Personal Injury Report for February LAW OF INERTIA HEAD INJURIES (Part 1) AND HOW THEY RELATE TO REAR-IMPACT COLLISIONS

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1 Frank McDiarmid, D.C., FRCCSS (Canada) ( Quadra Chiropractic City Centre Chiropractic 2602 Quadra Street 2832 Leigh Road Victoria, B.C. Langford, B.C. V8T 4E4 V9B 4G3 Tel: Tel: Fax: Fax: Dr. McDiarmid s Personal Injury Report for February LAW OF INERTIA HEAD INJURIES (Part 1) AND HOW THEY RELATE TO REAR-IMPACT COLLISIONS 1

2 Good Morning: The April 4-5, 2014 TLABC conference, in Vancouver, on brain injury, fast approaching, I thought I would give you an introduction to the topic and specifically how it relates to the rear-impact collision. The list of speakers is excellent, but the program does not appear to cover mtbi and whiplash. It is well established a person does not have to contact the interior of the vehicle s cabin in order to have a mtbi, and they do occur in Low Speed Rear-Impact Collsions (LOSRICs). Mild Traumatic Brain Injury, Not So Mild After All ScienceDaily (Feb. 22, 2010) Douglas Smith, MD, director of the Center for Brain Injury and Repair and professor of Neurosurgery at the University of Pennsylvania School of Medicine, presented findings on the molecular mechanism at play in mild traumatic brain injury (mtbi), commonly known as concussions, recently at the 2010 American Association for the Advancement of Science meeting in San Diego. Although mtbi affects over 1.7 million people each year in the United States, it is generally ignored as a major health issue. However, this "mild" form of injury induces persisting neurological and cognitive problems in many of these patients, exacting an enormous emotional and financial toll on society. Despite the prevalence and impact of mtbi, little is known about how mtbi affects nerve cells and connections in the brain, and therefore clinical outcomes after injury. Smith and colleagues have begun to amass data from human and animal studies on mtbi at 2-4 days after injury using advanced neuroimaging techniques. They have found distinct changes throughout the white matter in the brain. Also, protein markers of brain pathology were identified after mtbi in the blood of mtbi patients. Concussion, from the Latin concutere ("to shake violently")[1] or concussus ("action of striking together"),[2] is the most common type of traumatic brain injury. The terms mild brain injury, mild traumatic brain injury (MTBI), mild head injury (MHI), minor head trauma, and concussion may be used interchangeably,[3][4] although the last is often treated as a narrower category.[5] Although the term "concussion" is still used in sports literature as interchangeable with "MHI" or "MTBI", the general clinical medical literature now uses "MTBI" instead.[6] In this article, "concussion" and "MTBI" are used interchangeably. Frequently defined as a head injury with a temporary loss of brain function, concussion causes a variety of physical, cognitive, and emotional symptoms, which may not be recognized if subtle. Treatment involves monitoring as well as physical and cognitive rest (reduction of such activities as school work, playing video games and text messaging).[7] Symptoms usually resolve within three weeks, though they may persist or complications may occur for month or years.[8] 2

3 Those who have had one concussion seem more susceptible to another, especially if the new injury occurs before symptoms from the previous concussion have completely resolved.[9] There is also a negative progressive process in which smaller impacts cause the same symptom severity.[7] Repeated concussions may increase the risk in later life for dementia, Parkinson's disease, and/or depression.[9] A variety of signs accompany concussion including somatic (such as headache), cognitive (such as feeling in a fog), emotional (such as emotional changeability), physical signs (such as loss of consciousness or amnesia), behavioral changes (such as irritability), cognitive impairment (such as slowed reaction times), and/or sleep disturbances.[7] A 2010 Pediatrics review article focusing on children and adolescents noted that fewer than 10% of sports-related concussions had associated loss of consciousness.[10] Due to varying definitions and possible underreporting, the rate at which concussion occurs annually is not accurately known, but is estimated to be more than 6 per 1,000 people.[11] Common causes include sports injuries, bicycle accidents, motor vehicle collisions (remember, they haven t been called accidents >10 years), and falls, the latter two being the most frequent among adults.[12] In addition to a blow to the head, concussion may be caused by acceleration forces without a direct impact, and on the battlefield, MTBI is a potential consequence of nearby explosions.[13] It is not known whether the brain in concussion is structurally damaged or whether there is mainly a loss of function with only physiological changes.[14][needs update] Cellular damage has reportedly been found in concussed brains, but it may have been due to artifacts from the studies.[15] It is now thought that structural and neuropsychiatric factors may both be responsible for the effects of concussion.[16] Rear Impact Collision and the Law of Inertia Rear Impact Collisions are a major cause of concussion in the US, approximately 60% to 67% of all TBI are the result of MVC. The Law Of Inertia The object in question in a whiplash trauma is a human body. The human body has two large parts that have their own separate inertia, the trunk and the head. These two large pieces of inertial mass (the head and the trunk) are connected by a thin pole, the neck. Upon impact, the target vehicle begins to move forward into the occupant, making contact chiefly through the seat back. In accordance with Newton's 1st law of motion, the occupant's inertia resists this motion. 3

