Rivi

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Hello everyone,

Brace yourselves, a movie about football concussions, starring Will Smith, is coming in December.


I am curious about how accurate this will be, given the research on CTE and some of the limitations. I am also curious about how this will influence referrals and public perception. Any thoughts?
 

WisNeuro

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My prediction is that it will only further add to the mis-characterization of the literature and make it even harder for me to do my job in the future. We should start doing research on how much the iatrogenic effects of bad research and poorly written media articles affect outcomes over and above any actual brain damage.
 

cara susanna

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Man, that accent is inconsistent.
 

Fan_of_Meehl

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Jesus.

I'm not an expert (not a neuropsychologist) but I am a clinical psychologist working at VA who has been forced to contend with the mTBI issue (first as a C&P examiner where every friggin case that had comorbid PTSD (or potential PTSD) and a 'history of combat-related concussion' came with a requirement that I somehow disentangle presently reported symptoms of irritability, insomnia, (self-reported) memory problems, attention/conc. problems, etc.) as being due to PTSD or to residuals of the mTBI. This is a determination that basically every peer-reviewed source of information (including the official publications by the VA/DOD on the issue) I could get my hands on said couldn't really be done (and I said as much pointing to the specific literature). The answer is base-rates :).

There is no other area that I encounter in regular clinical practice where the public perception is SOOOOOO far off and discrepant from the actual clinical/scientific reality than the mTBI (residuals) / 'post-concussion syndrome.' And the foaming at the mouth fury of veterans presenting in my present position (post-deployment health psychologist) is only going to intensify over the time as a result, i.e., 'I have a TRAUMATIC BRAIN INJURY! I can't work! I verbally lash out at my wife/boss because I can't help it because I have a TRAUMATIC BRAIN INJURY! How the hell could they deny my service-connection increase to 100% and 'total and permanent unemployability status'??? I mean, doc, I have a TRAUMATIC BRAIN INJURY! They're messin' with my money, my life, my friggin FAMILY! They're HURTING MY CHILDREN!'

Jesus.

No, man...what your record confirms is that you reported that in 2005 (10 years ago) you were on deployment and a hatch came down hitting you on the head and you were dazed/confused for 5 min's with no loss of consciousness, no traumatic amnesia, no complications in the immediate aftermath and of course no demonstrable/imaged physical damage/complications.

What the record confirms is the HISTORICAL EVENT of hitting your head. You hit your head ten years ago. That's it. You are not 100% unemployable as a direct result. You do not have an iron-clad excuse for beating your wife and not even attempting to regulate your emotional/behavioral responses to normal life stressors. You do not deserve combined benefits (from social security disability and service-connected VA benefits) paid for by the tax payers for the rest of your life (60+ years?) to not work another day in your life.

Again, we're not talking moderate to severe head injuries (which we all know is or can be a completely different scenario)...we're talking bump on the head with no LOC or posttraumatic amnesia 10 years ago. It doesn't even pass the common sense layperson bull**** detector.
 

AcronymAllergy

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Jesus.

I'm not an expert (not a neuropsychologist) but I am a clinical psychologist working at VA who has been forced to contend with the mTBI issue (first as a C&P examiner where every friggin case that had comorbid PTSD (or potential PTSD) and a 'history of combat-related concussion' came with a requirement that I somehow disentangle presently reported symptoms of irritability, insomnia, (self-reported) memory problems, attention/conc. problems, etc.) as being due to PTSD or to residuals of the mTBI. This is a determination that basically every peer-reviewed source of information (including the official publications by the VA/DOD on the issue) I could get my hands on said couldn't really be done (and I said as much pointing to the specific literature). The answer is base-rates :).

There is no other area that I encounter in regular clinical practice where the public perception is SOOOOOO far off and discrepant from the actual clinical/scientific reality than the mTBI (residuals) / 'post-concussion syndrome.' And the foaming at the mouth fury of veterans presenting in my present position (post-deployment health psychologist) is only going to intensify over the time as a result, i.e., 'I have a TRAUMATIC BRAIN INJURY! I can't work! I verbally lash out at my wife/boss because I can't help it because I have a TRAUMATIC BRAIN INJURY! How the hell could they deny my service-connection increase to 100% and 'total and permanent unemployability status'??? I mean, doc, I have a TRAUMATIC BRAIN INJURY! They're messin' with my money, my life, my friggin FAMILY! They're HURTING MY CHILDREN!'

