Controversies And Future Directions

For two decades, mild head injury has been the focus of intense neuropsychological study, and significant progress has been made in our understanding of this not so silent epidemic. On the other hand, continuing controversies fire our interest in this growing area of intense medical and forensic concern. Although we have validated animal models that help to elucidate the mechanism and pathophysiology of some mild head injuries, we are still uncertain as to the prevalence and extent of real neurological (histological) impairment, the persistence of functional deficits, and possible disability. Typical recovery curves for the majority of these mild head injury patients are generally well-known; however, the risk factors (individual vulnerability) that contribute to poor recovery have not been subjected to sufficient scrutiny to enable researchers to be certain about their relative or absolute effects on outcome. In the forensic arena, we continue to face questions about the presence of underlying neuropa-thology, the best way to measure premorbid functioning to accurately assess the extent of neurocognitive compromise, and the relationship of compromised function to the trauma. Furthermore, we must continue to examine the veracity of subjective complaints by considering base rates for symptoms in the normal population and resolving questions regarding test-taking effort, symptom validity and exaggeration, and malingering-like behavior.

New neuroimaging techniques are evolving that enhance our capacity to identify lesions, and interfacing these techniques with physiological assessment (e.g., glucose supply and demand) and neuropsycho-logical evaluation will certainly contribute to a better understanding of the mild head injury phenomenon. Use of formulas to estimate premorbid intellectual functioning and interviews with significant others and employers/teachers can help to establish pretrauma cognitive and functional abilities. Tests of symptom validity and effort have been developed; although controversial, they can provide important data in a comprehensive neuropsychological assessment model. Finally, in the sports arena, although return-to-play guidelines have been developed to protect athletes against possible SIS, these criteria remain controversial since they lack a sufficient empirical basis. Even with limited controlled studies, however, experts in the field have established conservative guidelines, based on medical/neuropsychological experience, for measuring severity of concussion and reduced-risk return to play.

The complexity of mild head injury issues and our lack of clear scientific data and knowledge have created discomfort in the scientific/clinical community. When faced with this complexity, there is a tendency to become reductionistic in order to limit uncertainty and increase comfort. This reductionism may lead to simple, and perhaps inaccurate, understandings and extreme positions (i.e., all mild head-injured patients are either malingerers or neurologi-cally devastated). These simple extremes can breed scientism (extreme scientific skepticism) or charlatanism with regard to views on the previously mentioned issues in mild head injury.

One of the solutions to these problems is to develop a level of comfort with the ambiguity and lack of knowledge that we have concerning mild head injury. Recognition of the complexity of these issues will allow us to embrace this as a challenge to our clinical and scientific skills. Finally, it will be important for us to confront these controversies in our scientific inquiries and to share our concerns about issues with our patients, colleagues, and the forensic system.

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