a subgroup of approximately 15% may experi-
ence protracted cognitive recoveries (Alexander, 1995). An alternative interpretation of
results is that the subtle impairment, especially in the post-acute phase may actually reflect
a combination of 85% of individuals who do recover naturally, with the trend for slight
impairment remaining due to the effect of poorer outcome in a few cases with persistent
symptomatology. Dikmen et al. (1995) stated that while their overall conclusion was that
there were no persisting neuropsychological effects of mTBI, they could not rule out the
probability of a small sample of individuals having had more substantial impairments.
Additionally, after comparing the effects of prospective and clinical recruitment style on
348 K. A. R. Frencham et al.

neuropsychological outcome, Reitan and Wolfson (1999) questioned whether the latter
group was actually of greater clinical interest, since they were the individuals who would
present for neuropsychological intervention.
In conclusion, our study shows that measures of speed of processing, working mem-
ory and attention, memory, and executive function may be the most sensitive to dysfunc-
tion in individuals after mTBI, with memory being particularly affected in the acute phase,
and showing resolution with time since injury. Overall though, our findings echo the view
that the effects of mTBI on neuropsychological functioning are small, and in general reduce
to levels comparable with non-head injured individuals after the first three months. We reit-
erate the calls by previous researchers for future research to focus on outcome in the post-
acute phase, using large prospectively recruited samples, and incorporating tasks that are
proposed to be more cognitively demanding, and have more potential sensitivity to mTBI.

References
References marked with an asterisk indicate studies included in the meta-analysis.
Alexander, M. P. (1995). Mild traumatic brain injury: Pathophysiology, natural history, and clinical
management. Neurology, 45, 1253-1260.
Ardila, A., Glaeaon, L. M., & Rosselli, M. (1998). Toward a model of neuropsychological activity.
Neuropsychology Review, 8, 171-190.
*Batchelor, J., Harvey, A. G., & Bryant, R. A. (1995). Stroop Colour Word Test as a measure of
attentional deficit following mild head injury. Clinical Neuropsychologist, 9, 180-186.
*Bazarian, J. J., Wong, T., Hards, M., Leahy, N., Mookerjee, S., & Dombovy, M. (1999). Epidemi-
ology and predictors of post-concussive syndrome after minor head injury in an emergency popu-
lation. Bram/n/Mry. 13, 173-189.
Bernstein, D. M. (1999). Recovery from mild head injury. Brain Injury, 13, 151-172.
*Bemstein, D. M. (2002). Information processing difficulty long after self-reported concussion.
Journal of the International Neuropsychological Society, 8, 673-682.
•Binder, L. M. (1986). Persisting symptoms after mild head injury: A review of the postconcussive
syndrome. Journal of Clinical and Experimental Neuropsychology, 8, 323-346.
Binder, L. M. (1997). A review of mild head trauma. Part II: Clinical implications. Journal of Clinical
and Experimental Neuropsychology, 19, 432^57.
Binder, L., Rohling, M., & Larrabee, G. (1997). A review of mild head trauma. Part 1: Meta-analytic
review of neuropsychological studies. Journal of Clinical and Experimental Neuropsychology,
79,421^31.
Bleiberg, J., Kane, R. L., Reeves, D. L., Garmoe, W. S., & Halpem, E. (2000). Factor analysis of
computerised and traditional tests used in mild brain injury research. The Clinical Neuropsychol-
ogist, 14, 287-294.
Bohnen, N. I., Jolles, J., Twijnstra, A., Mellink, R., & Wijnen, G. (1995). Late neurobehavioral
symptoms after mild head injury. Brain Injury, 9, 27-33.
Bowden, S. C , Carstairs, J. R., & Shores, E. A. (1999). Confirmatory factor analysis of combined
Wechsler Adult Intelligence Scale-Revised and Wechsler Memory Scale-Revised scores in a
health community sample. Psychological Assessment, 11, 339-344.
Burton, D. B., Ryan, J. J., Axelrod, B. N., Schellenberger, T., & Richards, H. M. (2003). A confir-
matory factor analysis of the WMS-III in a clinical sample with cross validation in the standard-
ization sample. Archives of Clinical Neuropsychology, 18, 629-641.
Cicerone, K. D. (1997). Clinical sensitivity of four measures of attention to mild traumatic brain
injury. The Clinical Neuropsychologist, 11, 266-272.
Cohen, ]. (1988). Statistical power analysis for the behavioral sciences. (2 ed.). Hillsdale, NJ:
Lawrence Erlbaum.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 115-159.
 mTBI Research: Meta-Analysis Since 1995 349