Jesus.

No, man...what your record confirms is that you reported that in 2005 (10 years ago) you were on deployment and a hatch came down hitting you on the head and you were dazed/confused for 5 min's with no loss of consciousness, no traumatic amnesia, no complications in the immediate aftermath and of course no demonstrable/imaged physical damage/complications.

What the record confirms is the HISTORICAL EVENT of hitting your head. You hit your head ten years ago. That's it. You are not 100% unemployable as a direct result. You do not have an iron-clad excuse for beating your wife and not even attempting to regulate your emotional/behavioral responses to normal life stressors. You do not deserve combined benefits (from social security disability and service-connected VA benefits) paid for by the tax payers for the rest of your life (60+ years?) to not work another day in your life.

Again, we're not talking moderate to severe head injuries (which we all know is or can be a completely different scenario)...we're talking bump on the head with no LOC or posttraumatic amnesia 10 years ago. It doesn't even pass the common sense layperson bull**** detector.
Unfortunately, part of the message is perpetuated by other providers as well. Just in my own experiences, last week I heard a group of psychologists (which, unfortunately, included a neuropsychologist) debating if an individual's current "memory loss" was due to the persisting physiologic after-effects (e.g., "diffuse injury") of a remote mild TBI. I imagine it's driven, at least to some degree, by our history in psychology of perpetually wanting to side with and believe our patients combined with just a fundamental lack of knowledge (i.e., "oh, it involves the brain, it MUST be legit").

Mind you, this person hadn't even reported cognitive problems. Yet here's a group of psychologists about to refer them for a neuropsychological evaluation. Iatrogenic effects, anyone?
 
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Fan_of_Meehl

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With the explosion of 'published' (of varying quality/validity) information on every topic under the sun made possible by the internet the problem is the proportion of information that is quality information (peer-reviewed, edited, professionally-critiqued, 'vetted') is becoming less and less of the total universe of information out there for the public (and you and me) to access. Now, in our fields we know where to go to get the quality information (and how to spot poor quality or invalid presentations of info/data) but those who are not specialists in psychology/neuropsychology/academia/medicine do not.

Just for kicks I Googled 'mild traumatic head injury' (in Google News) and one of the first hits was a Huffington post article
authored by an

Amy Zellmer
-
Professional Photographer, Creative Business Coach, Writer, Traveler, life lover, TBI Survivor, and mommy to a rescue Yorkie

