Talk:Post-concussion syndrome

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This article was the subject of a Wiki Education Foundation-supported course assignment, between 2 September 2021 and 14 December 2021. Further details are available on the course page. Student editor(s): Fanman1999. Peer reviewers: Lexinr.

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Wiki Education Foundation-supported course assignment

This article was the subject of a Wiki Education Foundation-supported course assignment, between 15 January 2019 and 9 May 2019. Further details are available on the course page. Student editor(s): Shannonballard.

Above undated message substituted from Template:Dashboard.wikiedu.org assignment by PrimeBOT (talk) 07:01, 17 January 2022 (UTC)

Heading

[1] Revert first and ask questions later? Is that policy? 129.7.254.33 06:19, 23 October 2007 (UTC)

Well, you're right that that's not the normal practice. But in this case, a couple things: first, the info was put in front of a reference, so it made it look like the reference said that, which it didn't. Second, there's no reference for that information. According to the very fundamental verifiability policy, it's the responsibility of the person who wants to add the info to provide a reference for it. So if you want to add the info, all you need to do is find a source for it and cite it. delldot on a public computer talk 05:16, 13 January 2008 (UTC)

My views

Hi!

Usually in talk pages of articles in Wikipedia, no one is addressed in particular. In this case it's different. I know the one I am addressing has actually nurtured the article since more than last 20 months.

So, hi dilldot (on public computer)!

As I started reading your article, it just occurred to me that I should see the page history. I was amazed and overwhelmed to see the entire article being edited singlehandedly by you. Congratulations! I also happened to see your user page, Wikipedia (and neurology, in particular) seems to keep you really busy. I really feel overwhelmed by users who have put in as much effort as you. Well, I have just gone through "your" article

• I thought the lead is a bit longer than required. Especially information pertaining to treatment and prognosis should have been restricted. I know though some would disagree with this. But may be leaving that out would leave something to be looked forward to in the article. Moreover, with all the information given in it, it is looking more like a summary rather than a lead, which should be an "initiation" into the article and not the conclusion. Rather some information could be given about the salient features of concussion, viz., that the diagnosis is only on functional bases and that no structural changes are found.

• Shortened slightly. There's disagreement on the physiological basis of concussion, I think I'll leave discussion of that to concussion. delldot talk 20:31, 7 May 2008 (UTC)

• "The prevalence of PCS is not well known and varies based on the definition of the syndrome": I believe "prevalence" should be substituted with "incidence" as it is the latter that incorporates the concept of population at risk (in this case those who'd have met with TBI) as it would make better sense in knowing the incidence of PCS following TBI than knowing the prevalence in an entire population. This term (incidence, if and when incorporated) should also be wikilinked as it is an epidemiological term and not to be used loosely.

• I just went ahead and removed that sentence, it wasn't adding much anyway, and the prevalence thing is dealt with later. delldot on a public computer talk 04:45, 8 May 2008 (UTC)

• Well, this is a personal doubt, not necessarily pertinent to the article, but you've referred to primary and secondary apathy as distinct from primary (endogenous) and secondary (exogenous/reactive) depression? I hope I have used the correct terminology.

• Uh oh, not sure about this one, I may have introduced distortions. How's this simplification? "Apathy, or lack of motivation, another common symptom in PCS, may result directly from the syndrome or may be secondary to depression." delldot talk 20:59, 7 May 2008 (UTC)

• Would it be better to change the heading from "Cognition" to "Higher (mental) functions" as I am not completely sure if memory and language (as distinct from speech) would qualify as cognitive functions.

• Good point. So changed. delldot talk 20:16, 7 May 2008 (UTC)

• Under the heading "Controversy", "physiogenesis" has been wikilinked--firstly I haven't come across the term. It might be used specifically in neurology or psychology, and secondly, there's no entry in Wikipedia against such a term, so it might better to either remove the wikilink and explain the term there itself (which you have done partly), or start an article with that name. I have following suggestion though: "The debate has been referred to as 'psychogenesis versus physiogenesis', because there is question about how much of a role in the syndrome is played by organic factors involving brain dysfunction and how much is played by psychological factors."--->"The debate has been referred to as 'psychogenesis versus physiogenesis', because there is question about how much contribution is respectively made by psychological factors as aginst organic factors involving brain dysfunction. Any way, "how much role played by" was sounding a bit weird.

• Explained, wikilink removed. Implemented the wording suggestion, thanks! delldot talk 20:16, 7 May 2008 (UTC)

• It'd be better to change the heading to "Possible causes" rather that "Possible etiologies"--Wikipedia is meant for common man, after all--something I'm learning somewhat the harder way nowadays!

• Another good point. delldot talk 20:16, 7 May 2008 (UTC)

• "Proponents of the view that PCS has a physiological basis point to..." The word could be changed to physical or organic, or may be physical. Calling a mechanism leading to a disorder sounds just a bit inappropriate.

• Done. delldot talk 20:16, 7 May 2008 (UTC)

• "However, not all people with PPCS have abnormalities on imaging, and abnormalities in imaging such as fMRI, PET, and SPECT could result from comorbid conditions such as...could be changed to other contributing conditions that would make it less complicated for a common person to understand. Of course, if you are fond of the word, you could put it in braces (comorbid) like this ;)

• Done. delldot talk 20:31, 7 May 2008 (UTC)

• Malingering could be explained in short in the first line of the paragraph.

• Reworded with explanation. delldot talk 20:31, 7 May 2008 (UTC)

• It'd be nice to include some short description of cognitive behavioral therapy in the section dealing with "Psychotherapy"

• Done. delldot talk 20:31, 7 May 2008 (UTC)

• Again in "Epidemiology", the term "prevalence" has been used instead of incidence.

• I think the deal is that we're talking about how many people have it by a given amount of time after the injury; the sentence in the source I'm citing is, "Prevalence rates at three

months post-injury have been found to range from 24–84%". Reworded for clarification. delldot talk 21:12, 7 May 2008 (UTC)

I hope I haven't been very harsh in my review.

You must have noticed the entry of an article that I'd created--polyclonal response right below the entry of your nomination for good article. I'd be happy if you could go through it and share some views on it.

Best wishes for "GA" nomination.

Regards.

Ketan Panchal, MBBS (talk) 18:02, 7 May 2008 (UTC)

Thanks so much for the kind words and thorough review! Certainly not harsh in the least, very sensible. I've made a few changes and will make more tonight. delldot talk 20:16, 7 May 2008 (UTC)

Headache picture

I'm not convinced that a photo of a woman massaging her temples while reading in the library is a helpful representation in this article. Axl (talk) 09:24, 17 May 2008 (UTC)

Yeah, I admit it's definitely reaching. I've been having trouble thinking of how to illustrate this article: It's the most frustratingly intangible thing I've ever written about! I can remove the crappy picture. Any other ideas for images? delldot on a public computer talk 09:35, 17 May 2008 (UTC)

Hmm, I just had a look on Wikimedia Commons, and your young lady is the closest match. I'll keep looking. Axl (talk) 09:42, 17 May 2008 (UTC)

Aww, thank you Axl. Yeah, good luck on that, I didn't have any. :P If you think of any ideas for any images (i.e. not just for the symptoms section), definitely let me know. delldot on a public computer talk 09:45, 17 May 2008 (UTC)

[2] What do you think? Still reaching too much? delldot on a public computer talk 09:57, 17 May 2008 (UTC)

Unfortunately I couldn't find any appropriate headache pictures. Sigh However the EEG picture looks reasonable for this article. Axl (talk) 10:34, 24 May 2008 (UTC)

GA Review

This review is transcluded from Talk:Post-concussion syndrome/GA1. The edit link for this section can be used to add comments to the review. This is a very good article that does a great job of presenting a controversial topic, but it still has one major issue that prevents me from passing it—the prose. Here are a few suggestions for the lead:

• “Post-concussion syndrome, also known as postconcussive syndrome or PCS, is a set of symptoms that a person may experience for weeks, months, or occasionally even years after a concussion; a mild form of traumatic brain injury (TBI).” This sentence is ambiguous; it is unclear whether PCS or concussion is a form of traumatic brain injury.

• Better? delldot on a public computer talk 00:38, 2 June 2008 (UTC)

• "PCS may also occur in moderate and severe TBI." Holy TLA syndrome, starting here and persisting throughout the article. It’s OK to repeat the whole term once in a while, particularly when there are other acronyms close by.

• Done delldot on a public computer talk 00:38, 2 June 2008 (UTC)

• “Symptoms of PCS, the most common entity to be diagnosed after TBI...” —Does this mean “the entity most commonly diagnosed in someone following TBI”, or “the second most common diagnosis after TBI”, as in a “top ten” list of diagnoses in those presenting to a neurology service? :)

• Good catch, is this less ambiguous? delldot on a public computer talk 00:38, 2 June 2008 (UTC)

• “...may occur in 38–80% of mild head injury sufferers.” Per WP:MEDMOS, please avoid wording such as “sufferers” or “patients”. There are many substitutes you could use without sounding repetitive—“people who have sustained mild head injury”, “those with mild head injury”, “38–80% of mild head injury cases”...

• Done delldot on a public computer talk 00:38, 2 June 2008 (UTC)

• “Though there is no treatment for PCS itself, symptoms can be treated with medications and other therapies such as education and physical and behavioral therapy. The majority of PCS cases go away after a period of time.” What sort of education? Education about PCS and its prognosis? You may want to expand on this a little, e.g. “physical symptoms may be treated with medication and physical therapy, and cognitive ones may benefit from behavioral therapy.”

• The suggestion makes sense, but I'd have to find that explicitly in a source to put it in the article. Does the fix I used work? delldot on a public computer talk 00:38, 2 June 2008 (UTC)

I'll add comments on the remainder of the article later. Best, Fvasconcellos (t·c) 00:10, 2 June 2008 (UTC)

Many thanks for the very close attention! Let me know if there are still problems with my fixes. I look forward to seeing your review of the rest of the article! delldot on a public computer talk 00:38, 2 June 2008 (UTC)

Looking good so far, thank you for the prompt responses. Now, for some more! Let's take it from the bottom, with "History" :)

• "The controversy surrounding the cause of PCS was started in 1866 when Erichsen published a paper about persisting symptoms after MTBI." I don't think the term "mild traumatic brain injury" was used in the 1860s. Is it used in the source?
• "The idea of the complex of post-concussion symptoms..." How about "The idea that this set of symptoms forms/constitutes a distinct entity..."? Just a thought.
• "Later, the idea... was suggested by Charcot." Is this Jean-Martin Charcot? I think we have an article on that guy somewhere.. :)

More to come. Don't change the channel! Fvasconcellos (t·c) 15:56, 2 June 2008 (UTC)

done these -- Gurch (talk) 22:36, 2 June 2008 (UTC)

Thanks a ton gurch, you're the best. delldot talk 05:55, 3 June 2008 (UTC)

OK, here we go:

• In "Symptoms":
  • "About 10% of people with PCS are sensitive to noise or light..." Develop sensitivity/become sensitive to noise or light, maybe? Or maybe not, if you think that would make the sentence ambiguous. A piped links to photophobia would be nice.

    Rearranged a little to get the link in --Gurch (talk)

  • "One study found that while sufferers of chronic pain without TBI do report post-concussion symptoms..." How about symptoms similar to those found after a concussion/those of PCS"?

    Changed to something along the lines of the latter --Gurch (talk)

  • "...they report fewer symptoms related to memory, slowed thinking, and sensitivity to noise and light than MTBI sufferers do." No "sufferers", please, and keep "patients" to a minimum :)

    Changed by delldot --Gurch (talk)

• In "Possible causes":
  • "Factors that may cause PPCS may include physiological, psychological, or psychosocial factors..." Why are we starting with PPCS? Wouldn't it be better to lead with a brief discussion of the factors behind symptoms occurring shortly after trauma—after all, their etiology seems far less controversial—and then move on to the complex mix of factors associated with PPCS? "Factors... factors" is redundant.

    Removed the redundant 'factors', haven't done anything else yet --Gurch (talk)

    Rearranged a bit to put the more general info in front. Do you think it actually needs more content, or is this enough? delldot on a public computer talk 00:46, 4 June 2008 (UTC)

    The prose is reading much more clearly now, and I think the content is just fine. Excellent work :) Fvasconcellos (t·c) 01:20, 4 June 2008 (UTC)

  • "...whether symptoms are being exaggerated or feigned, for example for financial gain." Malingering hasn't been discussed yet; I'd drop "for financial gain" altogether and leave it to the later section on malingering.

    Was thinking of doing this before. Removed --Gurch (talk)

  • "Electroencephalograms, while usually normal..." ...usually normal in people with PCS?

    Changed by delldot

  • "The presence of PCS symptoms may be due to a combination of factors, including psychological and physiological ones." Could you... jazz this up a little? As is, it just seems redundant to the introduction of "Possible causes". Sorry for being vague here :)

    I did some rearranging and this sentence ended up very different. Is this ok? delldot on a public computer talk 01:47, 4 June 2008 (UTC)

  • "Proponents of the view that PCS has a physical or organic basis point to findings that concussed people score lower than expected on standardized tests of cognitive function." Wouldn't a decline in cognitive function be expected immediately after a concussion? If the source is talking about a persistent decline in scores, the sentence should be reworded.

    The finding that cognitive scores show deficits (in whatever time frame) is used to support the idea that neurocognitive dysfunction is occurring. Changed the wording, does this fix it? delldot on a public computer talk 02:10, 4 June 2008 (UTC)

  • "Studies have shown that people with PPCS score lower than controls on neuropsychological tests that measure attention, verbal learning, reasoning, and information processing." Would a link to information processing be appropriate here?