4 As the seat back continues to move forward, the occupant must yield. Initially, the thoracic curve is flattened by the seat back. This results in a vertical compressive force which is transmitted through the spine. So far, we have not been able to determine to what degree--if any--the lumbar spine also flattens. As the vertical compressive force (-z) continues up the spine, some rise of the torso also occurs. This is called ramping and is halted after 1-3 inches of vertical displacement, usually because of the restraining effect of the seat belt and the weight of the torso. Meanwhile, as the torso now is undergoing both a z acceleration vertical and an x linear acceleration, the head--also acting in accordance with Newton's 1st law of motion--attempts to remain at rest. As the vertical force extends upwards into the neck it initiates flexion of the upper cervical segments and hyperextension of the lower segments. As the torso continues to move forward, the neck begins to pull the head along with it. This has the effect of further flexing the upper cervical spine and hyperextending the lower cervical spine (primarily the C5-6 segments) and the spine assumes an s-shaped configuration, Figure below. The head also is induced to extend along with the neck as the head takes up the backset distance during the head lag phase. Depending on specific head restraint geometry (occupant's position relative to the restraint), head restraint contact will usually occur in about 100 msec at which time head translational acceleration will peak. Any stored energy in the seat back from its deflection (usually about 5-15 degrees) will be released as the occupant begins to more forward into the re-entry phase. This effectively increases the torso and head speed (overspeed). As this change of phase occurs, the direction of horizontal shear reverses rapidly and the rearward bending moment quickly gives way to a forward bending moment. Depending on the initial position of the occupant with respect to safety harnesses, the lap and shoulder portions will eventually restrain the forward moving torso which will effectively aggravate the neck's bending moment since the forward moving head's inertia again is behaving in accordance with Newton's 1st law of motion--this time in the x direction with some angular momentum and acceleration. The weight of the human head (10-12 lbs.) plus the force of a moving vehicle that may carry 10,000 to 20,000 pounds of force is not a good combination. Below is the example of the head striking which is also the same mechanism of the head striking the head rest. 4

5 From page 6 in the CDC: 5

6 Post-traumatic amnesia is better predictor of outcome after MTBI than loss of consciousness; recent research has indicated that amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following concussion than is LOC (less than 1 minute). CDC Toolkit, Heads Up: Brain Injury in Your Practice, Acute Concussion Evaluation (ACE), Instructions, p. 2 Emergency rooms miss MTBI 56% of time. Powell JM, Ferraro JV, Dikmen SS, Temkin NR, Bell KR, Accuracy of mild traumatic brain injury diagnosis. Arch Phys Med Rehabil Aug;89(8):

7 This is a troubling trend, this also indicate that most general medical practices, family practices, primary care physicians, urgent care facilities and chiropractic offices are also missing at least 56% of the injuries. Page 3: The purpose of the Personal Injury Report is to keep you updated on relevant academic concepts pertaining to side/rear impact whiplash injury patients. I hope that the information is useful in terms of enhanced understanding, as well as helpful for the personal injury attorneys to deal with insurance claim adjusters, healthcare providers and adverse medical experts. 7

