Does MTBI Really Exist

Awareness of mild traumatic brain injury (MTBI) was first noted in the literature more than 100 years ago wherein it was described as "a syndrome of multiple symptoms following minor or severe head injury." A century later, S. H. Auerbach coined the term "post-concussive syndrome," which could occur following a brain concussion. He noted that a brief loss of consciousness or no loss of consciousness, normal CT scans, and normal neurological examinations were typical. He also noted that "five principle factors" should be addressed in each person who has sustained a concussion, including, not only the possibility of brain injury, but also, head and neck injury, post-traumatic emotional stress, adverse affects of treatment, and secondary stress.

Historically, when there has appeared to be no evidence of structural damage to the brain and subjective complaints remain puzzling to the clinician, the tendency has been to question the psychiatric stability or the motives of the person. Suspicions have been further fueled by articles purporting "accident neurosis." The argument for "evidence of neuroticism" has included "lack of neurological signs" and a tendency for symptoms to occur in minor, versus severe, injuries, a greater incidence of MTBI in unskilled individuals, and a lack of post-concussion syndrome in sports. It has also been reported that there is an increased incidence of post-concussion syndrome when financial compensation is involved. Suspicion of secondary or financial gain has become a force that frequently prevents appropriate evaluation and treatment for those suffering from MTBI.

The majority of scientific literature supports the reality of MTBI. Studies have found that initial cognitive, emotional, and physical problems substantially diminish or resolve themselves within three months of the injury in approximately 70% of post-concussion cases. A single, uncomplicated, minor head injury typically results in no permanent, disabling, neurobehavioral impairment in most, but not all, MTBI cases. Other post-concussion cases have symptoms that linger for more than three months after the injury. The cumulative effect of repeated head injuries results in an increase in prolonged symptoms and inferior performance across a range of skills. Neuropsychological assessments of these cases have found impairments in memory, attention, and information-processing speed. Studies have concluded that head injuries with impaired consciousness, no matter how short, are capable of causing permanent, problematic consequences.

MTBI has been called a "silent epidemic" for many years. The media, which have promoted the idea that concussion is benign and that even severe TBI with coma eventually disappears, are now the venue for public recognition that concussions may carry considerable, long-term consequences. During the 1990's, this epidemic has become less silent because of the reporting of multiple concussions incurred by celebrity sports figures such as football players Joe Montana, Steve Young, and Troy Aikman. A number of prominent hockey stars have also incurred multiple head injuries.

As a result, in 1990 the Sports Medicine Committee of the Colorado Medical Society developed guidelines for an immediate field-side evaluation of concussion. Injuries are graded and a determination is made as to whether the person should return to play, be removed from the game, or seek further medical evaluation. The goal is to prevent repeated brain injuries, which may lead to severe brain damage or death. It is now estimated that approximately 800,000 persons in the U.S. suffer a mild traumatic brain injury each year. This estimate includes up to 80% or more of all persons with TBI seen in emergency departments. The true number of MTBI's per year is really not known due to the undocumented injured who are never seen in an emergency department. In addition, there are many persons hospitalized with more severe internal, spinal, and/or orthopedic injuries, leaving an MTBI totally undiagnosed or misdiagnosed.

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