    Done, probably by gurch. delldot on a public computer talk 01:47, 4 June 2008 (UTC)

  • "...one study found that cognitive and physical symptoms were not predicted by the adjustment of parents and family members after the injury..." Adjustment?

    Better? delldot on a public computer talk 02:10, 4 June 2008 (UTC)

• In "Psychological":
  • "Symptoms in PCS may be due to psychological or social factors, such as expectations that these symptoms will occur." Again, this seems redundant—I'd much rather have the section start with the sentence that follows ("It has been convincingly shown..."). Do you think you can work "...such as expectations that these symptoms will occur" into another portion of the paragraph?

    Done. [[[user:delldot on a public computer|delldot on a public computer]] talk 05:39, 4 June 2008 (UTC)

  • "Setbacks related to the injury, for example problems with physical, work, or social functioning..." How about Setbacks related to the injury, such as problems with physical or social functioning or [decreased/impaired/altered...] work performance? That would sound better IMHO (if the reference supports it, of course).

    The ref doesn't really specify what kind of setbacks occur at work. Is the slight rewording I did ok? delldot on a public computer talk 06:21, 4 June 2008 (UTC)

• In "Malingering":
  • "Additionally, people with more severe symptoms may be more likely to sue, all other things being equal." Seems obvious, but a reference would be nice :) I've piped a link to ceteris paribus.

    Tough one. I'm not sure I'm going to be able to find this in a ref, I haven't seen it before. An anon added it I think, it might be OR. I think I'll remove it as such but keep looking for a source for it. delldot on a public computer talk 06:21, 4 June 2008 (UTC)

Not done yet... :) Fvasconcellos (t·c) 15:00, 3 June 2008 (UTC)

Brilliant suggestions FV, thanks again for the effort you're putting in to giving this a thorough and thoughtful review. I'll hopefully have time to finish this up at work tonight, if they don't make me work too hard. ;) delldot talk 22:02, 3 June 2008 (UTC)

Thank you for the brilliant improvements to match the suggestions ;) I'll go over the rest of the article more thoroughly tonight (a quick read doesn't show much else needing work) and leave my final comments. Fvasconcellos (t·c) 15:45, 4 June 2008 (UTC)

Section break

OK, final comments:

• Under "Diagnosis":
  • "The ICD-10 first proposed a set of diagnostic criteria for PCS in 1992." This is a nitpick, but the ICD-10 doesn't really propose anything. The WHO may propose a set of diagnostic criteria, or it may be codified in the ICD-10.

    How's established? delldot on a public computer talk 03:09, 5 June 2008 (UTC)

  • Very impressive work on the table, few articles make good use of them.

    *Bows* ;) delldot on a public computer talk 08:57, 5 June 2008 (UTC)

  • Do you think a very brief (single-sentence or even parenthetical) description of the tests named in the last paragraph can be added?

    Is this enough? delldot on a public computer talk 08:57, 5 June 2008 (UTC)

  • "Because of the similarities to other conditions, such as depression, there is a risk that PCS may be misdiagnosed" Hmmm... any condition may be misdiagnosed, and few, if any, could ever be considered so distinctive as to not share characteristics of other diseases :) Do any of the cited sources expand on misdiagnosis, e.g. noting a "significant" risk of misdiagnosis, or that PCS is a "commonly misdiagnosed condition"? I'm basically looking for any qualifier that would assert why this risk is worth noting, and make this a less generic statement.

    I had originally intended this to be a kind of introductory sentence, to bring up the idea of differential diagnosis. Looking at the rest of the paragraph, it seemed redundant so I took it out. Is it too abrupt without it? delldot on a public computer talk 09:39, 5 June 2008 (UTC)

    Added "PCS, which shares symptoms with a variety of other conditions, is highly likely to be misdiagnosed in people with these conditions." delldot on a public computer talk 10:44, 5 June 2008 (UTC)

• In "Treatment":
  • "There is no scientifically established treatment for PCS, so the syndrome is usually not treated, though specific symptoms can be targeted." This is a really circular sentence. How about something really succinct, along the lines of Post-concussion syndrome is usually not treated, though specific symptoms can be addressed; for example...

    Done. delldot on a public computer talk 10:44, 5 June 2008 (UTC)

  • "Though no pharmacological treatments exist especially for PCS, doctors may prescribe medications used for symptoms that also occur in other conditions" Since the next sentences claim that medications should be avoided if possible, how about appending if necessary to "doctors may prescribe..."?

    Done. delldot on a public computer talk 03:09, 5 June 2008 (UTC)

  • "Side effects of medications..." Side effects should link to adverse drug reaction.

    Done. delldot on a public computer talk 03:09, 5 June 2008 (UTC)

  • "About 40% of PCS patients are referred to psychological consultation." Is this too few? A lot? Why are they referred? Is this meant to imply that some patients suffer deficits significant enough to warrant psychological treatment, is it meant to imply that more patients should get psychological support, or is it a simple statement of fact?

    It's a simple statement of fact, just a statistic. I rearranged it a little, does the context help? delldot on a public computer talk 11:20, 5 June 2008 (UTC)

  • "One study found that PCS patients who were coached to return to activities gradually, told what symptoms to expect, and trained how to manage them had a reduction in symptoms compared to a control group of uninjured people." Is my grasp on scientific methodology completely lost at this hour, or should this be a control group of PCS patients who received no such education?

    No, you're not nuts, this is actually a methodological flaw of a lot of PCS studies. Weird, huh? Don't know whether I should take out info from these studies, or maybe make it explicit that these studies have received criticism. delldot on a public computer talk 11:20, 5 June 2008 (UTC)

• In "Prognosis":
  • "Symptoms are largely gone in about half of people with concussion by one month after the injury and about two thirds by three months." How about Symptoms are largely gone in about half of people with concussion one month after the injury, and two thirds of people with minor head trauma are symptom-free within three months.

    Done. delldot on a public computer talk 03:09, 5 June 2008 (UTC)

  • "It is commonly believed that 15% of patients still suffer PCS 12 months after the injury, but this figure may be an overestimate because it is based on people admitted to a hospital." Is this actually commonly believed, e.g. mentioned frequently in the literature/part of neurology "lore"? :) "12 months" could me simply changed to "a year".

    That's exactly right--in fact, the ref I just switched to actually uses the words "clinical lore". Reworded and added a bit of info from new source, year thing done. delldot on a public computer talk 06:12, 5 June 2008 (UTC)

  • "At least in children, the way in which people cope with the injury after it occurs may have more of an impact than factors that existed prior to the injury." How about just The way in which children...?

    Done. delldot on a public computer talk 08:57, 5 June 2008 (UTC)

• Under "Epidemiology":
  • "Since PCS by definition only exists in people who have suffered a head injury, demographics and risk factors are similar to those for head injury; for example, young adults are at higher risk than others for receiving head injury" , and, consequently, of developing PCS?

    Done. delldot on a public computer talk 03:26, 5 June 2008 (UTC)

  • "Clinical research has found higher rates of PCS in children with TBI than in those with injuries to other parts of the body, and that PCS is more common in anxious children." Perhaps change PCS to post-concussion symptoms to avoid ambiguity?

    Done. delldot on a public computer talk 03:26, 5 June 2008 (UTC)

  • "Symptoms in children are similar to those in adults, but children exhibit fewer symptoms than do their adult counterparts." Counterparts seems more than a little awkward here. "PCS is rare in young children." How rare? How young? Rarer than in older children? Any more or less controversial a diagnosis in younger kids? Sorry for the third degree, you don't need to expand this—it would just be nice ;)

    No problem, good suggestions. Fixed the counterparts thing, I'll try to find more on the condition in children tonight. delldot on a public computer talk 13:36, 5 June 2008 (UTC)

Well, that's it. Please don't take it personally if any of the above was inordinately harsh, or unnecessary; I just like to know that I did my best to ensure that a Good Article is actually a good article :) Best, Fvasconcellos (t·c) 02:35, 5 June 2008 (UTC)

Not too harsh at all, everything is very reasonable and on-point. I certainly appreciate yout taking the extra time to do a thorough and high-quality review. I'll work on these and get them done as soon as I can. delldot on a public computer talk 08:57, 5 June 2008 (UTC)

OK, then. Thank you for your willingness to respond to each point, and for the excellent work. Since there is no deadline and no such thing as a perfect article, you may keep continue to improve and expand the article well after I've passed it as a GA—which I have just done. Congratulations, and don't forget to let me know when it's up at FAC ;) Best, Fvasconcellos (t·c) 14:31, 5 June 2008 (UTC)

redirect from Chronic Brain Syndrome

I'm not sure this redirect is quite right -- I've also seen chronic brain syndrome used as a term for dementia in general (here for example) -- maybe a disambiguation page?Matt Kurz (talk) 19:14, 1 June 2009 (UTC)

Shellshock

The opening sentence of the article currently says that post-concussion syndrome was "historically known as shellshock" - I've removed that because afaik it seems whoever wrote that was thinking of post-traumatic stress, but thought I'd mention it here in case I'm wrong. :-) 86.131.92.88 (talk) 17:20, 5 November 2009 (UTC)

That was me who added it, and no I didn't get confused with PTSD :-) Have a look at PMID 17974926 for more info on this. --sciencewatcher (talk) 18:28, 5 November 2009 (UTC)

I also disagree with the statement that shell shock was an old term for PCS. The two terms are not synonymous. Shell shock was a term that first described a set of symptoms affecting soldiers in the First World War. PCS describes similar symptoms that can occur in anyone who has previously sustained a mild Traumatic Brain Injury (TBI). The mild TBI, prior to PCS, may have been sustained in any scenario (including, but definitely not limited to soldiers in combat). It's true that mild TBI was/is one of the perceived causes of shell shock (tbi in the form of shock waves from explosions affecting the brain). I also observe that post-traumatic stress can be a factor in both PCS and shell shock, however, that is not what you have said. Shell shock and PCS are related but not in the way you have insinuated. The first sentence of the article should define the term PCS and mention any synonyms. It is not appropriate to use the term shell shock to define PCS, though it would be appropriate to say that PCS is now considered a possible contributing factor in shell shock. 80.1.55.240 (talk) 21:04, 30 November 2013 (UTC)

Image

This article could use an image in the lead. Not sure what but... Doc James (talk · contribs · email) 03:02, 19 December 2009 (UTC)

post-traumatic headache syndrome?

Should not this be mentioned? As a layperson I see no clear differences.

~~ —Preceding unsigned comment added by Elemming (talk • contribs) 07:43, 26 October 2010 (UTC)

It should be mentioned if there is a link. However I did a google scholar search and only found 5 hits for 'post-traumatic headache syndrome' and none seemed to mention post-concussion syndrome. --sciencewatcher (talk) 13:34, 26 October 2010 (UTC)

References

Malingering

This passage is either intentionally misleading, or not precise enough in what it entails. For instance, severity of symptoms and likelihood of litigation are profoundly confounded variables and this is not well documented in the section. It seems that the passage is trying to make the point that because the disorder is not well understood it is likely abused by attorneys and victims of trauma, but never makes this point explicit, and rather relies on "statistical trickery" (not necessarily on the part of the author) to make the claim that because litigation and severity of symptoms are positively correlated that it is likely that litigation increases the severity of these symptoms, which is undecidable. It should either be directly explained that the relationship is causal, or interpreted as an open question, for which the only evidence is speculation. I will only edit this section out once more, and after that I will leave it to the rest of the community.

108.67.152.150 (talk) 08:11, 17 November 2010 (UTC)

when this section was deleted, one reference to malingering remained in the article. i linked that instance to the wiki article and also put in a very short definition of it in the text.

additionally, although i haven't gone thru the article's history to read the section that was removed (more than once, apparently), i tend to agree that an entire section on it should not be in this article. for one thing, this article seems to have been primarily written/edited about 2008. there has been more study on this very question since then. (i'm going to add a new Talk section about this.) if there is no section on "malingering" on most of the wiki articles on diseases and disorders, then i don't see why there should be one for this particular disorder/syndrome. (as i noted, there has been further research.)Colbey84 (talk) 08:26, 27 November 2016 (UTC)

Post-concussion syndrome and tau protein

Does brain injury link NFL players, wounded warriors?, CNN, Stephanie Smith, May 16, 2012.

“ . . CTE derives some of its notoriety from cases like that of Dave Duerson, a former Chicago Bear who shot himself in the chest in 2011 and was found to have dense clusters of tau protein permeating his brain and spinal cord.

“Tau is released by neurons when the brain is rocked inside the skull and, when unleashed, tends to lodge in parts of the brain responsible for memory, judgment and mood.

“The same group of researchers at the Boston University School of Medicine who examined Duerson's brain excised thin slivers of brain tissue from four U.S. veterans who died suddenly. Those were compared to tissue taken from two other groups: three amateur football players and a professional wrestler with a history of concussion; and a control group of four young people who died suddenly with no history of concussion. . ”

" . . What the mouse study does is ask a very specific question lingering in the field, which is, can exposure to even a single blast result in brain damage that persists and possibly progresses?" Goldstein said.

“To answer that question, researchers exposed a group of mice to blast winds -- some up to 330 miles per hour -- that mimic what might occur in the wake of an IED blast and compared them to a group of mice the same age, living in the same conditions, that were not exposed to blasts.

“The effect of the blast is described by researchers as a "bobblehead effect," the brain rocking back and forth inside the skull, similar to what happens during a concussion, and in some people it leads to brain damage.