10 Ways You Can Help a Loved One Cope With Their Traumatic Brain Injury:

  1. Don't ask them what they need. We may not actually know "what" we need. Or we may feel embarrassed and don't want to be a burden or seem needy. Don't ask us if we'd like you to come over. We'll likely say no, but really mean yes. Just show up at our door with open arms.
  2. Bring over a meal (or three). We are likely suffering from a great deal of fatigue, headaches, and cognitive problems. We might not have the ability to cook for ourselves, or even go to the grocery store to buy the bare necessities. For myself personally, I couldn't figure out how to use my microwave or oven for several days. A warm, home cooked meal would have been greatly appreciated!
  3. Bring them groceries or basic household supplies. As much as we won't admit it, our finances are going to be really, really tight. Going to the grocery store may actually be a financial burden as much as it is a physical one. No one wants to admit when they're struggling, and just showing up with some milk, toilet paper, and chocolate chip cookies will definitely bring joy and relief.
  4. Offer to clean their house. Many of us suffer with vertigo, fatigue, and likely physical injuries from our accident. Simple tasks like taking out the garbage, doing laundry, and vacuuming can be daunting. Don't judge the condition of their home, and don't make them feel like they are doing a poor job of housekeeping, simply enter their home and start doing it for them. Take it a step further, and make them a class of ice water, tuck them into bed for a nap, and clean away while they rest!
  5. Offer to drive them to their doctor appointments. I was fortunate that I was able to drive after my accident, but many are not. I also encourage you to go one step further, and ask if they'd like you to sit in on the appointment. I went to all my appointments alone, and as I look back, I realize how little I remember. It would have been nice to have someone along to help advocate for my health, and to be able to explain to the doctor what they are observing of my daily behavior and how it may be altered from my "normal."
  6. Get them out of the house. Before you kidnap your loved one and take them on an adventure, make sure you ask them if they're feeling up to it. If it is an adventure that comes with some monetary costs, make it clear that you are buying (remember how I mentioned that finances may be really, really tight). Keep in mind that they may be sensitive to light, sounds, crowds, etc. and plan something accordingly. A trip to a flower garden (remind them to bring their sunglasses), or to a spa for a pedicure might be lovely options. You can ask them what they'd like to do, but be prepared for them to not be able to articulate a clear plan. Be prepared to plan it all out.
  7. Bring them flowers. I know that's totally cliche, but flowers really are beautiful and can brighten up anyones day!
  8. Send a card or care package. If you don't live nearby, sending a card stating that you're thinking of them will mean so very much. Just knowing that someone has their thoughts on you can go a long way in recovery. If you're feeling generous, you may also include a gift card to a local grocery or Target store.
  9. Show up with a movie and a book. Ask them if they would prefer to watch a movie, or have you read to them. Everyone's TBI is going to be different. Some can't handle to watch a movie or hear the sounds, and many can't read well. So offering to read a book to them might really make their day. If neither seem appealing to them at the time, snuggle up with them on the couch under a comfy blanket, and just be there for them. Sometimes sitting in silence with a loved one can really make a person's day.
  10. Watch their kids for a few hours. Or better yet, take them overnight. Being a parent with TBI has got to be overwhelming and exhausting. Knowing that their child(ren) is in good hands will give them comfort and allow them to rest and recharge for a few hours. Rest is SO important in the recovery process.
*THIS is where the mass of the lay public is getting their information regarding mild traumatic brain injury


 

AcronymAllergy

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Sigh. Like you've said, for survivors of moderate to severe injuries, things can be a bit different. But even then, we should always be focusing on increased functioning, remediation, and re-integration into the community, not on, "let's see how many responsibilities we can absolve people of."

Especially re: mild TBI, I wonder how Ms. Zellmer would feel if we replaced "TBI" in her recommendations with, "charley horse" or "sprained ankle," which are also injuries that lead to temporary effects that remit with time and from which the vast majority of folks completely recover. Although if you then told folks who'd sustained a sprained ankle that they'd "never be the same," and offered to drive them around to their appointments and watch their kiddos for hours or days at a time, I can almost guarantee we'd see a spike in the rates of "post-sprained ankle syndrome."
 
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Makes me glad I'm not a neuropsychologist or at a VA anymore. :D I have worked with a few patients who have had severe TBI and they do really struggle which is why they were referred for psychotherapy. The media hype and the malingerers just make it more difficult for us to get the services to the patients who need it by clogging up the system and frustrating us until we can begin to see everyone as a malingerer. I was feeling that way a couple of weeks ago after a busy week on call dealing with substance abusers just trying to avoid jail.
 

Therapist4Chnge

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Well…I guess the crush of referrals isn't going to lighten any time soon. It is crazy the amount of misinformation out there about concussions. I get it at work, at the gym, on airplanes, etc. Concussions are 95% of the reason why I actively avoid talking about my work outside of work. That said, I think a lot of good work is being done in the field, though those people aren't the ones stealing headlines.
 
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Fan_of_Meehl

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Seems like most of the referrals for mental health in VA today are either highly compensable (from a disability and service-connection standpoint) diagnoses of PTSD or mTBI or they are for 'adult ADHD' so someone can get themselves some psychostimulants. Would be an interesting epidemiological analysis to look at numbers/percentages of referrals for these three conditions to mental health services at VA over the years and compare to those of other mental disorders (especially the typically non-service-connected diagnoses (eating disorders? substance use disorders?)).
 
