text:
Concussion

A concussion, also known as a mild traumatic brain injury (mTBI), is a head injury that temporarily affects brain functioning. Symptoms may include loss of consciousness; memory loss; headaches; difficulty with thinking, concentration, or balance; nausea; blurred vision; dizziness; sleep disturbances, and mood changes. Any of these symptoms may begin immediately, or appear days after the injury. Concussion should be suspected if a person indirectly or directly hits their head and experiences any of the symptoms of concussion. Symptoms of a concussion may be delayed by 1–2 days after the accident. It is not unusual for symptoms to last 2 weeks in adults and 4 weeks in children. Fewer than 10% of sports-related concussions among children are associated with loss of consciousness.

Common causes include motor vehicle collisions, falls, sports injuries, and bicycle accidents. Risk factors include physical violence, drinking alcohol and a prior history of concussion. The mechanism of injury involves either a direct blow to the head or forces elsewhere on the body that are transmitted to the head. This is believed to result in neuron dysfunction, as there are increased glucose requirements, but not enough blood supply. A thorough evaluation by a qualified medical provider working in their scope of practice (such as a physician or nurse practitioner) is required to rule out life-threatening head injuries, injuries to the cervical spine, and neurological conditions and to use information obtained from the medical evaluation to diagnose a concussion. Glasgow coma scale score 13 to 15, loss of consciousness for less than 30 minutes, and memory loss for less than 24 hours may be used to rule out moderate or severe traumatic brain injuries. Diagnostic imaging such as a CT scan or an MRI may be required to rule out severe head injuries. Routine imaging is not required to diagnose concussion.

Prevention of concussions includes the use of a helmet when bicycling or motorbiking. Treatment includes physical and mental rest for 1–2 days, with a gradual step-wise return to activities, school, and work. Prolonged periods of rest may slow recovery and result in greater depression and anxiety. Paracetamol (acetaminophen) or NSAIDs may be recommended to help with a headache. Prescribed aerobic exercise may improve recovery. Physiotherapy may be useful for persisting balance problems, headache, or whiplash; cognitive behavioral therapy may be useful for mood changes. Evidence to support the use of hyperbaric oxygen therapy and chiropractic therapy is lacking.

Worldwide, concussions are estimated to affect more than 3.5 per 1,000 people a year. Concussions are classified as mild traumatic brain injuries and are the most common type of TBIs. Males and young adults are most commonly affected. Outcomes are generally good. Another concussion before the symptoms of a prior concussion have resolved is associated with worse outcomes. Repeated concussions may also increase the risk in later life of chronic traumatic encephalopathy, Parkinson's disease and depression.

Signs and symptoms
Concussion symptoms vary between people and include physical, cognitive, and emotional symptoms. Symptoms may appear immediately or be delayed by 1–2 days. Delayed onset of symptoms may still be serious and require a medical assessment. Up to one-third of people with concussion experience longer or persisting concussion symptoms, also known as post concussion syndrome or persisting symptoms after concussion, which is defined as concussion symptoms lasting for 4 weeks or longer in children and adolescents, and symptoms lasting for more than 14 days in an adult. The severity of the initial symptoms is the strongest predictor of recovery time in adults.

Physical
Headaches are the most common mTBI symptom. Others include dizziness, vomiting, nausea, lack of motor coordination, difficulty balancing, or other problems with movement or sensation. Visual symptoms include light sensitivity, seeing bright lights, blurred vision, and double vision. Tinnitus, or a ringing in the ears, is also commonly reported. In one in about seventy concussions, concussive convulsions occur, but seizures that take place during or immediately after a concussion are not "post-traumatic seizures", and, unlike post-traumatic seizures, are not predictive of post-traumatic epilepsy, which requires some form of structural brain damage, not just a momentary disruption in normal brain functioning. Concussive convulsions are thought to result from temporary loss or inhibition of motor function and are not associated either with epilepsy or with more serious structural damage. They are not associated with any particular sequelae and have the same high rate of favorable outcomes as concussions without convulsions.

Cognitive and emotional
Cognitive symptoms include confusion, disorientation, and difficulty focusing attention. Loss of consciousness may occur, but is not necessarily correlated with the severity of the concussion if it is brief. Post-traumatic amnesia, in which events following the injury cannot be recalled, is a hallmark of concussions. Confusion may be present immediately or may develop over several minutes. A person may repeat the same questions, be slow to respond to questions or directions, have a vacant stare, or have slurred or incoherent speech. Other concussion symptoms include changes in sleeping patterns and difficulty with reasoning, concentrating, and performing everyday activities.

A concussion can result in changes in mood including crankiness, loss of interest in favorite activities or items, tearfulness, and displays of emotion that are inappropriate to the situation. Common symptoms in concussed children include restlessness, lethargy, and irritability.

Forces
The brain is surrounded by cerebrospinal fluid, which protects it from light trauma. More severe impacts, or the forces associated with rapid acceleration, may not be absorbed by this cushion. Concussions, and other head-related injuries, occur when external forces acting on the head are transferred to the brain. Such forces can occur when the head is struck by an object or surface (a 'direct impact'), or when the torso rapidly changes position (i.e. from a body check) and force is transmitted to the head (an 'indirect impact').