“Two weeks after exposure to the blast, brain tissue in mice showed evidence of tau protein. . ”

I don't think our article currently discusses tau protein at all, and we probably should. FriendlyRiverOtter (talk) 18:47, 23 May 2012 (UTC)

...but not from the CNN website. See WP:MEDRS. --sciencewatcher (talk) 22:39, 23 May 2012 (UTC)

It's a reputable news agency, right? And it's in terms the lay person can understand. I generally prefer a variety of sources. FriendlyRiverOtter (talk) 22:48, 23 May 2012 (UTC)

Yes, but it fails WP:MEDRS - we shouldn't be using it for medical statements. Instead we should be relying on reviews in peer-reviewed journals. I had a quick look on google scholar, and the reviews seem to say that tau protein is not useful for diagnosing PCS. --sciencewatcher (talk) 23:11, 23 May 2012 (UTC)

Tau has been found in the autopsies of a number of football players. So, if the doctor has to wait for the patient to die, no, it probably isn't useful as a diagnostic tool. But it may be part of the physiological explanation of how repeated (even minor) concussions can cause real damage.

And I guess this might be a good time to point out, no, I am not a doctor, nor am I a medical researcher. I'm just someone of average intelligence interested in the topic. FriendlyRiverOtter (talk) 23:25, 23 May 2012 (UTC)

from . .

Wikipedia:Identifying reliable sources (medicine)

“ . . biomedical information in articles be based on reliable, third-party, published sources and accurately reflect current medical knowledge.

“Ideal sources for such content includes general or systematic reviews published in reputable medical journals, academic and professional books written by experts in the relevant field and from a respected publisher, and medical guidelines or position statements from nationally or internationally recognised expert bodies. . ”

Notice the first part, "reliable, third-party," that would include medical journalists. And the second part, the "Ideal sources" which include "systematic reviews" in medical journals and professional books written "by experts," well, it all depends on how good the expert is at writing! He or she may not be intending the general, nonspecialist audience at all. Again, we might be better off with a good medical journalist who's not afraid to put it in English. And the last part, "recognised expert bodies," that may be medical orthodoxy. That may be the work of a committee, and it may show. FriendlyRiverOtter (talk) 23:44, 23 May 2012 (UTC)

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TRAUMATIC BRAIN INJURY Chronic Traumatic Encephalopathy in Blast-Exposed Military Veterans and a Blast Neurotrauma Mouse Model, ABSTRACT, Science Translational Medicine, Goldstein, Fisher, Tagge, et al., Vol. 4, Issue 134, 16 May 2012.

“We examined a case series of postmortem brains from U.S. military veterans exposed to blast and/or concussive injury. We found evidence of chronic traumatic encephalopathy (CTE), a tau protein–linked neurodegenerative disease, that was similar to the CTE neuropathology observed in young amateur American football players . . ”

“ . . a blast neurotrauma mouse model . . ”

“ . . The contribution of blast wind to injurious head acceleration may be a primary injury mechanism . . ”

Agree with sciencewatcher. We need secondary reviews in the literature, especially in humans. Mouse studies do not count. Yobol (talk) 19:17, 25 May 2012 (UTC)

The mouse studies are one line of evidence. This same article also talks about autopsies on military veterans and football players. FriendlyRiverOtter (talk) 20:19, 25 May 2012 (UTC)

It's not just because it's on mice...it's also because it's a primary source. I'd urge you to read WP:MEDRS thoroughly. --sciencewatcher (talk) 21:59, 25 May 2012 (UTC)

So, we can't use good, straightforward, middle-of-the-road medical journalism, and we can't use primary sources either? It sure seems like we have put ourselves into an unnecessarily small box. FriendlyRiverOtter (talk) 17:56, 26 May 2012 (UTC)

And what about the Fifth Pillar: "Wikipedia does not have firm rules. Rules in Wikipedia are not carved in stone, . . . . and sometimes improving Wikipedia requires making an exception to a rule. . "

Certainly we can make exceptions, but this doesn't seem to be one of those cases. There are good reasons why we don't generally use primary sources in wikipedia, especially in medical articles. --sciencewatcher (talk) 18:35, 26 May 2012 (UTC)

What about the immediate below section that our first sentence just seems to be flat-out mistaken? FriendlyRiverOtter (talk) 18:40, 26 May 2012 (UTC)

And not just mouse study at all. "“We examined a case series of postmortem brains from U.S. military veterans . . " What I did, I took the CNN article and then I also included the professional publication CNN refers to. I think this is a pretty good way. It may not be "perfect" or "ideal." But this may be a case in which we are letting the perfect be the enemy of the good. FriendlyRiverOtter (talk) 19:45, 26 May 2012 (UTC)

It's still a primary source, single study so it fails WP:MEDRS. We can ignore MEDRS but only in exceptional circumstances. As stated above, there are very good reasons why we don't include studies like this - I think you should read WP:MEDRS to find out why... --sciencewatcher (talk) 20:36, 26 May 2012 (UTC)

CNN is not a primary source. CNN is a secondary source with a presumably seasoned medical reporter.

“ . . biomedical information in articles be based on reliable, third-party, published sources . . ” That includes mainstream journalism. FriendlyRiverOtter (talk) 20:59, 26 May 2012 (UTC)

CNN is a secondary source, but it fails WP:MEDRS badly. Again I'd suggest you read WP:MEDRS. --sciencewatcher (talk) 15:46, 27 May 2012 (UTC)

As I quoted from the first paragraph of WP:MEDRS above, on a straightforward reading it sure seems like this would include good, solid, mainstream medical journalism.

And please take a look at the below problems. This article needs a lot of help. If you have the time, I invite you to please help with some of the research. FriendlyRiverOtter (talk) 17:39, 29 May 2012 (UTC)

Yes, but read the second paragraph in WP:MEDRS. Also see the Popular press section: "The popular press is generally not a reliable source for scientific and medical information in articles". --sciencewatcher (talk) 18:01, 29 May 2012 (UTC)

Okay, continuing on with WP:MEDRS we have: "The popular press is generally not a reliable source for scientific and medical information in articles. Most medical news articles fail to discuss important issues such as evidence quality,[8] costs, and risks versus benefits,[9] and news articles too often convey wrong or misleading information about health care.[10] Articles in newspapers and popular magazines generally lack the context to judge experimental results. They tend to overemphasize the certainty of any result, for instance, presenting a new and experimental treatment as "the cure" for a disease . . . "

This is a caricature of the "popular press." If you look at CNN, or perhaps even more so ESPN which has done some excellent reporting on football and concussions, they have talked about evidence quality and how much weight to place on a particular study. I remember Dr. Sanjay Gupta being interviewed by a desk anchor on CNN about a concussion study. You're asking a doctor to put a study into lay language. And he wants to do a good job because he wants to maintain a good reputation with his professional colleagues. Perhaps it's not really peer review (which is not perfect either, for it has all the drawbacks of a committee), but it's a kind of peer review. Arguably, it's even a transparent kind of peer review. And ESPN has perhaps done even better reporting, because the journalists have examples of injuried athletes who they can ask doctors about, and thus get a healthy interchange going between theory and practice. And also shades of Dr. William Osler, one can learn a lot from the individual case study (yes, I am pretty well read, and when I was a younger person, I thought about medical school but it's not quite for me).

Perhaps the dialogue comes down to this: If we include CNN or ESPN, there is a theoretical risk that we might be wrong. But I think we're already wrong! Our very first sentence mis-emphasizes (let's put in that way) the time periods involved. (And after stating "weeks, months, or occasionally up to a year," the hedge phrase of "or more" is not near good enough. And other parts of this opening paragraph emphasize short-term. And that isn't always the case.)

The real downside of the purist, only-the-"best" sources seems to be that it's such a high threshold that the work hardly ever gets done. FriendlyRiverOtter (talk) 18:41, 29 May 2012 (UTC)

Agree with Yobol, user in question needs to provide recent secondary sources. Doc James (talk · contribs · email) 21:43, 29 May 2012 (UTC)

Our first sentence is just plain wrong

"Post-concussion syndrome, also known as postconcussive syndrome or PCS, and historically called shell shock, is a set of symptoms that a person may experience for weeks, months, or occasionally up to a year or more after a concussion – a mild form of traumatic brain injury (abbreviated TBI). . . "

" . . occasionally up to a year or more . . " No, incorrect, there are guys who are retired NFL players who have had serious symptoms for a lot longer than a year. Watch some ESPN in recent weeks and see this. And maybe this is a case in which just people telling their stories is running ahead of formalized research. Although I suspect this is the wiki disease of understating. When in doubt, when there's controversy, just understate, sand it down even more. Well, we end up doing our readers a disservice. If we have the sources to back it up (good not perfect sources) I don't think we need to excessively understate.

And the part about shell shock, I have most commonly heard that in reference to World War I and I've heard it described as serious depression. Well, maybe the concussive injuries were the cause of a lot of these cases of depression. "Shell shock" is how they best understood it at the time. I'm not sure we should lead with a historical term which is partially right, partially not. FriendlyRiverOtter (talk) 00:01, 24 May 2012 (UTC)

And look at the last sentence of the opening paragraph: " . . In late, persistent, or prolonged PCS (PPCS), symptoms last for over six months, or by other standards, three."

We are again emphasizing short-term. At the very least, we are taking a definite viewpoint when there is still considerable controversy and unknown. And actually, a lot of the news coverage is emphasizing a heck of a lot longer than six months. FriendlyRiverOtter (talk) 18:56, 26 May 2012 (UTC)

The lead is confusing in the proposed timing, wandering around between short term, long term and short term onset.

The shell shock part confusion is due to WWI misinterpretation of combat stress reaction, it was thought at the time, that the injury was due to explosives injuring the brain. Later study found that the issue was psychological, which is the current belief. There also seems to be some confusion in concepts. One can have traumatic brain injury that doesn't cause long term issues and one can have traumatic brain injury that causes damage that the brain cannot compensate for. The tau protein detection is an early finding in research that indicates damage has occurred in the past, with some being probable multiple injury induced changes. Even so, it's rather outside of the scope of the article, as it is ongoing research that is still poorly understood and utterly useless in diagnosing PCS. Head trauma is still not well understood. Relatively mild head injuries can result in significant emergent conditions, while more severe injuries can result in no significant medical issues, with little to lead researchers anything to ascertain why there is such a wide difference in spectrum with disparate mechanisms of injury. As an example, a man is hit with a back hoe and thrown two meters, his head being part of what was struck by the bucket. He got up and returned to work, only reporting bruising. Another man fell off the lowered back gate of a truck he was climbing into, landing on an unimproved dirt road. He was hospitalized for a subdural hematoma after complaining of vision changes several hours later. So, we have to consider when writing our rather poor level of understanding injuries of the head overall and the current extremely poor understanding of concussions in general.Wzrd1 (talk) 00:21, 15 August 2012 (UTC)

Physiological or Psychological? More sophisticated understanding is that it's BOTH-AND.

The Causes section is generally taking the either-or approach, whereas I think the newer understanding is that it's BOTH-AND. That both interact to cause a downward spiral.

In general, our article here needs a lot of work. And perhaps paradoxically, maybe we should seemingly lower our standards and go with a healthy number of good sources, rather than a scant number of 'perfect' or 'great' sources. FriendlyRiverOtter (talk) 00:15, 24 May 2012 (UTC)

i agree. 4 1/2 years later, the article still needs work. i found the article quite slanted when i read it. it's the little things--use of phrases like "most experts agree," "it has been argued," "it appears that," and "it has been argued," etc. then, the sources related to these phrases are quite out of date. especially for a medical article, and especially for a medical "issue" that has gotten a LOT of interest lately.Colbey84 (talk) 08:37, 27 November 2016 (UTC)

Not included in lead that it's typically a subsequent concussion which causes problems. This is a main fact which should be included.

The whole news coverage on concussions and brain injury, that it’s typically not the first concussion. But rather that it’s the fourth, or the seventh, or the second, that it is highly variable depending on each individual. For example, let’s say a cyclist (not just to pick on football) has experienced a concussion and has largely recovered, and this cyclist asks his or her doctor: “Doctor, will I be okay even if I get a second concussion?”

As I understand it, with current knowledge and information, the doctor cannot say one way or another. (although with each concussion, the third, the fourth, the fifth, the risk increases that the next one will prove to be damaging).

This has been a central fact in the news coverage of concussions. And yes, I think someone who has maybe worked ten years or longer as a medical journalist, like a reporter for CNN, LA Times, etc, etc, etc, often are pretty good sources. They can act as ‘bridge’ persons between medical publications written for doctors and interested lay persons like ourselves. And we don’t need to dive into how much experience a particular medical journalist has or what his or her credentials are. Rather, this is where we trust the credibility of the source (with all kind of judgment calls on our part of course). And so, I come back to the not very dramatic conclusion that we want a variety of good sources.

And to be clear, I am not a medical journalist either. I am just someone who is interested in the topic.FriendlyRiverOtter (talk) 19:34, 26 May 2012 (UTC)

Aggressively skeptical claims regarding second-impact syndrome. No references cited.

from Prognosis section (last paragraph):

" . . . If another blow to the head occurs after a concussion but before its symptoms have gone away, there is a very slight risk of developing the extremely rare but deadly second-impact syndrome (SIS). In SIS, the brain rapidly swells, greatly increasing intracranial pressure. People who have repeated mild head injuries over a prolonged period, such as boxers and Gridiron football players, are at risk for Chronic traumatic encephalopathy (or the related variant dementia pugilistica), a severe, chronic disorder involving a decline in mental and physical abilities."

" . . a very slight risk . . "

" . . the extremely rare but deadly . . "

Wow. How definite we are without any references whatsoever.

And I'm not saying we should emphasize the danger side. I'm advocating middle-of-the-road. Let's just try to lay the known information onto the table without either over-stated or under-stating.