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I'm not an expert (not a neuropsychologist) but I am a clinical psychologist working at VA who has been forced to contend with the mTBI issue
This is a bit random, but it seems like a good place to ask, do you know how a recent grad (undergrad+no publications) could create a path to this type of work (clinical and [traumatic] brain injuries)? What I have in mind is a combination of clinical psychology and neuroscience/neurorehabilitation. There is a nearby VA mental health clinic, which I figure would be a good starting point, but the website doesn't state whether research is actively being conducted or even list the current psychologists.
 

WisNeuro

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This is a bit random, but it seems like a good place to ask, do you know how a recent grad (undergrad+no publications) could create a path to this type of work (clinical and [traumatic] brain injuries)? What I have in mind is a combination of clinical psychology and neuroscience/neurorehabilitation. There is a nearby VA mental health clinic, which I figure would be a good starting point, but the website doesn't state whether research is actively being conducted or even list the current psychologists.
The VA's don't hire too many undergrad RA's to help with this work. Takes too long to get through orientation and they tend to not hang around that long, waste of resources. Additionally, not many VA's are actively researching this outside of some of the medical centers. You could check at a local university to see if anyone is involved with such research. But, it's pretty dependent on location and available opportunity.
 
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Unreal..... This is why the system is so effed up. Because you all seem to think everything related to TBI/concussion is psychological and not real. I pray none of you suffer one and go thru the hell inside your head to learn how far off base you are :)

First off, mTBI means you were unconscious for less than 30 minutes. It has NOTHING to do with severity of symptoms. Moderate is 30 minutes. Severe is comma. That's it. Loss of consciousness. That's what the classifications are for. and you don't even have to lose consciousness. You make it appear that unless you're drooling and have trouble walking and talking that you're fine.......

I fell smack on the back of my head and was briefly knocked out. My world is forever changed in that instance. I still have trouble processing how to use anything touch screen that asks a series of questions (like at a gas pump.... "press the green button for yes" etc) and short-term memory problems persist almost 2 years later as well as spatial reasoning, vertigo, balance issues, double vision, face numbness, and headaches.

I don't understand how you can blanketly pass-off TBI as mostly psychological. It frightens me that you are the doctors of our future.
 
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I don't understand how you can blanketly pass-off TBI as mostly psychological. It frightens me that you are the doctors of our future.
most of the people that have posted in this thread are current neuropsychologists. (not students)
 

PsyDr

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Unreal..... This is why the system is so effed up. Because you all seem to think everything related to TBI/concussion is psychological and not real. I pray none of you suffer one and go thru the hell inside your head to learn how far off base you are :)

First off, mTBI means you were unconscious for less than 30 minutes. It has NOTHING to do with severity of symptoms. Moderate is 30 minutes. Severe is comma. That's it. Loss of consciousness. That's what the classifications are for. and you don't even have to lose consciousness. You make it appear that unless you're drooling and have trouble walking and talking that you're fine.......

I fell smack on the back of my head and was briefly knocked out. My world is forever changed in that instance. I still have trouble processing how to use anything touch screen that asks a series of questions (like at a gas pump.... "press the green button for yes" etc) and short-term memory problems persist almost 2 years later as well as spatial reasoning, vertigo, balance issues, double vision, face numbness, and headaches.

I don't understand how you can blanketly pass-off TBI as mostly psychological. It frightens me that you are the doctors of our future.
Ignoring the research literature and becoming upset when it's used doesn't exactly help your point...
 

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Unreal..... This is why the system is so effed up. Because you all seem to think everything related to TBI/concussion is psychological and not real. I pray none of you suffer one and go thru the hell inside your head to learn how far off base you are :)

First off, mTBI means you were unconscious for less than 30 minutes. It has NOTHING to do with severity of symptoms. Moderate is 30 minutes. Severe is comma. That's it. Loss of consciousness. That's what the classifications are for. and you don't even have to lose consciousness. You make it appear that unless you're drooling and have trouble walking and talking that you're fine.......

I fell smack on the back of my head and was briefly knocked out. My world is forever changed in that instance. I still have trouble processing how to use anything touch screen that asks a series of questions (like at a gas pump.... "press the green button for yes" etc) and short-term memory problems persist almost 2 years later as well as spatial reasoning, vertigo, balance issues, double vision, face numbness, and headaches.