8 This spring is the final leg in my journey to be able to qualify as an expert witness in crash reconstruction. Previously you would have to hire an ACR, which for the most part really did nothing when it came to relating the injuries to the crash. As one of only a very small handful of health care providers, in Canada, certified in Crash Reconstruction I am able to testify regarding issues related to the crash itself, the biomechanics of how the person(s) were injured, and of course the clinical, all in one siting and all from one person, something never before made available to counsel on Vancouver Island, let alone the lower mainland. As we all know only 3-5% of these cases over make it to trial, and the number one reason these cases fail (let alone get minimal settlements) is failure to link the specifics of the crash to the specifics of the injuries. Having an IME report, including all three components, is proving most enlightening when talking settlement amounts and the other side claims your client could not have been injured. Because the average medical doctor has as much training in these injuries as they do in dentistry, your clients own doctors lack of findings is typically used against your client. Those days are now over!!!! Let s start to introduce some actual science into these cases and get away from so many of those tired, and outdated, arguments. My hope is that this, and earlier PI Reports, will help us on the road to less reliance on Cultural Authority and more reliance on peer reviewed literature. Additionally, your law firm has access to daily phone consultation (or ) with me, to discuss any pertinent issues you might face, on a particular case. That applies as much to defense as plaintiff counsel. Frank McDiarmid, DC, FRCCSS (Canada) directly: References: 1. Pearce JM (2007). "Observations on concussion. A review". European Neurology 59 (3 4): doi: / PMID Brooks D, Hunt B (2006). "Current concepts in concussion diagnosis and management in sports: A clinical review". BC Medical Journal 48 (9): National Center for Injury Prevention and Control (2003). "Report to congress on mild traumatic brain injury in the United States: Steps to prevent a serious public 8

9 health problem" (PDF). Atlanta, GA: Centers for Disease Control and Prevention. Retrieved Petchprapai N, Winkelman C (2007). "Mild traumatic brain injury: determinants and subsequent quality of life. A review of the literature". Journal of Neuroscience Nursing 39 (5): PMID Sivák Š, Kurča E, Jančovič D, Petriščák Š, Kučera P (2005). "Nácrt súcasného pohl'adu na problematiku l'ahkých poranení mozgu so zameraním na dospelú populáciu" [An outline of the current concepts of mild brain injury with emphasis on the adult population] (PDF). Časopis Lėkařů Českých (in Slovak) 144 (7): PMID Barth JT, Varney NR, Ruchinskas RA, Francis JP (1999). "Mild head injury: The new frontier in sports medicine". In Varney NR, Roberts RJ. The Evaluation and Treatment of Mild Traumatic Brain Injury. Hillsdale, New Jersey: Lawrence Erlbaum Associates. pp ISBN Retrieved McCrory, P; Meeuwisse, W; Johnston, K; Dvorak, J; Aubry, M; Molloy, M; Cantu, R (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): doi: / PMC PMID Anderson T, Heitger M, Macleod AD (2006). "Concussion and mild head injury". Practical Neurology 6 (6): doi: /jnnp Kenneth Maiese (January 2008). "Concussion". The Merck Manual Home Health Handbook. 10. From 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, Cassidy JD, Carroll LJ, Peloso PM, Borg J, von Holst H, Holm L, et al. (2004). "Incidence, risk factors and prevention of mild traumatic brain injury: Results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury". Journal of Rehabilitation Medicine 36 (Supplement 43): doi: / PMID Ropper AH, Gorson KC (2007). "Clinical practice. Concussion". New England Journal of Medicine 356 (2): doi: /nejmcp PMID Warden, Deborah L.; French, Louis M.; Shupenko, Leslie; Fargus, Jamie; Riedy, Gerard; Erickson, Marleigh E.; Jaffee, Michael S.; Moore, David F. (2009). "Case report of a soldier with primary blast brain injury". NeuroImage 47: T doi: /j.neuroimage PMID Shaw NA (2002). "The neurophysiology of concussion". Progress in Neurobiology 67 (4): doi: /s (02) PMID Rees PM (2003). "Contemporary issues in mild traumatic brain injury". Archives of Physical Medicine and Rehabilitation 84 (12): doi: /j.apmr PMID

