The frequently diverging evolution of different medical specialties is usually a natural and necessary aspect of medical progress. As more knowledge accrues related to devastating conditions such as traumatic brain injury (TBI), it is inevitable that physicians specialize and subspecialize to develop the talents and skills required for optimal patient care. Unfortunately, this often results in specialized knowledge becoming segregated in a small group of practitioners, and constant guard is required to prevent this. This special issue of The Journal of Head Trauma Rehabilitation was conceived as a way to attempt to bridge the gap that sometimes exists between neurological subspecialties such as epileptogy, movement disorders, and behavioral medicine and the specialty of physical medicine and rehabilitation, which is often charged with the primary responsibility of caring for survivors of TBI.

Two contributions deal with perhaps the best-studied long-term complication of moderate and severe traumatic brain injuries: posttraumatic epilepsy (PTE). The manuscript by Hudak et al aims to raise the awareness of the TBI community to advances in epilepsy diagnosis that have taken place over the past 10 years. PTE has long been recognized as a common and usually disabling complication of TBI, which is often refractory to the best current therapies. Largely because of advances in digital electroencephalography (EEG) and computerized algorithms to interpret EEG data, most academic medical centers (and quite a few other tertiary care hospitals) now have the ability to perform long-term video-EEG (VEEG) monitoring of patients with paroxysmal spells of altered consciousness or behavior. Although such evaluations are expensive, the contribution by Hudak and her group indicates that they frequently result in diagnoses that potentially impact therapy. Perhaps the most striking finding of this study was the high fraction of patients diagnosed with epileptic seizures and treated unsuccessfully with anti-epileptic drugs, who turned out to have psychogenic nonepileptic seizures after VEEG monitoring. Prospective studies on the usefulness and cost-effectiveness of such studies in survivors experiencing frequent, disabling seizures are the next step.

The contribution by Bushnik et al focuses on the psychosocial problems experienced by patients with PTE. This is a particularly relevant discussion given the findings of Hudak et al. Epileptologists have recently recognized that cryptogenic epilepsy results in significant cognitive and behavioral problems during the inter-ictal period, and the degree of psychosocial impairment is imperfectly correlated to the apparent severity of the epileptic seizures. Data presented and reviewed by Bushnik et al should stimulate new studies on this important issue.

O'Suilleabhain and Dewey summarize their experience with movement disorders after head injury. These are relatively common and probably an underdiagnosed and undertreated complication of moderate and severe TBI. The nosology of these movement disorders is often obscure to nonneurologists, but it is inevitably the first step toward accurate diagnosis and treatment. Unfortunately, the therapeutics of these commonly disabling disorders is still in its infancy, and there is great need for more research.

Finally, Hammond et al present their studies on long-term cognitive outcome after TBI. They take advantage of the multi-institutional TBI Model Systems database, a uniquely valuable (and expensively accrued) resource that is well-suited for this type of analysis. A significant fraction of patients continued to improve after one year, a fact that should be reassuring to patients and their families. Somewhat surprisingly, while the overall trend was for improvement between 1 and 5 years after TBI, a significant subset of patients (between 10% and 20%, depending on the measure chosen) appear to deteriorate after having initially improved. Discovery of environmental or genetic factors associated with long-term improvement or deterioration after TBI is critically important to developing novel therapies. The contribution by Hammond et al is an important early step in this field.

In the perfect world, neurologists would work closely with physiatrists, physical therapists, neurosurgeons, psychologists, and psychiatrists in the management of TBI. That is what our patients deserve. Unfortunately, the lack of resources and manpower frequently makes such a team approach difficult in many of our hospitals. Our hope is that the contributions in the special issue of JHTR will be of some assistance in fulfilling this task.