I don't understand how you can blanketly pass-off TBI as mostly psychological. It frightens me that you are the doctors of our future.
Just to clarify- mTBI doesn't mean someone was unconscious for less than 30 minutes. You say in your next(ish) sentence that LOC isn't necessary for an mTBI/concussion. From what I've seen/read, most classifications are based on GCS ratings post-injury.

No one was saying that there are no sequelae of TBI (or even mTBI). They are saying that within a few days to weeks, nearly everyone that had a concussion is back to normal. And that research has shown that there are certain factors that are consistently seen in people who don't return to baseline... and those factors are largely not biological. External variables (e.g., lawsuits, wanting to get disability, athletes wanting to return to play) may also affect recovery/motivation and complicate assessment of symptoms, as well.

Moderate and severe TBI are a different story. Sorry you've been having difficulties with your recovery.
 
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WisNeuro

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What LETSGONYR said. Some of us have years of experience working with a wide range of head injuries from mild to severe in acute rehabilitation settings. Some of us also do research in this field. Anecdotes do not trump the empirical science. An extremely small minority of mTBI sufferers most likely do experience some lingering issues. But, we exist in a world where 30-60% of people with mTBI where there is some primary and secondary gain available fail performance validity testing, often at chance or below levels. Additionally, we also have good evidence on the iatrogenic effects that are possible depending on what a person believes about their injury. If you'd like some of the citations for this research, we'd be happy to provide it. There is quite a bit out there.
 
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Pragma

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I'm really not looking forward to explaining why this movie is problematic to my family and friends over the holidays. Boooooooo.
 

erg923

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It would cool if it was alien invaders causing mass TBI throughout the land.
 

erg923

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Comment on MSNBC website article: "Two thumbs up on Concussion. A must see for all parents who are letting their sons play this brutal brain destroying sport!"

Are people really this dumb? Sometimes the scientific illiteracy of the general population is alarming to me.
 
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I'm not surprised. This is the same general population that takes vaccination advice from a Playboy Playmate over the AMA, and climate change advice from Ted Cruz over 97%+ of the scientific community.
You mean Mr. Haney? I think he actually sold snake oil on the show Green Acres. Even if I agreed with Cruz at all, how could I honestly vote for him without laughing?
 

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Cruz only looks remotely reasonable because of the absurdity that is The Donald still being a thing. All in all, it's a brilliant ploy by the GOP, trot out a far right, racist, xenophobic, homophobic candidate with no reasonable substantive policy stances to make the rest of the field look less crazy by comparison.
 
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Cruz only looks remotely reasonable because of the absurdity that is The Donald still being a thing. All in all, it's a brilliant ploy by the GOP, trot out a far right, racist, xenophobic, homophobic candidate with no reasonable substantive policy stances to make the rest of the field look less crazy by comparison.
Brilliant and the GOP are you sure that is not an oxymoron? ;)
On the other hand, my wife thinks that The Donald is a brilliant and secret democratic strategy to get Hillary elected. She tends to be more conspiracy minded than myself. :D
 

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Cruz only looks remotely reasonable because of the absurdity that is The Donald still being a thing. All in all, it's a brilliant ploy by the GOP, trot out a far right, racist, xenophobic, homophobic candidate with no reasonable substantive policy stances to make the rest of the field look less crazy by comparison.
That's been my theory since the beginning. Scary bad options on all sides. I'm vital NG for Bernie...even though I disagree w. 95% of the way he wants to spend my (tax) money.
 

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"Its a big club...and you aint in it."
-George Carlin

 
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I'm not surprised. This is the same general population that takes vaccination advice from a Playboy Playmate over the AMA, and climate change advice from Ted Cruz over 97%+ of the scientific community.
I posted links to a few journal articles questioning the validity of CTE on another (more pop culture oriented) forum I sometimes frequent and was shouted down by people claiming I was a shill for the NFL. Scary, scary stuff. I'm reminded of a study I read about a year ago that discussed how presenting people with evidence counter to their beliefs often makes them just dig in even more; it's certainly been supported by personal experience time and time again.
 