10 16. Riggio S, Wong M (2009 Apr). "Neurobehavioral sequelae of traumatic brain injury". Mt Sinai J Med 76 (2): doi: /msj PMID Satz P, Zaucha K, McCleary C, Light R, Asarnow R, Becker D (1997). "Mild head injury in children and adolescents: A review of studies ( )". Psychological Bulletin 122 (2): doi: / PMID Comper P, Bisschop SM, Carnide N, Tricco A (2005). "A systematic review of treatments for mild traumatic brain injury". Brain Injury 19 (11): doi: / ISSN PMID Aubry M, Cantu R, Dvorak J, Graf-Baumann T, Johnston K, Kelly J, Lovell M, McCrory P, Meeuwisse W, Schamasch P; Concussion in Sport Group. (2002). "Summary and agreement statement of the first International Conference on Concussion in Sport, Vienna 2001*". British Journal of Sports Medicine 36 (1): PMC PMID Cantu RC (2006). "An overview of concussion consensus statements since 2000" (PDF). Neurosurgical Focus 21 (4:E3): Parkinson D (1999). "Concussion confusion". Critical Reviews in Neurosurgery 9 (6): doi: /s ISSN Head Injury: Triage, Assessment, Investigation and Early Management of Head Injury in Infants, Children and Adults (PDF). National Institute for Health and Clinical Excellence. September ISBN Retrieved Ruff RM, Grant I (1999). "Postconcussional disorder: Background to DSM-IV and future considerations". In Varney NR, Roberts RJ. The Evaluation and Treatment of Mild Traumatic Brain Injury. Hillsdale, New Jersey: Lawrence Erlbaum Associates. p ISBN Cobb S, Battin B (2004). "Second-impact syndrome". The Journal of School Nursing 20 (5): doi: / PMID Kushner D (1998). "Mild Traumatic brain injury: Toward understanding manifestations and treatment". Archives of Internal Medicine 158 (15): doi: /archinte PMID Lee LK (2007). "Controversies in the sequelae of pediatric mild traumatic brain injury". Pediatric Emergency Care 23 (8): doi: /pec.0b013e ea. PMID Benton AL, Levin HS, Eisenberg HM (1989). Mild Head Injury. Oxford [Oxfordshire]: Oxford University Press. pp. v. ISBN X. 28. van der Naalt J (2001). "Prediction of outcome in mild to moderate head injury: A review". Journal of Clinical and Experimental Neuropsychology 23 (6): doi: /jcen PMID Savitsky EA, Votey SR (2000). "Current controversies in the management of minor pediatric head injuries". American Journal of Emergency Medicine 18 (1): doi: /s (00) PMID Parikh S, Koch M, Narayan RK (2007). "Traumatic brain injury". International Anesthesiology Clinics 45 (3): doi: /aia.0b013e318078cfe7. PMID

11 31. Iverson GL (2005). "Outcome from mild traumatic brain injury". Current Opinion in Psychiatry 18 (3): doi: /01.yco ae. PMID Larner AJ, Barker RJ, Scolding N, Rowe D (2005). The A-Z of Neurological Practice: a Guide to Clinical Neurology. Cambridge, UK: Cambridge University Press. p ISBN Cantu RC (2001). "Posttraumatic Retrograde and Anterograde Amnesia: Pathophysiology and Implications in Grading and Safe Return to Play". Journal of Athletic Training 36 (3): PMC PMID McCrory P, Johnston K, Meeuwisse W, Aubry M, Cantu R, Dvorak J, Graf- Baumann T, Kelly J, Lovell M, Schamasch P (2005 Apr). "Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004". Br J Sports Med. 39(4) (4): doi: /bjsm PMC PMID Bowen AP (2003). "Second impact syndrome: A rare, catastrophic, preventable complication of concussion in young athletes". Journal of Emergency Nursing 29 (3): doi: /men PMID Erlanger DM, Kutner KC, Barth JT, Barnes R (1999). "Neuropsychology of sportsrelated head enjury: Dementia pugilistica to post concussion syndrome". The Clinical Neuropsychologist 13 (2): doi: /clin PMID McCrory PR, Berkovic SF (1998). "Concussive convulsions. Incidence in sport and treatment recommendations". Sports Medicine 25 (2): PMID Perron AD, Brady WJ, Huff JS (2001). "Concussive convulsions: Emergency department assessment and management of a frequently misunderstood entity". Academic Emergency Medicine 8 (3): doi: /j tb01312.x. PMID Quality Standards Subcommittee of the American Academy of Neurology (1997). "Practice Parameter: The Management of Concussion in Sports (Summary Statement)" (PDF). American Academy of Neurology. pp Retrieved Anderson MK, Hall SJ, Martin M (2004). Foundations of Athletic Training: Prevention, Assessment, and Management. Lippincott Williams & Wilkins. p ISBN Retrieved Mayo Clinic Staff (2007). "Concussio". Mayo Clinic. Retrieved Heegaard W, Biros M (2007). "Traumatic brain injury". Emergency Medicine Clinics of North America 25 (3): , viii. doi: /j.emc PMID Pellman EJ, Viano DC (2006). "Concussion in professional football: Summary of the research conducted by the National Football League's Committee on Mild Traumatic Brain Injury" (PDF). Neurosurgical Focus 21 (4): E12. PMID Poirier MP (2003). "Concussions: Assessment, management, and recommendations for return to activity". Clinical Pediatric Emergency Medicine 4 (3): doi: /s (03)