*Collins, M., Grindel, S., Lovell, M., Dede, D., Moser, D., Phalin, B., Nogle, S., Wasik, M., Cordry,
D., Klotz Daugherty, M., Sears, S., Nicolette, G., Indelicato, P., & McKeag, D. (1999). Relation-
ship between concussion and neuropsychological performance in college football players. Journal
of the American Medical Association, 282.
Comerford, V. E., Geffen, G. M., May, C , Medland, S. E., & Geffen, L. B. (2002). A rapid screen of
the severity of mild traumatic brain injury. Journal of Clinical and Experimental Neuropsycho-
logy, 24,409^19.
Dikmen, S., & Levin, H. (1993). Methodological issues in the study of mild head injury. Journal of
Head Trauma Rehabilitation, 8, 30-37.
Dikmen, S., Machamer, J., & Temkin, N. (2001). Mild head injury: Facts and artifacts. Journal of
Clinical and Experimental Neuropsychology, 23, 729-738.
Dikmen, S. S., Machamer, J. E., Winn, H. R., & Temkin, N. R. (1995). Neuropsychological outcome
at 1-year post head injury. Neuropsychology, 9, 80-90.
Dikmen, S., McLean, A., & Temkin, N. (1986). Neuropsychological and psychosocial consequences
of minor head injury. Journal of Neurology, Neurosurgery & Psychiatry, 49, 1227-1232.
*Echemendia, R. J., Putukian, M., Mackin, R. S., Julian, L., & Shoss, N. (2001). Neuropsychologi-
cal test performance prior to and following sports-related mild traumatic brain injury. Clinical
Journal of Sport Medicine, II, 23-31.
Fisher, D. C , Ledbetter, M. F., Cohen, N. J., Marmor, D., & Tulsky, D. S. (2000). WAIS-III and
WMS-III profiles of mildly to severely brain-injured patients. Applied Neuropsychology, 7,
126-132.
•Goldstein, F. C , Levin, H. S., Goldman, W. P., Clark, A. N., & Kenehan Altonen, T. (2001).
Cognitive and neurobehavioral functioning after mild versus moderate traumatic brain injury in
older adults. Journal of the International Neuropsychological Society, 7, 373-383.
Hedges, L. V., & Olkin, I. (1985). Statistical Methods for Meta-Analysis. Orlando, Florida:
Academic Press.
*Hinton-Bayre, A., Geffen, G., & McFarland, K. (1997). Mild head injury and speed of information
processing: A prospective study of professional rugby league players. Journal of Clinical and
Experimental Psychology, 19, 275-289.
Hugenholtz, H., Stuss, D., Stetham, L., & Richard, M. (1988). How long does it take to recover from
a mild concussion? Neurosurgery, 22, 853-858.
Lees-Haley, P. R., Green, P., Rohling, M. L., Fox, D. D., & Allen, L. M. (2003). Commentary on
"The lesion(s) in mild traumatic brain injury: implications for clinical neuropsychology".
Archives of Clinical Neuropsychology, 585, 1-10.
*Macchiocci, S., Barth, J., Wayne, A., Rimel, R., & Jane, J. (1996). Neuropsychological functioning
and recovery after mild head injury in collegiate athletes. Neurosurgery, 39, 510-514.
*Mangels, J. A., Craik, F. 1. M., Levine, B., Schwartz, M. L., & Stuss, D. T. (2002). Effects of
divided attention on episodic memory in chronic traumatic brain injury: A function of severity
and strategy. Neuropsychologia, 40, 2369-2385.
•Mathias, J. L., & Coats, J. L. (1999). Emotional and cognitive sequelae to mild traumatic brain
injury. Journal of Clinical and Experimental Neuropsychology, 21, 200-215.
McAllister, T. W., & Arciniegas, D. (2002). Evaluation and treatment of postconcussive symptoms.
NeuroRehabilitation, 17, 265-283.
•McAllister, T. W., Sparling, M. B., Flashman, L. A., Guerin, S. J., Mamoudan, A. C , & Saykin, A.
J. (2001). Differential working memory load effects after mild traumatic brain injury. Neurolm-
age, 14.
McLean, A., Temkin, N. R., Dikmen, S. S., & Wyler, A. R. (1983). The behavioral sequelae of head
injury. Journal of Clinical Neuropsychology, 5, 361-376.
Mild Traumatic Brain Injury Committee, American Congress of Rehabilitation Medicine, Head
Injury Interdisciplinary Special Interest Group. (1993). Definition of mild traumatic brain injury.
Journal of Head Trauma Rehabilitation, 8, 86-87.
Miller, L. S., & Rohling, M. L. (2001). A statistical interpretative method for neuropsychological
lest d&t&. Neuropsychology Review, 11, 143-169.
350 K. A. R. Frencham et al.

