Talk:Post-concussion syndrome/GA2

GA Reassessment

Article (edit | visual edit | history) · Article talk (edit | history) · Watch

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" [1] 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.

• [2]
• [3]
• 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.'

---

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)