12 45. Guskiewicz KM, Mihalik JP, Shankar V, et al. (2007). "Measurement of head impacts in collegiate football players: Relationship between head impact biomechanics and acute clinical outcome after concussion". Neurosurgery 61 (6): ; discussion doi: /01.neu a. PMID Gever D (December 7, 2007). "Any football helmet hit can cause potential concussion". MedPage Today. Retrieved Bigler ED (2008). "Neuropsychology and clinical neuroscience of persistent postconcussive syndrome". Journal of the International Neuropsychological Society 14 (1): doi: /s x. PMID P Rousseau, A Post, T B Hoshizaki (2009). "The effects of impact management materials in ice hockey helmets on head injury criteria". Proceedings of the Institution of Mechanical Engineers, Part P: Journal of Sports Engineering and Technology 223 (4): doi: / jset36. ISSN McAllister TW, Sparling MB, Flashman LA, Saykin AJ (2001). "Neuroimaging findings in mild traumatic brain injury". Journal of Clinical and Experimental Neuropsychology 23 (6): doi: /jcen PMID Herring SA, Bergfeld JA, Boland A, Boyajian-O'Neil LA, Cantu RC, Hershman E, et al. (2005). "Concussion (mild traumatic brain injury) and the team physician: A consensus statement" (PDF). Medicine and Science in Sports and Exercise (American College of Sports Medicine, American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Sports Medicine) 37 (11): doi: /01.mss PMID Giza CC, Hovda DA (2001). "The Neurometabolic Cascade of Concussion". Journal of Athletic Training 36 (3): PMC PMID Hardman JM, Manoukian A (2002). "Pathology of head trauma". Neuroimaging Clinics of North America 12 (2): , vii. doi: /s (02) PMID Hall RC, Hall RC, Chapman MJ (2005). "Definition, diagnosis, and forensic implications of postconcussional syndrome". Psychosomatics 46 (3): doi: /appi.psy PMID CNN ( ). "Dead Athletes Brains Show Damage From Concussions". Boston University: Center for the Study of Traumatic Encephalopathy. Retrieved McCrory PR, Berkovic SF (2001). "Concussion: The history of clinical and pathophysiological concepts and misconceptions". Neurology 57 (12): doi: /wnl PMID Cook RS, Schweer L, Shebesta KF, Hartjes K, Falcone RA (2006). "Mild traumatic brain injury in children: Just another bump on the head?". Journal of Trauma Nursing 13 (2): PMID Kay A, Teasdale G (2001). "Head injury in the United Kingdom". World Journal of Surgery 25 (9): doi: /s PMID