(And the little bit I've read, this second-impact syndrome may be different from post-concussion syndrome with depression, irritability, memory loss.) FriendlyRiverOtter (talk) 20:13, 26 May 2012 (UTC)

I'm going to go ahead and delete this paragraph and refer here. It is a judgement call whether a lousy section is better than no section at all. FriendlyRiverOtter (talk) 20:22, 26 May 2012 (UTC)

Toned down the language and added references. Doc James (talk · contribs · email) 21:41, 29 May 2012 (UTC)

Four current problems with our article (May 2012).

1) We don't mention tau protein.

2) We don't mention in the lead that it's primarily a danger of subsequent concussions.

3) The first sentence of our entire article estimates lower time periods, and this is simply not always the case.

4) We are taking an either-or approach to the question of physiological or psychological.

I ask people who can spare the time to please jump in and help out with both the writing and the research. FriendlyRiverOtter (talk) 21:01, 26 May 2012 (UTC)

I don't see how our article meets criteria of good article.

Maybe it did at one time, and we didn't keep it. Or maybe it's been changed over time.

I have pretty much decided to request and recommend that this article be demoted from being classified as a Natural sciences good article. Now, in keeping with the spirit of openness, I invite people's comments. And I'm willing to wait a couple of days. In fact, I hope the discussion both informally and more formally about whether to demote this article will draw people in with the interest and, more importantly, the time to make our article better.

As it currently stands, if a young person is in the 10th grade and is thinking about medical school, or if he or she is a senior in college, I don't see how our article does that good a job in providing an overview of known information. Or, if our reader is a parent who has a 14-year-old son interested in playing football, I don't see how our article provides a very good overview of what is known regarding post-concussion syndrome. In fact, we might end up doing that parent a disservice. FriendlyRiverOtter (talk) 21:10, 26 May 2012 (UTC)

I think the main problem here is you are confusing this page with Chronic traumatic encephalopathy. It may be better for you to slow down, read this page and that page and understand the difference before posting further. Yobol (talk) 21:51, 26 May 2012 (UTC)

In the big swaths I have read, I have seen what sure appears to be substantial problems with our article as it's currently written. No, I don't think I am going to slow done, other than holidays and family activities of course.  :>)

Our article as it currently stands needs a fair amount of help. If you have the interest and can spare the time, please consider jumping in and helping with the research. FriendlyRiverOtter (talk) 17:50, 29 May 2012 (UTC)

Introduction from primary source, which acts as a literature review

ORIGINAL ARTICLE, “Permanent post-concussion symptoms after mild head injury,” Brain Injury, 25(5): 462–470, NIGEL S. KING & SIMON KIRWILLIAM, May 2011.

Introduction

“ . . ‘mild head injury’ (MHI) . . ”

“ . . ‘postconcussion symptoms’ (PCS) . . ”

“ . . Twenty-to-forty per cent may, however, continue to experience PCS at 6 months post-injury [5] and a small minority still have difficulties at 1 year and beyond [6]. . ”

“ . . Studies have also identified predisposing factors to experiencing more severe or longer lasting PCS. These include; (i) being over the age of 40 [11, 12]; (ii) being female [12, 13]; (iii) sustaining previous MHIs [12, 14]; (iv) having pre- or post-morbid psychopathology or substance misuse [15]; and (v) pursuing a compensation claim [16]. . ”

References

[5.] Englander J, Hall K, Simpson T, Chaffin S. Mild traumatic brain injury in an insured population; subjective complaints and return to employment. Brain Injury 1992;6:161–166.
[6.] Binder LM, Rohling ML, Larrabee GJ. A review of mild head trauma. Part 2: clinical implications. Journal of Clinical and Experimental Neuropsychology 1997;19:432–457.
.
.
[12.] Edna TH, Cappelen J. Late postconcussional symptoms in traumatic head injury. An analysis of frequency of risk factors. Acta Neurochirurgica 1987;86:1–12.
.
[14.] Gronwall D, Wrightson P. Cumulative effects of concussion. Lancet 1975;2:995–999.

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My local library has databases which includes Brain Injury, including a PDF of the full article. I'm not sure whether it's available generally over the Internet.

Here's the abstract: http://informahealthcare.com/doi/abs/10.3109/02699052.2011.558042 But apparently one needs to log in to see the entire article. FriendlyRiverOtter (talk) 19:45, 29 May 2012 (UTC)

Introductions to primary sources do not act as reviews. Pubmed has a button on the left side that will limit your search to review articles. Please use reviews from the last 5 or 10 years at most. Cheers Doc James (talk · contribs · email) 21:30, 29 May 2012 (UTC)

GA Reassessment

This discussion is transcluded from Talk:Post-concussion syndrome/GA2. The edit link for this section can be used to add comments to the reassessment.

There are at least four current substantial problems with our article:

1) The very first sentence of our article emphasizes lower time periods, and this is not always the case.

The ref makes this emphasizes. "last for weeks and sometimes months after the injury" [3] Do you have better sources that contradict this?Doc James (talk · contribs · email) 21:11, 29 May 2012 (UTC)

Well, I hate to outcompete a doctor just on the basis of ESPN, but on this one I might! If we say " . . sometimes months . . ," wow, for many cases we are way understating. Watch the case studies on ESPN for retired football players, plus your colleague Dr. Sanjay Gupta on CNN, plus the literature review for this study:

ORIGINAL ARTICLE, “Permanent post-concussion symptoms after mild head injury,” Brain Injury, 25(5): 462–470, NIGEL S. KING & SIMON KIRWILLIAM, May 2011.

Introduction

“ . . Twenty-to-forty per cent may, however, continue to experience PCS at 6 months post-injury [5] and a small minority still have difficulties at 1 year and beyond [6]. . ”

[Immediately above in discussion section]

And before we too quickly dismiss case studies as mere anecdotal, we might want to remind ourselves what Dr. William Osler said about the case study. And afterall, all a research study is, is talking to people and separating people (hopefully) into the two groups of best current treatment and best new treat. FriendlyRiverOtter (talk) 21:55, 29 May 2012 (UTC)

I generally think that it's okay for the lead to focus on the majority of cases, rather than accounting for the "small minority", especially when the statement is still technically accurate ("several years", after all, is just "many months"). WhatamIdoing (talk) 00:38, 30 May 2012 (UTC)

Agreed. If our reliable sources focus on the short-term, so do we. Yobol (talk) 01:40, 30 May 2012 (UTC)

WhatamIdoing, but we're not trying to merely be technically accurate, right? I hope we're trying to be genuinely informative. And I hope we cover the range of cases, both less serious and more. FriendlyRiverOtter (talk) 19:36, 30 May 2012 (UTC)

Yobol, I'd say that's one of the questions very much at issue. If the mainstream media is at all correct (and ESPN seems to have done some first-rate reporting), I think we will find a number of medical sources focusing on other than short-term. FriendlyRiverOtter (talk) 19:36, 30 May 2012 (UTC)

ESPN does not meet WP:MEDRS. Yobol (talk) 19:45, 30 May 2012 (UTC)

2) We don't mention in the lead that it's primarily a danger of subsequent concussions.

What do you mean by " it's "?Doc James (talk · contribs · email) 21:11, 29 May 2012 (UTC)

I mainly mean the risk and the danger. And this is pounded again and again by the mainstream media, including Dr. Gupta. FriendlyRiverOtter (talk) 21:55, 29 May 2012 (UTC)

Please locate WP:MEDRS compliant sources that mention the prominence of dangers of subsequent concussion. Yobol (talk) 01:39, 30 May 2012 (UTC)

I’m sorry that I don’t have time to be more through but here are some resources that should meet your needs.

• [4]
• [5]
• Prentice W E. Arnheim’s Principles of Athletic Training: A Competency-Based Approach. McGraw-Hill Higher Education. 2009; Ch 26:925-931

ITasteLikePaint (talk) 03:30, 12 June 2012 (UTC)

Thank you for finding these sources. FriendlyRiverOtter (talk) 19:45, 12 June 2012 (UTC)

3) We don't mention tau protein.

Do you have a secondary source that states we should?Doc James (talk · contribs · email) 21:11, 29 May 2012 (UTC)

Do a search on google news, and I suspect it will come up again and again. And absolutely, I support good mainstream medical journalism (wouldn't you feel more with that than with me, just some random person on the Internet?) FriendlyRiverOtter (talk) 21:55, 29 May 2012 (UTC)

News articles are generally primary sources (see WP:PRIMARYNEWS). WhatamIdoing (talk) 00:40, 30 May 2012 (UTC)

I believe this user is confusing or at least conflating post-concussion syndrome with Chronic traumatic encephalopathy (note that tau protein is discussed prominently there, and my quick review of sources point to the tau protein in relation to that disease process and not PCS in particular. Yobol (talk) 01:39, 30 May 2012 (UTC)

It may be the case that the mainstream media is using the term post-concussion syndrome in a broader sense than physicians use it, perhaps roughly analogous to how physicists have a narrow definition of the word "work." Or, perhaps Chronic Traumatic Encephalopathy is the stiffy, formal term whereas post-concussion syndrome. I'm not necessarily saying this is the case, but I am open to the idea that something like this is going on. And if so, this will be something we'll want to tell our readers very early on. FriendlyRiverOtter (talk) 19:46, 30 May 2012 (UTC)

You need to provide sources here. We're going nowhere discussing your interpretation of what you read or saw somewhere in the media. Yobol (talk) 19:57, 30 May 2012 (UTC)

Sources above and below. For example, do you really think Dr. Mark Aubry is that far mistaken? FriendlyRiverOtter (talk) 20:07, 30 May 2012 (UTC)

4) We are taking an either-or approach to the question of physiological or psychological.

This sentence here in the lead of that section makes it clear we are not. " It is not known to exactly what degree the symptoms are due to organic factors, such as microscopic damage to the brain, and to other factors, such as psychological ones."--Doc James (talk · contribs · email) 21:11, 29 May 2012 (UTC)

Then our article should reflect this degree of simply not knowing. FriendlyRiverOtter (talk) 21:55, 29 May 2012 (UTC)

I think we adequately state we do not know the exact etiology, so do not understand how we are supposedly taking an either-or approach. Yobol (talk) 01:39, 30 May 2012 (UTC)

And these are just the parts I've looked at. There are probably other parts as well. Yes, we probably do need to demote the article, and at the same time we need people helping with the research. FriendlyRiverOtter (talk) 18:10, 29 May 2012 (UTC)

Have you checked the references that support the content in question? Doc James (talk · contribs · email) 21:11, 29 May 2012 (UTC)

Now, Doc James, I am not one of your residents trying to write a really good (and formal) paper. I'm more of an artist and philosopher. I'd probably drive you crazy as a resident (even though I wouldn't mean to).

Let me ask you this, if two parents brought in their 14-year-old son suffering from a football concussion, and sitting in the waiting room, they used their iphone to review our wiki article so they would have better questions to ask you compared to a CNN article, which way are they going to be better informed. FriendlyRiverOtter (talk) 21:44, 29 May 2012 (UTC)

I see many instances of the popular press getting medicine wrong. Wikipedia's accuracy in general is far greater. Now back to the GAR. Doc James (talk · contribs · email) 21:49, 29 May 2012 (UTC)

Well, let me ask you as a physician, if someone gets one concussion, isn't there an increased risk that a second or third concussion might be more damaging? And if that answer is yes, we are not more accurate with this article.

This one I think I'm right. This one I think ESPN actually does some pretty good journalism (which should not be that much of a surprise, for sports journalism typically is better than political journalism). I mean, we want to bring medicine to the people, right? FriendlyRiverOtter (talk) 21:53, 29 May 2012 (UTC)

Again, I'm probably not as smart as your residents! But I do have a knack of asking good questions. FriendlyRiverOtter (talk) 22:48, 29 May 2012 (UTC)

PS On good days, on days when I'm really running the top of my game, I can find and pull from one professional publication. And the intro to Brain Injury, May 2011, is pretty much my work for the day.

ORIGINAL ARTICLE, “Permanent post-concussion symptoms after mild head injury,” Brain Injury, 25(5): 462–470, NIGEL S. KING & SIMON KIRWILLIAM, May 2011.

Introduction

“ . . ‘mild head injury’ (MHI) . . ”

“ . . ‘postconcussion symptoms’ (PCS) . . ”

“ . . Studies have also identified predisposing factors to experiencing more severe or longer lasting PCS. These include; . . . . (iii) sustaining previous MHIs [12, 14] . . . . ”

References

[12.] Edna TH, Cappelen J. Late postconcussional symptoms in traumatic head injury. An analysis of frequency of risk factors. Acta Neurochirurgica 1987;86:1–12.
.
[14.] Gronwall D, Wrightson P. Cumulative effects of concussion. Lancet 1975;2:995–999.

---

This is a primary article which reports an original study; [u]however, the Introduction section is a review of previous studies[/u]. Or, at least it sure seems that way to me. Or we can ask, how small and narrow a box are we going to put ourselves in. FriendlyRiverOtter (talk) 22:29, 29 May 2012 (UTC)

news item from Canadian Medical Association Journal

Physicians must be brought up to speed on concussion risks, CMAJ News, Canadian Medical Association Journal, Jordan Fallis, 2012 Feb 7; Vol. 184 (2), pp. E113-4. Date of Electronic Publication: 2011 Dec 19.