Mittenberg, W., Canyock, E. M., Condit, D., & Patton, C. (2001). Treatment of post-concussion
syndrome following mild head injury. Joumal of Clinical and Experimental Neuropsychology,
23, 829-836.
Mittenberg, W., & Strauman, S. (2000). Diagnosis of mild head injury and the postconcussion syn-
drome. Journal of Head Trauma Rehabilitation, 15, 783-791.
O'Connor, T. A., & Bums, N. R. (2003). Inspection time and general speed of processing. Personal-
ity and Individual Differences, 35,113-724.
*Ponsford, J., Willmott, C , Rothwell, A., Cameron, P., Kelly, A., Nelms, R., Curran, C , & Ng, K.
(2000). Factors influencing outcome following mild traumatic brain injury in adults. Joumal of
the International Neuropsychological Society, 6, 568-579.
*Potter, D. D., Bassett, M. R. A., Jory, S. H., & Barrett, K. (2001). Changes in event-related
potentials in a three-stimulus auditory oddball task after mild head injury. Neuropsychologia, 37,
1464-1472.
Raskin, S. A., Mateer, C. A., & Tweeten, R. (1998). Neuropsychological assessment of individuals
with mild traumatic brain injury. The Clinical Neuropsychologist, 12, 21-30.
*Reitan, R. M., & Wolfson, D. (1999). The two faces of mild head injury. Archives of Clinical Neu-
ropsychology, 14, 191-202.
Reitan, R. M., & Wolfson. (2000). The neuropsychological similarities of mild and more severe
head injury. Neuropsychology, 15, 433^W2.
Rosenthal, R. (1991). Meta-analytic procedures for social research. (Rev. ed.). Newbury Park:
Sage.
Rosenthal, R., & Dimatteo, M. R. (2001). Meta-analysis: Recent developments in quantitative meth-
ods for literature reviews. Annual Review of Psychology, 52, 59-82.
Rosenthal, R., & Dimatteo, M. R. (2002). Meta-analysis. In H. Pashler & ]. Wixted (eds.), Stevens'
handbook of experimental psychology: Vol. 4. Methodology in experimental psychology (pp.
391-421). New York: Wiley.
Sangal, R. B., & Sangal, J. M. (1996). Closed head injury patients with mild cognitive complaints
without neurological or psychiatric findings have abnormal visual P300 latencies. Biological
Psychiatry, 39.
Satz, P., Alfano, M. S., Light, R., Morgenstem, H., Zaucha, K., Asamow, R. F., & Newton, S.
(1999). Persistent post-concussive syndrome: A proposed methodology and literature review to
determine the effects, if any, of mild head and other bodily injury. Joumal of Clinical & Experi-
mental Neuropsychology, 21, 620-628.
*Segalowitz, S. J., Bernstein, D. M., & Lawson, S. (2001). P300 event related potential decrements
in well-functioning university students with mild head injury. Brain and Cognition, 45, 342-356.
Stewart, D. P., Kaylor, J., & Koutanis, E. (1996). Cognitive deficits in presumed minor head-injured
patients. Academic Emergency Medicine, 3, 21-26.
Stuss, D. T., Binns, M. A., Camith, F. G., Levine, B., Brandys, C. F., Moulton, R. J., Snow, W. G.,
& Schwartz, M. L. (2000). Prediction of recovery of continuous memory after traumatic brain
injury. Neurology, 54, 1337-1344.
Stuss, D. T., Stetham, L. L., Hugenholtz, H., & Richard, M. T. (1989). Traumatic brain injury: A
comparison of three clinical tests, and analysis of recovery. The Clinical Neuropsychologist, 3,
145-156.
Tulsky, D. S., & Price, L. R. (2003). The joint WAIS-m and WMS-III factor structure: Development
and cross-validation of a six-factor model of cognitive functioning. Psychological Assessment, 15,
149-162.
van der Heidjen, P., & Donders, J. (2003). A confirmatory factor analysis of the WAIS-III in
patients with traumatic brain injury. Joumal of Clinical and Experimental Neuropsychology, 25,
59-65.
*Voller, B., Benke, T., Benedetto, K., Schnider, P., Auff, E., & Aichner, F. (1999). Neuropsycho-
logical, MRI and EEG findings after very mild traumatic brain injury. Brain Injury, 13, 821-827.
Wechsler, D. (1981). Wechsler Adult Intelligence Scale-revised. San Antonio, TX: The Psychological
Corporation.
 mTBI Research: Meta-Analysis Since 1995 351

Wechsler, D. (1987). Wechsler Memory Scale - revised. San Antonio, TX: The Psychological
Corporation.
Wechsler, D. (1997a). Wechsler Adult Intelligence Scale-third edition. San Antonio TX: The Psycho-
logical Corporation.
Wechsler, D. (1997b). Wechsler Memory Scale-third edition. San Antonio, TX: The Psychological
Corporation.
Zakzanis, K. K. (1998). Brain is related to behavior (p < .05)*. Joumal of Clinical and Experimental
Neuropsychology, 20, 419-427.
Zakzanis, K. K. (2001). Statistics tell the truth, the whole truth, and nothing but the truth: Formulae,
illustrative numerical examples, and heuristic interpretation of effect sizes for neuropsychological
researchers. Archives of Clinical Neuropsychology, 16, 653-667.
Zakzanis, K. K., Graham, S. J., & Campbell, Z. (2003). A meta-analysis of structural and functional
brain imaging in dementia of the Alzheimer's type: A neuroimaging profile. Neuropsychology
Review, 13, 1-18.