Introduction

Mild head injury/concussion has become the single most important disorder in neuropsychological assessment practice in the United States in the past two decades, and it will likely remain a primary focus of clinical and research endeavors for years. Its dominance in neuroscientific study is predicated on several factors: prevalence and costs, morbidity, forensic relevance, societal sensitivity, and its controversial underpinnings.

It is difficult to estimate the prevalence of head injury in the United States each year since statistical analyses must rely on information generated through emergency room records, regional and state traumatic brain injury registries, and Centers for Disease Control data collection. Most of these systems are limited to monitoring moderate to severe disorders that require active medical assessment, intervention, hospitaliza-tion, and significant rehabilitation, which are often irrelevant in mild head injury cases. Fifty-five to 75% of all emergency room-reported head traumas are considered mild in nature, and the U.S. Census Bureau estimates the incidence of mild head injury to be approximately 1.3 million per year. This figure must be considered conservative since many mild head injuries occur with little or no loss of consciousness, require no medical treatment, have rapid and complete recovery, and therefore do not come to the attention of the medical/health care community. Traumatic brain injury has long been viewed as a major public health concern. Nevertheless, as a National Institutes of Health consensus development panel suggested, the likely society burden is even greater than previously conceptualized since mild head injury is frequently underdiagnosed. Costs associated with this disorder, when considering assessment, treatment, and lost work, are estimated to be in the billions of dollars each year.

Most studies indicate that the vast majority of individuals experiencing mild head injuries suffer little if any lasting neuropsychological deficits (morbidity), but there is a substantial group of patients who demonstrate deficits in neurocognitive functioning at 1 month postinjury and a small minority with longer lasting sequelae. These latter individuals may be diagnosed with a complicated mild head injury or postconcussion disorder/syndrome. These postconcussion disorder symptoms, even though usually temporary, can be devastating to the socioeconomic, emotional, interpersonal, and occupational functioning of these individuals, who have been termed the "miserable minority.''

Although the percentage of patients with mild head injury who experience more severe and longer lasting neurocognitive, medical, and emotional deficits appears to be small, the absolute number of patients in this postconcussion disorder group is likely quite large given the high overall incidence of mild head injury. Since these individuals are the exception to the rules of fast recovery and no permanent impairments, the veracity of their complaints and symptoms are often questioned, which argues for forensic considerations and solutions to personal injury compensation issues. In this context, comprehensive neurocognitive assessments and evaluation of effort and symptom validity are of critical importance. The financial implications for patients, expert medical/neuropsychological witnesses, and attorneys are substantial.

In recent years, society has become more aware and sensitive to the negative consequences of mild head injury through media exposure of celebrities, specifically athletes (particularly in professional football and hockey), who have experienced multiple concussions and whose careers have been threatened. Multiple concussive and subconcussive blows have also been linked to early development of degenerative neurologic conditions such as dementia puglisitca (boxer's encephalopathy), which has also afflicted high-profile athletes and brought sports such as boxing under greater scrutiny by safety commissions.

Finally, mild head injury has been the focus of considerable neuropsychological interest and research based on the many controversies that surround it and obfuscate our complete understanding. Controversial issues include the following:

1. Can we achieve a universally accepted definition?

2. Does mild head injury result in an identifiable neurologic injury/process?

3. What is the natural recovery curve for mild head injury and what roles do individual vulnerability and risk factors play in outcome?

4. What are the best methods for assessing mild head injury and effort/symptom validity in the forensic setting?

5. How can we best assess return to play criteria to avoid catastrophic outcome (second impact syndrome) in sports concussion?

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