' . . added Dr. Mark Aubry, chief medical officer for Hockey Canada. “We’re getting more severe in our return-to-play guidelines because we’re learning more about the injury. We’re realizing it doesn’t heal that fast, and what may appear mild, may be more severe and prolonged than you think.” . '

' . . Part of that problem has been that players’ symptoms recede and they are often eager to get back out on to the ice, Aubry said. But 30% of those players score abnormally on neuropsychological tests, he added. “This means cognitive recovery may follow the resolution of symptoms. And we should probably be keeping our athletes out that much longer.” . '

' . . the Canadian Medical Association and the Canadian Academy of Sport and Exercise Medicine cohosted a workshop for physicians in December 2011 which brought together representatives from major national physician groups as a part of bid to collaboratively develop guidelines to optimize the care of concussed patients, Kissick said. . '

' . . The current guidelines were developed in 2008, when the Third International Conference on Concussion in Sport developed the Consensus Statement on Concussion in Sport, which lays out evidence-based guidelines for physicians, trainers and other health care professionals on how to treat concussed patients (http://sportconcussions.com/html/Zurich%20Statement.pdf). An update is expected to be released after a conference to be held in Zurich, Switzerland in November 2012.'

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I suspect we're going to say that this is not good enough!

So, we're going to so quickly dismiss Dr. Mark Aubry  ?  ?  ?

And what's at risk, well, a student writes a paper based on the current article and feels really burned when he or she gets a mediocre grade because our article is not quite accurate. Or more seriously, a parent goes to our article for information and later decides 'Well, I guess it went okay. The doctor we got was actually pretty good. Wikipedia sure didn't help.' No, we're not trying to give medical advice, nor should we. But we are trying to provide medical information which enables a parent or anyone else to ask better questions. FriendlyRiverOtter (talk) 19:09, 30 May 2012 (UTC)

This article does not mention "post concussion syndrome". Yobol (talk) 20:09, 30 May 2012 (UTC)

It doesn't use the phrase, but Dr. Mark Aubry is saying that seemingly minor concussions are now viewed as somewhat more serious than they were viewed before. And a fair amount of medical thinking is going is this direction. FriendlyRiverOtter (talk) 20:15, 30 May 2012 (UTC)

This article discusses the condition "post concussion syndrome", it is not an appropriate place for a general discussion of concussions. To change this article, we need sources that discuss this condition. Yobol (talk) 20:17, 30 May 2012 (UTC)

This is correct. No where in this CMAJ news item is the phrase "post concussion syndrome" used. However, the opening sentence is:

'Canadian physicians have often been uninformed about the long-term consequences of concussions suffered in sport . . ' And what is "long-term consequences" if not post-concussion syndrome? And . .

' . . With the evidence continuing to mount on the negative long-term consequences of head injuries . . '

Dr. Aubry: “ . . We’re realizing it doesn’t heal that fast, and what may appear mild, may be more severe and prolonged than you think.”

' . . The severity of those consequences is becoming ever more apparent, said Dr. Kristian Goulet, medical director at the Eastern Ontario Concussion Clinic and the Pediatric Sports Medicine Clinic of Ottawa. Every year in the United States, “225 000 new patients are showing effects of long-term head injury. This isn’t necessarily just mild headaches, but chronic depression, substance abuse, and dementia as well.” . '

This is some of the same symptoms we discuss in our article (although other than dementia pugilistica, we don't really discuss dementia, at least not by name, and we don't discuss drug abuse following concussion).

And yes, I would feel more comfortable if the author had specifically used the phrase "post-concussion syndrome." And this is potentially where a doctor being interviewed on a reputable news show can potentially be worth his or her weight in gold. The doctor can be asked, "Is this what you guys also call post-concussion syndrome?"

And from the above ORIGINAL ARTICLE, “Permanent post-concussion symptoms after mild head injury,” Brain Injury, KING & KIRWILLIAM, May 2011:
" . . Historically these have been termed ‘mild’ and ‘moderate’ injuries (for PTA<1 hour and 1–24 hours, respectively). More recent taxonomies, however, have classified all injuries witha PTA of less than 24 hours as ‘mild head injury’(MHI) [2]. . "

Maybe there has been a similar move in the professional literature away from the term "post-concussion syndrome."

And Yobol, this is where I'd ask you to help me. Please help me with some of the research. FriendlyRiverOtter (talk) 21:37, 30 May 2012 (UTC)

if our article is so perfect, how'd we have the following free-floating paragraph for so long?

Our prognosis section previously ended with this paragraph:

" . . . If another blow to the head occurs after a concussion but before its symptoms have gone away, there is a very slight risk of developing the extremely rare but deadly second-impact syndrome (SIS). In SIS, the brain rapidly swells, greatly increasing intracranial pressure. People who have repeated mild head injuries over a prolonged period, such as boxers and Gridiron football players, are at risk for Chronic traumatic encephalopathy (or the related variant dementia pugilistica), a severe, chronic disorder involving a decline in mental and physical abilities."

Notice the emphatic phrases such as "very slight risk" with no supporting references whatsoever!

I removed this paragraph. Doc James, to his credit, added it back, added some references, and toned down the phraseology. You can read about this in the history:

http://en.wikipedia.org/w/index.php?title=Post-concussion_syndrome&action=history

To me, our article seems to have a general skeptical bias.

Be that as it may, the question can be raised, how did a free-standing paragraph stay so long in a GA article? We seem to have very high standards as far as gate keeping for any new changes (maybe even impossibly high standards, or we've put ourselves in such a small box we can hardly move). And at the same time, very little time and effort is spent reviewing the article and making sure it's still up to date. FriendlyRiverOtter (talk) 20:28, 30 May 2012 (UTC)

This is not the place for a meta-discussion about the GA process or how well articles are monitored. Please focus on the point of this discussion, the improvement and evaluation, with specifics, of this article as it is. Yobol (talk) 20:34, 30 May 2012 (UTC)

The GAR is to discuss ways to improve content. Concerns need to be support by secondary sources exclusively. Thanks. Doc James (talk · contribs · email) 00:17, 31 May 2012 (UTC)

Consensus statement from 3rd International Conference on concussion in sport, Nov. 2008.

Consensus statement on concussion in sport – The 3rd International Conference on concussion in sport, held in Zurich, November 2008, Journal of Clinical Neuroscience, P. McCrory, W. Meeuwisse, K. Johnston, J. Dvorak, M. Aubry, M. Molloy, R. Cantu, 16 (2009) 755–763.

I think this is an example of what we’re looking for. Now, this is going to take a while to go through. And people, if you have the time, please jump in and help. FriendlyRiverOtter (talk) 21:25, 31 May 2012 (UTC)

Yes exactly. A great ref. Here it is formatted.

McCrory, P (2009 Jul-Aug). "Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008". Journal of athletic training. 44 (4): 434–48. PMID 19593427. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

Doc James (talk · contribs · email) 23:30, 31 May 2012 (UTC)

Thank you for the formatting and for a reference which also includes ready access to the end material. I've pulled some parts from this article. FriendlyRiverOtter (talk) 17:11, 2 June 2012 (UTC)

Some selected parts from this article:

“ . . . . the authors acknowledge that the science of concussion is evolving and therefore management and return to play (RTP) decisions remain in the realm of clinical judgment on an individualized basis. . . . ”

1.1. Definition of concussion “ . . . . In a small percentage of cases, however, post-concussive symptoms may be prolonged. . . . ”

1.2 Classification of Concussion “There was unanimous agreement to abandon the “simple” versus “complex” terminology . . . . The panel, however, unanimously retained the concept that most (80–90%) concussions resolve in a short period (7–10 days), although the recovery time frame may be longer in children and adolescents.”

2.1. Symptoms and signs of acute concussion
“ . . . . The suspected diagnosis of concussion can include one or more of the following clinical domains:
(a) symptoms: somatic (e.g. headache), cognitive (e.g. feeling like in a fog) and/or emotional symptoms (e.g. lability)
(b) physical signs (e.g. loss of consciousness, amnesia)
(c) behavioral changes (e.g. irritablity)
(d) cognitive impairment (e.g. slowed reaction times)
(e) sleep disturbance (e.g. drowsiness).”
. .
2.2. On-field or sideline evaluation of acute concussion “ . . . and particular attention should be given to excluding a cervical spine injury. . . . ”

“ . . . . Brief NP test batteries that assess attention and memory function have been shown to be practical and effective. Such tests include the Maddocks questions and the Standardized Assessment of Concussion (SAC). Standard orientation questions (e.g. time, place, person) have been shown to be unreliable . . . . It should also be recognized that the appearance of symptoms might be delayed several hours following a concussive episode.”

3.2. Objective balance assessment “Published studies, using both sophisticated force plate technology, as well as those using less sophisticated clinical balance tests (e.g. the Balance Error Scoring System), have identified postural stability deficits lasting approximately 72 hours following a sport-related concussion. . . . ”

4) CONCUSSION MANAGEMENT
“The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program of exertion prior to medical clearance and RTP. . . . ”

“ . . . . With this stepwise progression, the athlete should continue to proceed to the next level if asymptomatic at the current level. Generally each step should take 24 hours . . . . ”

4.5. The role of pre-participation concussion evaluation “ . . . . A structured concussion history should include specific questions as to previous symptoms of a concussion; not just the perceived number of past concussions. It is also worth noting that dependence upon the recall of concussive injuries by teammates or coaches has been demonstrated to be unreliable. . . . Questions pertaining to disproportionate impact versus symptom severity matching may alert the clinician to a progressively increasing vulnerability to injury. . . . ”

7) INJURY PREVENTION
“There is no good clinical evidence that currently available protective equipment . . . . In specific sports such as cycling, motor, and equestrian sports, protective helmets may prevent other forms of head injury (eg, skull fracture) . . . . ”

7.3 Risk Compensation “ . . . . This is where the use of protective equipment results in behavioural change, such as the adoption of more dangerous playing techniques . . . . ”

Concussion injury advice (To be given to concussed athlete)
“If you notice any change in behavior, vomiting, dizziness, worsening headache, double vision or excessive drowsiness, please telephone the clinic or nearest hospital emergency department immediately.”
“ . . Use paracetamol or codeine for headache. Do not use aspirin or anti-inflammatory medication . . ”

And this is just a first pass. I want to look at this again. FriendlyRiverOtter (talk) 17:32, 2 June 2012 (UTC)

issues with Treatment section of our article

This section starts out with:
"Post-concussion syndrome is usually not treated,[24] though specific symptoms can be addressed;[16] for example, people can take pain relievers for headaches and medicine to relieve depression, dizziness,[40] or nausea.[24] Rest is advised, but is only somewhat effective.[41] . . . "

Which is not exactly saying the same thing as the above censensus statement:
“The cornerstone of concussion management is physical and cognitive rest until symptoms resolve and then a graded program . . . . ”

The Medication subsection of Treatment states:
" . . there may be a benefit to avoiding narcotic medications.[43] In addition, headache medications may cause rebound headaches when they are discontinued.[44] . . "

which is not the same thing at all as the concensus statement:
“ . . Use paracetamol or codeine for headache. Do not use aspirin or anti-inflammatory medication . . ”

I think the next thing is to look up these references. If both (or several) references are good and say different things, let's just be open about that. FriendlyRiverOtter (talk) 20:49, 10 June 2012 (UTC)

---

[24] The Merck Manual Home Health Handbook, Concussion, last full review/revision January 2008 by Kenneth Maiese, MD.

“ . . . Later, people may experience headache, the sensation of spinning, light-headedness, fatigue, poor memory, inability to concentrate, irritability, depression, and anxiety. These symptoms are called the postconcussion syndrome. . . ”

“ . . . Postconcussion syndrome symptoms are common during the week after concussion and commonly resolve during the second week. However, sometimes, symptoms persist for months or, rarely, years. People who have had a concussion also seem to be more susceptible to another one, particularly if the new injury occurs before symptoms from the previous concussion have completely gone away. . . ”

“ . . . For concussion, acetaminophen [Tylenol] is given for pain. Aspirin or another nonsteroidal anti-inflammatory drug (NSAID— . . . ) should not be taken because they interfere with blood clotting and may contribute to bleeding from damaged blood vessels. Rest is the best treatment for a concussion.

“Treatment for postconcussion syndrome is based on the severity of the symptoms. Rest and close observation are important. People who experience emotional difficulties may need psychotherapy. Repeated concussions may increase a person's risk in later life for dementia, Parkinson's disease, and depression. People should not return to contact sports after a concussion until all ill effects have resolved and medical evaluation has been completed.”

This is the source we cite for saying "Post-concussion syndrome is usually not treated,[24] . . " And I don't see where we're getting that. This source is saying rest, Tylenol for pain, medical evaluation, as far as the basics.

And again, standing offer, please jump in and help with reviewing new sources and reviewing and updating our article. My time is pretty limited. I'll do what I can, but I can use some help. FriendlyRiverOtter (talk) 21:27, 10 June 2012 (UTC)

---

from the 2008 consensus statement:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2707064/

" . . During this period of recovery while symptomatic following an injury, it is important to emphasize to the athlete that physical AND cognitive rest is required. Activities that require concentration and attention (eg, scholastic work, video games, text messaging, etc) may exacerbate symptoms and possibly delay recovery. . "

" . . The panel strongly endorsed the view that children should not be returned to practice or play until clinically completely symptom free, which may require a longer time frame than for adults. . "

Summarizing the return-to-play steps in table 1:
1. Complete physical and cognitive rest
2. light aerobic activity (less than 70% of maximum predicted heart rate, no resistance training)
3. sport-specific activities such as running drills and skating drills
4. non-contact training drills (exercise, coordination and cognitive load)
5. full-contact practice.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2707064/table/attr-44-04-01-t01/

“ . . If any postconcussion symptoms occur while in the stepwise program, then the patient should drop back to the previous asymptomatic level and try to progress again after a further 24-hour period of rest has passed. . ”

When I get the time, I plan to summarize this and put it into our Treatment section. I want our article to reflect latest information. Please help out if you can. FriendlyRiverOtter (talk) 15:43, 11 June 2012 (UTC)

I also find issue with the treatment section of the article. Treatment for post-concussion syndrome is becoming much more common, with a variety of treatment options. One thing that should probably be added is that a combination of multiple treatment options is usually more effective than just one.Lmorgan9 (talk) 16:49, 11 June 2012 (UTC)

That certainly seems to make sense, especially for a part of the body as complex as the brain. Now, it is important that we find the references, but if we can find good ones, let's roll with them. I welcome your interest in the topic of Post-concussion syndrome, and whatever time you can devote to making our article better will be most appreciated. FriendlyRiverOtter (talk) 19:47, 11 June 2012 (UTC)

The lead to the Treatment section did include the phase " . . or nausea. . .ref name="merck"/>" when in fact the Merck reference does not even use the word nausea a single time. Wow. I think we should simply take a deep breath and acknowledge that the accuracy of wiki articles can erode over time. And then let's do what we can to bring our article up to date.