13 58. "Facts About Concussion and Brain Injury". Centers for Disease Control and Prevention Retrieved Borg J, Holm L, Cassidy JD, et al. (2004). "Diagnostic procedures in mild traumatic brain injury: Results of the WHO collaborating centre task force on mild traumatic brain injury". Journal of Rehabilitation Medicine 36 (Supplement 43): doi: / PMID Moser RS, Iverson GL, Echemendia RJ, Lovell MR, Schatz P, Webbe FM et al. (2007). "Neuropsychological evaluation in the diagnosis and management of sports-related concussion". Archives of Clinical Neuropsychology 22 (8): doi: /j.acn PMID Maroon JC, Lovell MR, Norwig J, Podell K, Powell JW, Hartl R (2000). "Cerebral concussion in athletes: Evaluation and neuropsychological testing". Neurosurgery 47 (3): ; discussion doi: / PMID Randolph C (2011). "Baseline neuropsychological testing in managing sportrelated concussion: does it modify risk?". Curr Sports Med Rep 10 (1): doi: /jsr.0b013e d. PMID Binder LM (1986). "Persisting symptoms after mild head injury: A review of the postconcussive syndrome". Journal of Clinical and Experimental Neuropsychology 8 (4): doi: / PMID Delaney JS, Abuzeyad F, Correa JA, Foxford R (2005). "Recognition and characteristics of concussions in the emergency department population". Journal of Emergency Medicine 29 (2): doi: /j.jemermed PMID Bryant RA (2008). "Disentangling mild traumatic brain injury and stress reactions". New England Journal of Medicine 358 (5): doi: /nejme PMID Jump up ^ Levy ML, Ozgur BM, Berry C, Aryan HE, Apuzzo ML (2004). "Birth and evolution of the football helmet". Neurosurgery 55 (3): ; discussion doi: /01.neu aa. PMID Willer B, Leddy JJ (2006). "Management of concussion and post-concussion syndrome". Current Treatment Options in Neurology 8 (5): doi: /s ISSN PMID Reymond MA, Marbet G, Radü EW, Gratzl O (1992). "Aspirin as a risk factor for hemorrhage in patients with head injuries". Neurosurgical Review 15 (1): doi: /bf PMID "What Can I Do to Help Feel Better After a Concussion?". Atlanta, GA: Center of Disease Control. March 8, Jump up ^ Thornton K, Carmody D (2008). "Efficacy of traumatic brain injury rehabilitation: interventions of QEEG-guided biofeedback, computers, strategies, and medications". Applied Psychophysiology and Biofeedback 33 (2): doi: /s z. 69. Anderson MK (2003). Fundamentals of sports injury management. Lippincott Williams & Wilkins. p. 79. ISBN

14 70. "Information about NICE clinical guideline" (PDF). National Institute for Health and Clinical Excellence. September Retrieved Murray ED, Buttner N, Price BH (2012). "Depression and Psychosis in Neurological Practice". In Bradley WG, Daroff RB, Fenichel GM, Jankovic J. Bradley's neurology in clinical practice. 1 (6th ed.). Philadelphia, PA: Elsevier/Saunders. p ISBN Alexander MP (1995). "Mild traumatic brain injury: Pathophysiology, natural history, and clinical management". Neurology 45 (7): doi: /wnl PMID Masferrer R, Masferrer M, Prendergast V, Harrington TR (2000). "Grading scale for cerebral concussions". BNI Quarterly (Barrow Neurological Institute) 16 (1). ISSN Schulz MR, Marshall SW, Mueller FO, et al. (November 2004). "Incidence and risk factors for concussion in high school athletes, North Carolina, ". American Journal of Epidemiology 160 (10): doi: /aje/kwh304. PMID De Beaumont, Louis; Theoret, Hugo; Mongeon, David; Messier, Julie; Leclerc, Suzanne; Tremblay, Sebastien; Ellemberg, Dave; Lassonde, Maryse (2009). "Brain function decline in healthy retired athletes who sustained their last sports concussion in early adulthood". Brain 132 (Pt 3): doi: /brain/awn347. PMID Ryan LM, Warden DL (2003). "Post concussion syndrome". International Review of Psychiatry 15 (4): doi: / PMID 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): doi: /appi.neuropsych PMID Harmon KG (1999). "Assessment and management of concussion in sports". American Family Physician 60 (3): , 894. PMID Cantu RC (2007). "Chronic traumatic encephalopathy in the National Football League". Neurosurgery 61 (2): doi: /01.neu PMID Mendez MF (1995). "The neuropsychiatric aspects of boxing". International Journal of Psychiatry in Medicine 25 (3): doi: /cumk-tht1- X98M-WB4C. PMID Jordan BD (2000). "Chronic traumatic brain injury associated with boxing". Seminars in Neurology 20 (2): doi: /s PMID

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