There is a tremendous amount of confusion, controversy, and misinformation on the issue of MTBI, post-concussion syndrome (PCS), and whiplash injuries. On one side of the equation are physicians who believe that PCS is faked. In fact, in a recent survey of physicians' attitudes about PCS and whiplash, nearly 25% of family practice doctors and 23% of orthopedists reported that they questioned the authenticity of PCS. They were even more likely to question the validity of whiplash. On the other side is another group of physicians that strongly believe that the psychiatric and attentional difficulties after whiplash are a result of neurological damage to the brain.

 
Complicating the whole issue is the role of chronic pain. Pain as a result of tissue damage can also overlap with the symptoms found in patients with MTBI. Causal Relationship with Whiplash Accidents As we saw in the section on Biomechanics, tremendous forces can be applied to the body during a "mild" whiplash accident.
 

A 1996 study thoroughly summarized the causes of MTBI. MTBI needs only sufficient angular rotation of the head (without impact) to occur, although unreported head impact in MVA is common. Rear-end impact causes the head on the relaxed neck to be left behind momentarily. Front-end collision causes the head to be propelled forward. The head moves in a combination of planes (lateral and sagittal) and torsion around the tethering neck, which changes the brain's position and movement relative to the enclosing skull and often causes impact within the confining space. It is unpredictable which structures will be over-stressed and damaged. MTBI is determined by: the point of impact and its direction, velocity, and accelerating or decelerating effect; whether the neck is braced; whether the rotation is accelerated or steady; the relative strength of the head-neck junction; ratio of brain mass to head mass; duration of the impact impulse; and characteristics of the scalp. Intensive head movement causes contusions of the frontal and temporal poles from translational motion, most severe at the crests of gyri, but which can extend subcortically. Lacerations occur of the base of the brain from lateral or angular motion. Rotation in the coronal plane causes shearing of internal structures and penetrating blood vessels and tensile and compression strains. Head impact causes skull and brain deformation; energy directed inwardly coup, contre-coup and/or diffuse brain injury, and pressure gradients.

Patients receiving whiplash injury of the neck can also suffer from a cerebral concussion. If the head is thrown forward and then strikes the steering wheel or windshield, a head injury can occur. Also, mechanical deformation of the brain occurs during the acceleration/deceleration phase of the injury and a concussion can occur without the head actually striking anything. The brain lies relatively free within the skull. As the head moves, the brain, because of its inertia, tends to maintain its position within the vault. The moving skull may therefore concuss the brain either as it rotates backward or as it accelerates forward. Repeated studies have shown that a large percentage (a 1961 study showed 46%) of whiplash patients showed abnormal EEG readings, cerebral concussion, bleeding on the brain surface and upper spinal cord and/or blood pockets in the space(s) between the skull and brain.

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