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AcronymAllergy

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I posted links to a few journal articles questioning the validity of CTE on another (more pop culture oriented) forum I sometimes frequent and was shouted down by people claiming I was a shill for the NFL. Scary, scary stuff. I'm reminded of a study I read about a year ago that discussed how presenting people with evidence counter to their beliefs often makes them just dig in even more; it's certainly been supported by personal experience time and time again.
This would, in part, be some of the rationale behind Motivational Interviewing as a therapeutic technique.

I've been shouted down by physicians touting "biomarker"-this and "CSF"-that when discussing my concerns and criticisms of CTE and long-term physiological effects of concussions.

Mind you, I'm not completely writing off the idea that one or (more likely, if anything) many more concussions may be found to result in lasting physiological changes. I continue to attempt to evaluate all of the research that's being released with an open mind. But we do know what the preponderance of evidence thus far indicates about the long-term clinically-measurable/meaningful effects of concussions.

I saw a comment made elsewhere by a neuropsych student (I believe) that said something akin to, "why are we so resistant to the idea that football causes long-term damage?" My response would be the opposite--why are some so wedded to the idea that it (or a concussion) must, in and itself, cause long-term damage? This is why the scientific process exists--to help minimize the biases that might be induced by "common sense" gut feelings.
 

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I saw a comment made elsewhere by a neuropsych student (I believe) that said something akin to, "why are we so resistant to the idea that football causes long-term damage?" My response would be the opposite--why are some so wedded to the idea that it (or a concussion) must, in and itself, cause long-term damage? This is why the scientific process exists--to help minimize the biases that might be induced by "common sense" gut feelings.
Exactly. And, people aren't willing to consider predisposing risk factors/mediator/moderator variables that are likely driving the relationship. And an unwillingness to acknowledge how messy and small the "CTE" datasets are. I think the majority of my scientific minded neuro colleagues do not hold the view that CTE exists. They hold the view that the literature out there is in it's infancy and full of holes. We should be doing more research in the area, but we should interpret the data as it is. As it stands, this has not happened and many of us practicing today have to deal with the iatrogenic side effects.
 
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I'm pretty sure that the general public is connecting the deaths in wrestling/football (where brain damage certainly could have played a role) and assuming that all head injuries (no nuance) could result in the same thing.
 

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I'm pretty sure that the general public is connecting the deaths in wrestling/football (where brain damage certainly could have played a role) and assuming that all head injuries (no nuance) could result in the same thing.
The general populous needs to hear from more clinicians and academics (who can speak at an appropriate level of understanding), as there are far too many hacks out there profiteering from fear-mongering.

I try and educate the public, physicians, and legislators...but it's like spitting into the ocean in most cases. I've found neurologists and chiropractors to be the most difficult to educate....who not surprisingly have the most to gain from sham treatments.

I helped craft some statutes earlier this yr about concussion management and having to navigate the misinformation and jockeying by interest groups was 90% of the battle. Optometrists, chiropractors, OTs, and a few other groups all tried to wedge themselves into the middle of things...with little to no ACTUAL training or support for their intereventions.
 
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WisNeuro

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Perhaps, but the other side of that equation is that we don't know how much head injuries play a role in the professional athlete deaths. We seem to conveniently gloss over years of mental health issues and drug/alcohol abuse. Which, could conceivably be a side effect of head injury, but not likely the one factor given that professional athletes are healthier, live longer, and commit far fewer crimes than the general population as a whole.

Edit: responding to psych844
 

AcronymAllergy

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Perhaps, but the other side of that equation is that we don't know how much head injuries play a role in the professional athlete deaths. We seem to conveniently gloss over years of mental health issues and drug/alcohol abuse. Which, could conceivably be a side effect of head injury, but not likely the one factor given that professional athletes are healthier, live longer, and commit far fewer crimes than the general population as a whole.

Edit: responding to psych844
Indeed. And not even necessarily drug/alcohol abuse, but also years of use of who knows what "performance-enhancing" substances, chronic use of prescribed/administered painkillers, effects from years of general bodily wear and tear (which may well factor into mental health status), effects from the "culture" of various professional athletic organizations, etc.