I corrected some of these problems and added a subsection entitled "Physical and cognitive rest." Everyone, please, jump in and help if you have the time. Thanks. FriendlyRiverOtter (talk) 00:37, 12 June 2012 (UTC)

---

Trying to get good link for Willer and Leddy source.

Willer B, Leddy JJ (2006). "Management of concussion and post-concussion syndrome". Current Treatment Options in Neurology. 8 (5): 415–426. doi:10.1007/s11940-006-0031-9. PMID 16901381. {{cite journal}}: Unknown parameter |month= ignored (help)

http://www.springerlink.com/content/d7w2n822k2u6507v/fulltext.pdf

" . . Evidence from basic animal research suggests that an initial period of physical and cognitive rest is therapeutic after concussive injury [10, Class II], but in a randomized human trial complete bed rest was ineffective in reducing symptoms [26, Class I]. The literature is in general agreement that relative rest (ie, avoiding studying and physical exertion but resuming normal activities of daily living as soon as possible [24, Class III]) for the first 2 to 5 days after concussion is important because strenuous cognitive and physical activity may exacerbate symptoms and delay recovery [12••, Class III]. . "

" . . Activity – Once the patient is asymptomatic at rest, he or she is advised to progress stepwise from light aerobic activity such as walking or stationary cycling up to sport or work-specific activities (see following text) [12••, Class III]. However, there is no evidence-based research to quantify specific activity type, intensity, and progression rate. . "

work towards improving lead

some references in lead:

---

Legome E. 2006. Postconcussive syndrome. eMedicine.com. Accessed January 1, 2007.

" . . Depending on the definition and the population examined, 29-90% of patients experience postconcussive symptoms shortly after the traumatic insult. . "

" . . . Although no universally accepted definition of postconcussive syndrome exists, most of the literature defines the syndrome as the development of at least 3 of the following symptoms: headache, dizziness, fatigue, irritability, impaired memory and concentration, insomnia, and lowered tolerance for noise and light. Confusion exists in the literature, with some authors defining it as symptoms of at least 3 months' duration, while others define it as symptoms appearing within the first week. In this article, the syndrome is loosely defined as symptom occurrence and persistence within several weeks after the initial insult. Persistent postconcussive syndrome (PPCS) is generally defined as symptoms lasting more than 6 months, though some authors define it as symptoms lasting more than 3 months. [We use a fair amount of this in lead, probably too much]

"The ICD-10 criteria include a history of traumatic brain injury (TBI) and the presence of 3 or more of the following 8 symptoms: (1) headache, (2) dizziness, (3) fatigue, (4) irritability, (5) insomnia, (6) concentration or (7) memory difficulty, and (8) intolerance of stress, emotion, or alcohol.

"The DSM-IV criteria are . . [similar and even more complicated] . . "

It's good to show a variety of estimated time frames and definitions. Respecting our readers as equals, we are letting them see that there is live controversy in the field. All the same, probably should move some of this to the body of our article and use a summarized range in the lead. FriendlyRiverOtter (talk) 21:00, 12 June 2012 (UTC)

---

Schnadower D, Vazquez H, Lee J, Dayan P, Roskind CG (2007). "Controversies in the evaluation and management of minor blunt head trauma in children". Current Opinion in Pediatrics. 19 (3): 258–264. doi:10.1097/MOP.0b013e3281084e85. PMID 17505183.{{cite journal}}: CS1 maint: multiple names: authors list (link) <--currently available only as abstract

Serious issue in Diagnosis section.

Currently in our article: "In order to meet these criteria, a patient must have had a head injury with loss of consciousness[23] and develop at least three of the eight symptoms marked with a check mark in the table at right under "ICD-10" within four weeks.[33][34]"

Notice the part "with loss of consciousness" That is incorrect. And that is way old school.

As an example of one of the many more modern sources, the above 2008 Consensus statement: http://sportconcussions.com/html/Zurich%20Statement.pdf " . . . Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. In a small percentage of cases, however, post-concussive symptoms may be prolonged. . . "

Okay, plot thickens, and I'm willing to acknowledge messy facts, from ICD-10
ICD-10, International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version for 2010, F07.2 Postconcussional syndrome, World Health Organization.
"A syndrome that occurs following head trauma (usually sufficiently severe to result in loss of consciousness) and includes a number of disparate symptoms such as headache, dizziness, fatigue, irritability, difficulty in concentration and performing mental tasks, impairment of memory, insomnia, and reduced tolerance to stress, emotional excitement, or alcohol."

"usually sufficient severe" That's different from what our article currently says. And then ICD-10itself was approved in 1990 and implemented in 1993, i.e. close to twenty years ago. Let's just lay this on the table as clearly as we can.

Pediatric Psychopharmacology: Principles and Practice, Andres Martin, Oxford University Press, 2003 page 749: “The ICD-10, which was developed by the WHO as a classification of diseases, was approved in 1990 and implemented in 1993 (World Health Organization, 1993).”

From our article: "The ICD-10 established a set of diagnostic criteria for PCS in 1992." Boake C; McCauley SR; Levin HS; Pedroza C; Contant CF; Song JX; et al. (2005). "Diagnostic criteria for postconcussional syndrome after mild to moderate traumatic brain injury". Journal of Neuropsychiatry and Clinical Neurosciences. 17 (3): 350–6. doi:10.1176/appi.neuropsych.17.3.350. PMID 16179657. {{cite journal}}: Unknown parameter |author-separator= ignored (help)

I changed this to approved in 1990 and implemented in 1993.

From our article: "Preoccupation with the injury may be accompanied by the assumption of a "sick role" and hypochondriasis.[32]"

Substantial sections of our article seem to have a viewpoint of skepticism and downplaying. And that's not exactly the same at all of laying the information we have on the table, as messy as it may be. Not exactly the same at all. Yes, should include the skeptical side, should include a lot more besides.

And please jump in and help.  :>) The above are merely suggestions. Help in any way which you think most improves our article. Thanks. FriendlyRiverOtter (talk) 19:12, 13 June 2012 (UTC)

Perhaps the next project is to check the following source:

---

Yeates KO, Taylor HG (2005). "Neurobehavioural outcomes of mild head injury in children and adolescents". Pediatric Rehabilitation. 8 (1): 5–16. PMID 15799131. This is the source previously used to say post-concussion syndrome required loss of consciousness and then 3 of 8. And perhaps this link to whole article. http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=3&hid=15&sid=6977537d-264d-4416-b6f1-5d1fbd1a7250%40sessionmgr110 (library database)

"The vast majority of closed-head injuries (CHI) in children are of mild severity. Even if only a small proportion of children with mild CHI suffer persistent negative outcomes, then mild CHI is a serious public health problem. . "

Neurobehavioural outcomes of mild CHI
" . . In some cases, moreover, the post-concussive symptoms persist over time, lasting months or even years, despite the resolution of any deficits on standardized cognitive testing, and may be associated with significant functional morbidity [16–19]. The reason for the inconsistency of the findings concerning standardized cognitive testing as opposed to subjective symptom reports is a major source of debate in the scientific literature regarding mild CHI. . "

" . . the diagnostic criteria in ICD-10 and DSM-IV embody a longstanding controversy . . "

" . . The ICD-10 criteria reflect the assumption that post-concussive symptoms have a functional aetiology. Although the ICD-10 requires a history of head trauma associated with a loss of consciousness [the above 2010 version of ICD-10 downsteps this to a parenthetic note "(usually sufficiently severe to result in loss of consciousness)"], the subjective symptoms are said to occur in the absence of neuropsychological impairment and in association with psychological pre-occupation, hypochondriasis and adoption of a sick role. . "

" . . Although ‘psychogenesis’ and ‘physiogenesis’ are often described as competing explanations, they are not mutually exclusive [23,34]. . "

" . . Factor analyses of postconcussive symptom questionnaires have indicated that the symptoms can be arrayed along several dimensions, which are typically labelled cognitive (e.g. inattention, forgetfulness), somatic (e.g. headaches, dizziness, fatigue), emotional (e.g. irritability, depression) and behavioural (e.g. impulsivity, poor social judgement). . "

" . . In previous research on children with moderate-to-severe CHI, it was found that symptoms occurring shortly after an injury were more strongly related to pre-morbid child and family status, injury severity and post-injury cognitive functioning than to post-injury parent and family adjustment. In contrast, later symptoms, especially those involving emotional or behavioural problems, were related less to pre-morbid factors or injury characteristics and more to post-injury parent adjustment and family stressors and resources unrelated to the injury [39]. . "

Conceptual and methodological issues in research

" . . Children with positive findings on neuroimaging have usually been omitted and participants have not always been required to have any concussive symptoms associated with their injuries. . "

" . . More recently, non-injured children matched on demographic variables have been used as a comparison group [14]. Non-injured children do not constitute the best comparison group, however, because they are not equated to head-injured children in terms of the experience of a traumatic injury or ensuing medical treatment. Research also suggests that children who sustain traumatic injuries are more likely to display pre-morbid behavioural disorders, such as attention-deficit/hyperactivity disorder [43]. . "

" . . the measurement of post-concussive symptoms has typically been limited to questionnaires and rating scales, which almost always have been completed only by parents [15,16,18,39]. The agreement between child and parent reports of post-concussive symptoms has not been examined, nor has the agreement in symptom reports generated using different methods (i.e. questionnaire/rating scale vs structured interview). . "

" . . Previous research has also often focused on neuropsychological outcomes and paid scant attention to the relationship between mild CHI in children and functional outcomes such as school performance, general physical health and health care utilization. In adults, mild CHI and persistent post-concussive symptoms have been associated with chronic occupational disability (e.g. delayed return to work) [19,27]. . "

" . . Children with mild CHI are often treated as a homogenous group and compared to children without mild CHI without regard to whether factors such as loss of consciousness or abnormalities on neuroimaging increase the risk of negative outcomes [12,14]. . "

" . . Research also needs to incorporate measures of non-injury related risk factors, such as pre-morbid child status, post-injury parental coping . . "

" . . In many cases, children with pre-morbid learning or behaviour problems are omitted from studies, despite the possibility that those children are most at risk for persistent post-concussive symptoms. . "

" . . Below-average parent and family functioning exacerbate the negative effects of severe CHI, whereas above-average parent and family functioning buffer those effects. In a study focused specifically on neurobehavioural symptoms, it was found that parental psychological adjustment and family resources were significant predictors of emotional and behavioural symptoms in the first year post-injury, accounting for more variance than injury severity [39]. . "

" . . Of the existing longitudinal studies, moreover, few have followed children for more than relatively brief periods [50,51]. . "

" . . Existing longitudinal studies also can be criticized for failing to adopt a developmental approach in modelling outcomes. . "

" . . Studies of the outcomes of mild CHI have typically focused on group outcomes, in part because most common statistical techniques yield results that are based on group data. . "

" . . In clinical practice, however, one is interested in knowing whether the occurrence of mild CHI accounts for outcomes in a particular patient . . "

" . . Fortunately, the advent of techniques such as random slopes regression, in which regression coefficients vary systematically across individuals, and mixture modelling, which can be used to identify latent classes of individuals based in part on variations in background factors, should enable a more sophisticated examination of factors related to individual outcomes [55]. However, these techniques require relatively large samples, so that future studies are likely to require multiple sites to generate a sufficient number of participants. . "

Still a lot more article to look at, and then summarize. Again, please jump in and help. FriendlyRiverOtter (talk) 21:18, 14 June 2012 (UTC) FriendlyRiverOtter (talk) 21:18, 18 June 2012 (UTC)

Progress

I have notice that this has been open for over two months now. Are we any closer to getting a resolution? AIRcorn (talk) 08:37, 14 August 2012 (UTC)

Second Evaluation

GA review (see here for what the criteria are, and here for what they are not)

1. It is reasonably well written.

   a (prose): b (MoS for lead, layout, word choice, fiction, and lists):

2. It is factually accurate and verifiable.

   a (references): b (citations to reliable sources): c (OR):

3. It is broad in its coverage.

   a (major aspects): b (focused):

4. It follows the neutral point of view policy.

   Fair representation without bias:

5. It is stable.

   No edit wars, etc.:

6. It is illustrated by images, where possible and appropriate.

   a (images are tagged and non-free images have fair use rationales): b (appropriate use with suitable captions):

7. Overall:

   Pass/Fail:

1.a: I am a healthcare professional with quite a bit of training in the topic and there are parts of the [Post-concussion_syndrome#Causes] section that were to technical for me to understand.
b: looks good to me
2.a: Very well referenced
b: Some of the references used are too old. There has been an enormous amount of information that has come out in the last five years and I personally wouldn't trust anything that came out before 2010.
c: I didn't find any original research in this article; however, I didn't go through the article with a fine toothed comb
3.a: The article seems to cover all the major points on the topic
b: The article seems to stay on topic
4.a: The article seems to have a neutral point of view
5.a: The article doesn't seem to be in dispute although there is a large amount of editing going on to improve the article for this review
6.Note: This article would benefit from additional images.
a: Image has appropriate CC licence
b: Image is appropriately used and captioned
7.Fail

1. Overly complicated and jargon filled in some areas
2. Outdated references providing outdated information

ITasteLikePaint (talk) 02:11, 18 October 2012 (UTC)

Given the discussion here and at FriendlyRiverOtter (talk · contribs) I have decided to go ahead and delist this article. There are some good suggestions for improving the article. AIRcorn (talk) 11:51, 13 October 2012 (UTC)

I agree with the decision to delist. And I invite people to get involved in helping to make the article better. I thank Doc James, whose help as a practicing physician has been very valuable. I also thank Yobol for bringing up a number of good points, for example, this point: okay, a person who experiences trauma (whether direct or indirect) to the head has been checked for signs of neck injury, has been watched for worsening symptoms in the hours and day(s) afterward (and debatable whether waking the patient every couple of hours that first night is necessary, or whether the person would get more benefit out of uninterrupted sleep). Then the person has followed the standard recommendation of cognitive and physical rest in the days after the injury (and taking care not to get a second concussion). And most people (80 to 90%) have their symptoms go away after seven to ten days. But if the person is unlucky and is in that 10 to 20% and is still having symptoms, say six weeks down the road where they are squarely in the range of post-concussion syndrome, how much benefit is more rest going to do really? That's how I understand one of Yobol's points and I think it's a very good point. FriendlyRiverOtter (talk) 16:32, 17 October 2012 (UTC)

Consensus statement on concussion in sport – The 3rd International Conference on concussion in sport, held in Zurich, November 2008, Journal of Clinical Neuroscience, P. McCrory, W. Meeuwisse, K. Johnston, J. Dvorak, M. Aubry, M. Molloy, R. Cantu, 16 (2009) 755–763.

Also, from the American Academy of Pediatrics, Clinical Report, "Sport-Related Concussion in Children and Adolescents", Pediatrics, Mark E. Halstead, MD, Kevin D. Walter, MD, The Council on Sports Medicine and Fitness, Vol. 126 No. 3, September 1, 2010. (This is a review article we are not yet using in Post-concussion syndrome.)

It is less a question of will additional rest be beneficial and more of a question of being able to tolerate and adequately function in anything but rest and are they still at risk for Second impact syndrome. ITasteLikePaint (talk) 02:11, 18 October 2012 (UTC)

As I understand it, and I am not a doctor, just a person interested in the topic, second impact syndrome is (thankfully) relatively rare, whereas post-concussion syndrome is relatively common.

And as I also understand, it is often a series of concussions, and at one point, a person starts having real trouble. That, for example, a person can recover from five concussions, and the sixth one, they don't recover that well, or they recover much slowly. Or, it could be the 3rd concussion, or 7th concussion, or 12th. That there seems to be a random aspect, or at least an aspect no doctor in the world can predict in advance. FriendlyRiverOtter (talk) 17:27, 18 October 2012 (UTC)

How common post-concussion syndrome is is dependent on how you define it. I haven't read research on incidence rates for either condition but in my opinion they're both pretty rare. The only differences are that we know how to prevent second impact syndrome and that it will kill you. As for your second statement specifically there is a misconception that I want to make clear. You can get post-concussion syndrome from your very first concussion. Some people get concussions all the time and always bounce back just fine, some people never recover from their first. You are right though in that, as far as we can tell so far, there is no rhyme or reason to post-concussion syndrome. Both conditions are why concussions are treated so "aggressively" these days. ITasteLikePaint (talk) 02:01, 19 October 2012 (UTC)

Recent additions

I am concerned by the recent additions which seem to be adding material about concussions in general, rather than a discussion about post-concussion syndrome in particular. This does not seem appropriate here. Yobol (talk) 22:33, 14 June 2012 (UTC)

Yes agree completely. This content would belong on the page on concussion rather than here. Will I appreciate FriendlyRiverOtter efforts I have returned the page to how it was before. Before we said "Post-concussion syndrome is usually not treated" and this was changed to "The cornerstone of concussion management is physical and cognitive rest". While the latter is indeed true it applies to concussion.Doc James (talk · contribs · email) 03:48, 15 June 2012 (UTC)

Is that true, that post-concussion syndrome is usually not treated?

Because not according to the Merck source. FriendlyRiverOtter (talk) 20:01, 15 June 2012 (UTC)

You are indeed correct and I have corrected the text to match the source.Doc James (talk · contribs · email) 20:34, 15 June 2012 (UTC)

The Merck source discusses both concussions and PCS. It is important that we discuss the two separately and not conflate them. When the Merck source does not describe PCS specifically, we should assume it is discussing concussions in general. Yobol (talk) 20:02, 15 June 2012 (UTC)

There's going to be some overlap. I think we should accept that. From 2008 Consensus Statement:

McCrory, P (2009 Jul-Aug). "Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008". Journal of athletic training. 44 (4): 434–48. PMID 19593427. {{cite journal}}: Check date values in: |date= (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)

“ . . The panel, however, unanimously retained the concept that most (80–90%) concussions resolve in a short period (7–10 days), although the recovery time frame may be longer in children and adolescents. . ”

So, we can begin to ask, Does that mean symptoms and treatment past 7-10 days are talking about post-concussion?

Now, in the case of Merck, we get lucky. They directly use the phrase. But we're not always going to have that luxury. FriendlyRiverOtter (talk) 20:15, 15 June 2012 (UTC)

[24] The Merck Manual Home Health Handbook, Concussion, last full review/revision January 2008 by Kenneth Maiese, MD. The last paragraph reads:
"Treatment for postconcussion syndrome is based on the severity of the symptoms. Rest and close observation are important. People who experience emotional difficulties may need psychotherapy. Repeated concussions may increase a person's risk in later life for dementia, Parkinson's disease, and depression. People should not return to contact sports after a concussion until all ill effects have resolved and medical evaluation has been completed."

I will update our article to reflect this. And, I could use some help checking content against references. FriendlyRiverOtter (talk) 20:22, 15 June 2012 (UTC)

There should be minimal overlap. This is not the article on concussions. This is a different article, and we should not provide information on one when it is more appropriate in another article. From an article that focuses on concussions in general, and mentions PCS briefly, unless it specifically discusses mention PCS we should assume they are discussing concussions in general. There is no reason to use general "concussion" sources when we have multiple good sources which speak to PCS specifically. Yobol (talk) 20:25, 15 June 2012 (UTC)

And I have reverted the addition which discusses concussion in general to treatment section. As PCS can last for months, it makes no sense that "rest and close observation" be the treatment for this condition. Yobol (talk) 20:33, 15 June 2012 (UTC)

Changed it slightly. Do you think that is a fair balance? The ref does not say treatment is nothing but says it is rest and potentially psychotherapy. Close observation is not really a treatment.Doc James (talk · contribs · email) 20:37, 15 June 2012 (UTC)

I'm not sure why we're even using the Merck source; we have multiple review articles cited, which would probably be better sources. I'll go through some at some point, but "rest" as a treatment for a condition that can last for months makes little sense to me (but makes plenty of sense as a treatment for acute concussion). Yobol (talk) 20:39, 15 June 2012 (UTC)

Yobol, neither one of us are doctors (I don't think. I know I'm not a doctor, I guess the baseline is that approximately 1 out of 500 (?) persons is). I really don't want to question the references other than other areas we can research. Now, Doc James is a doctor. But if anything he faces a greater challenge. Doc James, I'm sure you know you can't just speak freely like you might on TV and educate the public, right? I mean, the talk page to a considerable extent, but the article itself, has to be right down the middle with references. My guess is, that it's probably harder for a doctor just like it would be harder for an expert on the Renaissance to update that page. FriendlyRiverOtter (talk)

I think the Merck source conflates concussions and PCS too much, (and think that the treatment discussion conflates them as well) and would prefer to use sources that speaks specifically to PCS, especially when we have multiple review articles available for that purpose (which are our preferred source per WP:MEDRS. I will eventually go through these review articles, but have my priorities elsewhere at the moment. Yobol (talk) 20:50, 15 June 2012 (UTC)

I am starting to ask myself, does the professional literature draw that big a distinction between concussion symptoms and post-concussion symptoms? FriendlyRiverOtter (talk) 21:37, 16 June 2012 (UTC)

Yobol, I think you bring up a very good point when you basically say, yes, I can see how rest makes plenty of sense as treatment in the immediate aftermath of a concussion, but for symptoms which have gone on for several months, how much good is additional rest really going to do? And this highlights the potential seriousness of post-concussion syndrome. Serious, potential lifetime injury, yes, sadly the case. All the stuff I've read and skimmed, the only treatment I can recall which might help is the example and analogy of antidepressants being given (still experimentally?) to stroke victims in an effort to grow additional nerve connections. (Standard advice for antidepressants is that the first one tried may not 'click' for a particular patient, but another one may. And also, often important to step down in phases.) I'd very much like to have the references for additional treatments.

From the 2008 Consensus Statement: " . . retained the concept that most (80–90%) concussions resolve in a short period (7–10 days) . . " So maybe the gray area is day 11, 12, 13, and running into several weeks. That's perhaps where additional rest, both cognitive and physical, might really make a difference. Plus, the whole concept of the stepwise return which the consensus statement talks about. FriendlyRiverOtter (talk) 17:42, 18 June 2012 (UTC)

Diagnosis section

In our Diagnosis section, it currently states: "In order to meet these criteria, a patient must have had a head injury with loss of consciousness[23] and develop at least three of the eight symptoms marked with a check mark in the table at right under "ICD-10" within four weeks.[33][34]"

Now, what ICD-10 actually says, ICD-10, International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) Version for 2010, F07.2 Postconcussional syndrome, World Health Organization.
"A syndrome that occurs following head trauma (usually sufficiently severe to result in loss of consciousness) and includes a number of disparate symptoms such as headache, dizziness, fatigue, irritability, difficulty in concentration and performing mental tasks, impairment of memory, insomnia, and reduced tolerance to stress, emotional excitement, or alcohol."

To me, this is so old school. Concussion <--> loss of consciousness, that's like a 1950s understanding. The seemingly 2010 revision "(usually sufficiently severe . . ," I guess is some improvement. But I think it would help a lot to include things like the 2008 Concensus Statement, " . . may or may not involve loss of consciousness. . " And in general, I favor us finding and including a variety of good sources. FriendlyRiverOtter (talk) 20:58, 15 June 2012 (UTC)

Treatment section

I think there's a lot of benefit to the 2008 Consensus statement where they talk about a graded series of steps as far as reintroducing oneself to activities. And they emphasize both physical rest and cognitive rest, including such activities as school and video games. The graded series and the cognitive rest are two things a lot of people are not going to know, or only know partially, and we have an authoritative source backing them up.

I've read some doctors prescribe antidepressants after a stroke in an attempt to help a patient grow new nerve connections (not new nerve cells themselves). I mean, what it is, is what it is. Don't know if this works, don't know if physicians also prescribe antidepressants post concussion. I do think depression is starting to get the attention it deserves as a serious condition and a treatable condition. I've also read that the first antidepressant is not necessarily the one which will work for a patient, and that it's sometimes important for a person to step down from an antidepressant in phases even if the medication doesn't seem to be working. Now, this is getting a little far afield, but I've heard depression mentioned often enough in the context of post-concussion, that I think it's valuable to include some of this information, provided we can find good sources.

Merck recommends aspirin or similar NOT be used for headache that if there's damaged blood vessels, can lead to bleeding.

2008 Consensus Statement end material, Concussion injury advice:
“ . . Use paracetamol or codeine for headache. Do not use aspirin or anti-inflammatory medication . . ”

Concussion, last full review/revision January 2008 by Kenneth Maiese, MD:
" . . For concussion, acetaminophen is given for pain. Aspirin or another nonsteroidal anti-inflammatory drug (NSAID—see Pain: Nonsteroidal Anti-Inflammatory Drugs) should not be taken because they interfere with blood clotting and may contribute to bleeding from damaged blood vessels. . "

Whereas our article currently writes: " . . Side effects of medications may affect people suffering the consequences of MTBI more severely than they do others, and thus it is recommended that medications be avoided if possible; . . ref name="McAllister02"/> there may be a benefit to avoiding narcotic medications. . . ref name="ropper"> . . " Well, the obvious contradiction is that codeine is an opiate and thus arguably a 'narcotic,' and I don't know about paracetamol. Of course, doesn't mean it's a bad thing. Like any medication, properly used, under a doctor's guidance, can be beneficial. And I think we should put at least a fair amount of weight on the 2008 Consensus Statement.

And then there's the whole dynamic aspect. From Merck: " . . Repeated concussions may increase a person's risk in later life for dementia, Parkinson's disease, and depression. . " From the Consensus statement . . . Zurich, November 2008: "4.5. The role of pre-participation concussion evaluation . . . . Questions pertaining to disproportionate impact versus symptom severity matching may alert the clinician to a progressively increasing vulnerability to injury. . . ”

I take it, this rather technical formal language, what they're saying is if a football player or a hockey player gets another concussion from a smaller blow, wow, that's kind of a warning sign, a sign to ease back, to start enjoying your non-contact sports, and to give the contact sports a good. Once again, the dynamic aspect, which needs to be a part of the conversation.

And what about the old school advice that after a head injury, a person should be watched, and the first night sleeping they should be woken up every 90 minutes (?) or so. And then there's the tragedy which happened to the actress Natasha Richardson several years ago while skiing. This may have been a different type of head injury, highlighting the importance of a clinician evaluating for a range of potential injuries. FriendlyRiverOtter (talk) 20:51, 16 June 2012 (UTC)

International conference on concussion and sport scheduled for Nov. 2012

Physicians must be brought up to speed on concussion risks, CMAJ News, Canadian Medical Association Journal (CMAJ), Jordan Fallis, Vol. 184 (2), February 7, 2012, (first published electronically December 19, 2011).

" . . . Revisions to international concussion guidelines are also needed, the panelists argued [special seminar on concussions in hockey held at Scotiabank Place in December 2011]. The current guidelines were developed in 2008, when the Third International Conference on Concussion in Sport developed the Consensus Statement on Concussion in Sport, which lays out evidence-based guidelines for physicians, trainers and other health care professionals on how to treat concussed patients (http://sportconcussions.com/html/Zurich%20Statement.pdf). An update is expected to be released after a conference to be held in Zurich, Switzerland in November 2012."

So, when this comes out, we can read it and possibly incorporate parts of it into our article. And at the same time, we can also look for other good sources. FriendlyRiverOtter (talk) 18:47, 25 June 2012 (UTC)

re: "It has been convincingly shown that psychological factors play an important role in the presence of post-concussion symptoms."

I was just reading the source for this claim, and it doesn't convincingly show that (depending on what exactly is meant by 'psychological'). The author may believe this is true, but that would only justify saying something like "Some researchers are convinced that it has been shown that psychological factors play an important role in the presence of post-concussion symptoms."

Given the difficulty of meaningfully diagnosing PCS and the potential for confounding factors, I think that this claim needs to be more cautiously phrased. Evidence that, post-concussion, those with on-going symptoms are also likely to develop emotional or cognitive cannot really be used to claim that they play an important role in the presence of post-concussion symptoms, particularly given how little we understand as to what causes people to suffer from mental health problems. — Preceding unsigned comment added by 87.115.186.110 (talk) 01:40, 9 November 2013 (UTC)

DSM V

the DSM V is out and it doesn't have "postconcussional disorder" in it. so all references to that should either be removed, or adjusted to show that it is only in the DSM-IV (and maybe earlier). i'd think this is obvious/factual enough, but if a source is needed: http://www.acnr.co.uk/2015/04/postconcussion-syndromedisorder-or-mild-traumatic-brain-injury-diagnostic-issues-and-treatment/ or, to show that others were wondering about it: https://www.researchgate.net/post/Where_did_the_Post-Concussive_Disorder_of_DSM- Colbey84 (talk) 13:13, 27 November 2016 (UTC)

2016 - this article needs some serious updating

some of the sources are pretty old, especially for a medical article, and especially for a medical topic that has had a LOT of interest. combining these older sources with the use of phrases like "most experts agree," "it has been argued," "it appears that," "it has been argued" (and others) makes this article appear slanted. i mean, one of these sources is from 1995, and as was noted on this Talk page in another section, we should "use reviews from the last 5 or 10 years at most."

i don't have time to really dig into this (or into editing this page), but i note that others have shown quite an interest in this article, so maybe someone will find the time to work on this. i did find some possible sources. this one was mentioned before on this Talk page, but it was updated, so this is a link to the newer version: "Military blast exposure, ageing and white matter integrity" http://brain.oxfordjournals.org/content/138/8/2278

but the biggest issue with this article is now summed up by this: "A longstanding controversy surrounding PCS concerns the nature of its etiology..." and then the way the rest of the article is presented (as i noted, with the above phrases). i don't know for sure whether this is still a controversy, but my quick perusal of some of the following sources seems to indicate that it's not. or not as much of one.

• "Postconcussive Syndrome in the ED" – Sep. 2016

http://emedicine.medscape.com/article/828904-overview "While recent research has shown that psychological factors may be present early, other studies using imaging techniques such as magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT), and magnetoencephalography (MEG) have demonstrated the presence of organic brain injury in patients with persistent postconcussive syndrome at greater than 1 year after injury."

• "Classification and Complications of Traumatic Brain Injury" – June 2016:

http://emedicine.medscape.com/article/326643-overview

• "Role of Pre-Morbid Factors and Exposure to Blast Mild Traumatic Brain Injury on Post-Traumatic Stress in United States Military Personnel." – Mar. 2016:

https://www.ncbi.nlm.nih.gov/pubmed/27027526

• "Traumatic Brain Injury (TBI) - Definition and Pathophysiology" – 2015:

http://emedicine.medscape.com/article/326510-overview

• "Prevalence of mental health conditions after military blast exposure, their co-occurrence, and their relation to mild traumatic brain injury." – 2015:

https://www.ncbi.nlm.nih.gov/pubmed/26479126

• "Mild traumatic brain injury and postconcussive syndrome: a re-emergent questioning" – 2012:

https://www.ncbi.nlm.nih.gov/pubmed/22980474

• "CURRENT CONTROVERSIES IN TRAUMATIC BRAIN INJURY" – 2011:

http://www.aqua.ac.nz/upload/resource/Current%20controversies%20in%20traumatic%20brain%20injury.pdf

• "Mild traumatic brain injury (concussion) during combat: lack of association of blast mechanism with persistent postconcussive symptoms." – 2010:

https://www.ncbi.nlm.nih.gov/pubmed/20051900

• "Experience with mild traumatic brain injuries and postconcussion syndrome at Kandahar, Afghanistan." – 2010:

https://www.ncbi.nlm.nih.gov/pubmed/21181651

this page has MANY sources on it (and an interesting discussion). but one of the participants noted that the following 5 sources were directly related to this controversy: How soon can the demyelinating process start in mild traumatic brain injury?: https://www.researchgate.net/post/How_soon_can_the_demyelinating_process_start_in_mild_traumatic_brain_injury

Stapert et al 2006 http://arnop.unimaas.nl/show.cgi?fid=4933 Silver et al, 2009 http://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2009.08111676 Bigler, 2013a http://journal.frontiersin.org/article/10.3389/fnhum.2013.00395/abstract Le et al 2008 http://online.liebertpub.com/doi/abs/10.1089/neu.2008.0566 Spencer et al 2010 http://online.liebertpub.com/doi/abs/10.1089/neu.2008.0566

Colbey84 (talk) 13:39, 27 November 2016 (UTC)

Merck manual as source

Decided i should probably put this is a separate section, as i noted in the "Dubious" tag there would be one. It's not so much that i think a Merck online manual is "dubious," but that i thought the way it was being used was. As in, for a sentence talking about malingering and, basically, people lying about their medical symptoms to get a benefit in some other way, the source was a Merck manual that discussed PEDIATRIC PCS.

AND...that Merck page is no longer available. So it can't even be perused to see if Merck truly asserted that children were claiming they had concussive symptoms so they could get a check from someone. I did find 2 available Merck pages, but didn't change that reference because i was unsure what the intent of the original author was.

• Merck Manuals, Professional version, Traumatic Brain Injury

http://www.merckmanuals.com/professional/injuries-poisoning/traumatic-brain-injury-tbi/traumatic-brain-injury

• Merck Manuals, Consumer version, Concussion

http://www.merckmanuals.com/home/injuries-and-poisoning/head-injuries/concussion

Colbey84 (talk) 13:46, 27 November 2016 (UTC)

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Hyperbaric oxygen therapy

Yesterday I added a paragraph to say:

Recently hyperbaric oxygen therapy has been found to help the brain recover. Patients were treated with pure oxygen at a pressure of 2 atm absolute in a series of 40 one-hour sessions.

This was promptly reverted by User:Sciencewatcher with the comment that the study had no control and that a controlled study of 2012 found no effect. So I reverted back to my versioin with the comment that he should read the reference in New Scientist. Now he has reverted that again saying that New Scientist is not a reliable source for medical information. I doubt that he read the article, because rather than making medical claims, it quotes Lindell Weaver, the author of a study in 2015 which concluded that hyperbaric oxygen therapy was no better than a sham treatment. He admits that the "sham" treatment did involve putting people into a hyperbaric chamber, so actually they were getting a higher-than-normal oxygen pressure, and that "the burden of evidence is starting to suggest there is a favourable effect". The New Scientist article also says that in the new research they could see that the hyperbaric oxygen therapy caused regrowth of blood vessels and nerve fibre in the affected region of the brain. This would not happen in a sham treatment. This is in the "reliable source" in the second reference I gave. But I object to excluding a source like the New Scientist article on the excuse that the magazine is not a reliable reference. Can Sciencewatcher deny that Weaver said the above, just because it's in New Scientist rather than the Lancet? Let's not be slaves to technicalities. Let's try to give readers the most up-to-date information on what's going on in this field of research! Eric Kvaalen (talk) 07:44, 12 November 2017 (UTC)

If you read WP:MEDRS it explains why we don't use sources like newscientist for medical information. Also, your argument doesn't hold water. We know that psychological treatments do in fact cause changes in brain structure. If the hyperbaric oxygen had an effect, you would expect it to be dose dependent, so having mildly elevated pressure would be a valid placebo. That's why we don't use sources like newscientist, because they don't rigorously examine the science. --sciencewatcher (talk) 16:30, 12 November 2017 (UTC)

I find it very frustrating that whenever I add some interesting or potentially useful information to an article like this, someone who has a "watchpoint" set on the article comes along within minutes and, because he has never heard the information before or thinks it's nonsense, reverts my changes. They always cite backup from this or that Wikipedia policy. These people always get the last word, because no one else pays attention, and you can't just revert or you'll be accused of waging an edit war. But Wikipedia policy can be cited both ways. There's a policy saying that we should use second- or third-hand sources rather than first-hand sources because the former show that something is significant and accepted by a wider group than just the researchers. So for example, my New Scientist article says that one of the researchers who hadn't found an effect is now admitting that there probably is an effect (not just placebo). But then Sciencwatcher says that New Scientist is off limits, so we can't even mention this interesting line of research! I'll bet that in a few years it will be clear that hyperbaric oxygen therapy does work and it will be used all over the world. By the way, even if it were a placebo effect, it would be worth doing! Eric Kvaalen (talk) 09:33, 15 November 2017 (UTC)

Look, it's nothing to do with me. Feel free to re-add your change and I won't revert it (but someone else probably will, as it is a clear violation of MEDRS). I would suggest you read up on MEDRS and see why we rely on peer-reviewed secondary sources (which new-scientist isn't). --sciencewatcher (talk) 17:22, 15 November 2017 (UTC)

Suggestions to improve the article

Hi @Fanman1999: thanks for all your hard work to improve this article. I reversed your edit for now, but it is still archived. Do you mind adding your suggestions here so we can go through them slowly and ensure that all the content is appropriate for Wikipedia before adjusting the article live? I encourage you to also speak with your instructor and consult WP:MEDRS to help determine which sources are appropriate for Wikipedia. This is a tough topic to edit on. You may need to use your instructor as well to help you interpret the secondary study papers that you find. Concussion research is evolving rapidly (and is super interesting), basically anything pre-2017 is outdated. Thanks so much. It is great to see new editors here, we hope that you stick around and help improve the article! JenOttawa (talk) 23:03, 1 December 2021 (UTC)

Pinging @Ian (Wiki Ed): here as well from Wikieducation. The folks at Wikied are excellent at helping students and have a ton of great resources.JenOttawa (talk) 23:07, 1 December 2021 (UTC)

Section on upper cervical care

I was bold and removed a small paragraph on chiropractic methods as it was based on one case series report. Here is the removed text (pasted below. If anyone has ideas for how to improve this section with higher quality sources that meet MEDRS please add in.

Upper cervical care 
Post-concussion syndrome can sometimes be the result of a misalignment in the upper cervical spine (neck) specifically the C1 (Atlas) or C2 (Axis) which surround the brain stem. Some individuals have found relief through upper cervical care. An upper cervical chiropractor is a specialist who uses x-rays to identify misalignments in the upper cervical spine then gently repositions the top two bones of the neck. There are currently approximately seven different chiropractic methods of repositioning the C1 bone, however the three most popular techniques are NUCCA (adjustment done by hand), Blair Technique (adjustment done by hand), and Atlas Orthogonal (adjustment done by a machine).
 

JenOttawa (talk) 17:36, 19 July 2023 (UTC) JenOttawa (talk) 17:36, 19 July 2023 (UTC)

@Dinoz1: if you disagree with this please reach out or discuss here. Happy to work together to improve this article and leave in if we can find higher quality sources.JenOttawa (talk) 17:40, 19 July 2023 (UTC)

There is one recent systematic review here that I just found sharing evidence on non-pharmacological whiplash treatment and mTBI. PMID 33682560. The 6th Consensus on Concussion in Sport would also be helpful for improving this article as they have a recommendation that is based on expert consensus and the results of their systematic review on interventions. JenOttawa (talk) 17:52, 19 July 2023 (UTC)

@JenOttawa: Hi JenOttawa. I apologize for the revert, I had no idea about the weak source, thanks for pinging me and letting me know about this. I was a bit confused on why the IP left no edit summary (which i mistaked for an unexplained deletion). Cheers, Dinoz1 (chat?) (he/him) 18:10, 19 July 2023 (UTC)

Hi @Dinoz1: no problem at all. I am not sure who the IP was either, the edit just caught my eye so I checked the source. I felt badly removing it right after you put it back in, it was not my intention! Have a terrific day! JenOttawa (talk) 18:23, 19 July 2023 (UTC)