Forces may cause linear, rotational, or angular movement of the brain or a combination of them. In rotational movement, the head turns around its center of gravity, and in angular movement, it turns on an axis, not through its center of gravity. The amount of rotational force is thought to be the major component in concussion and its severity. As of 2007, studies with athletes have shown that the amount of force and the location of the impact are not necessarily correlated with the severity of the concussion or its symptoms, and have called into question the threshold for concussion previously thought to exist at around 70–75 g.

The parts of the brain most affected by rotational forces are the midbrain and diencephalon. It is thought that the forces from the injury disrupt the normal cellular activities in the reticular activating system located in these areas and that this disruption produces the loss of consciousness often seen in concussion. Other areas of the brain that may be affected include the upper part of the brain stem, the fornix, the corpus callosum, the temporal lobe, and the frontal lobe. Angular accelerations of 4600, 5900, or 7900 rad/s2 are estimated to have 25, 50, or 80% risk of mTBI respectively.

Pathophysiology
In both animals and humans, mTBI can alter the brain's physiology for hours to years, setting into motion a variety of pathological events. As one example, in animal models, after an initial increase in glucose metabolism, there is a subsequent reduced metabolic state which may persist for up to four weeks after injury. Though these events are thought to interfere with neuronal and brain function, the metabolic processes that follow concussion are reversible in a large majority of affected brain cells; however, a few cells may die after the injury.

Included in the cascade of events unleashed in the brain by concussion is impaired neurotransmission, loss of regulation of ions, deregulation of energy use and cellular metabolism, and a reduction in cerebral blood flow. Excitatory neurotransmitters, chemicals such as glutamate that serve to stimulate nerve cells, are released in excessive amounts. The resulting cellular excitation causes neurons to fire excessively. This creates an imbalance of ions such as potassium and calcium across the cell membranes of neurons (a process like excitotoxicity).

At the same time, cerebral blood flow is relatively reduced for unknown reasons, though the reduction in blood flow is not as severe as it is in ischemia. Thus cells get less glucose than they normally do, which causes an "energy crisis".

Concurrently with these processes, the activity of mitochondria may be reduced, which causes cells to rely on anaerobic metabolism to produce energy, increasing levels of the byproduct lactate.

For a period of minutes to days after a concussion, the brain is especially vulnerable to changes in intracranial pressure, blood flow, and anoxia. According to studies performed on animals (which are not always applicable to humans), large numbers of neurons can die during this period in response to slight, normally innocuous changes in blood flow.

Concussion involves diffuse (as opposed to focal) brain injury, meaning that the dysfunction occurs over a widespread area of the brain rather than in a particular spot. It is thought to be a milder type of diffuse axonal injury, because axons may be injured to a minor extent due to stretching. Animal studies in which rodents were concussed have revealed lifelong neuropathological consequences such as ongoing axonal degeneration and neuroinflammation in subcortical white matter tracts. Axonal damage has been found in the brains of concussion patients who died from other causes, but inadequate blood flow to the brain due to other injuries may have contributed. Findings from a study of the brains of deceased NFL athletes who received concussions suggest that lasting damage is done by such injuries. This damage, the severity of which increases with the cumulative number of concussions sustained, can lead to a variety of other health issues.

The debate over whether concussion is a functional or structural phenomenon is ongoing. Structural damage has been found in the mildly traumatically injured brains of animals, but it is not clear whether these findings would apply to humans. Such changes in brain structure could be responsible for certain symptoms such as visual disturbances, but other sets of symptoms, especially those of a psychological nature, are more likely to be caused by reversible pathophysiological changes in cellular function that occur after concussion, such as alterations in neurons' biochemistry. These reversible changes could also explain why dysfunction is frequently temporary. A task force of head injury experts called the Concussion In Sport Group met in 2001 and decided that "concussion may result in neuropathological changes but the acute clinical symptoms largely reflect a functional disturbance rather than structural injury."

Using animal studies, the pathology of a concussion seems to start with mechanical shearing and stretching forces disrupting the cell membrane of nerve cells through "mechanoporation". This results in potassium outflow from within the cell into the extracellular space with the subsequent release of excitatory neurotransmitters including glutamate which leads to enhanced potassium extrusion, in turn resulting in sustained depolarization, impaired nerve activity and potential nerve damage. Human studies have failed to identify changes in glutamate concentration immediately post-mTBI, though disruptions have been seen 3 days to 2 weeks post-injury. In an effort to restore ion balance, the sodium-potassium ion pumps increase activity, which results in excessive ATP (adenosine triphosphate) consumption and glucose utilization, quickly depleting glucose stores within the cells. Simultaneously, inefficient oxidative metabolism leads to anaerobic metabolism of glucose and increased lactate accumulation. There is a resultant local acidosis in the brain and increased cell membrane permeability, leading to local swelling. After this increase in glucose metabolism, there is a subsequent lower metabolic state which may persist for up to 4 weeks after injury. A completely separate pathway involves a large amount of calcium accumulating in cells, which may impair oxidative metabolism and begin further biochemical pathways that result in cell death. Again, both of these main pathways have been established from animal studies and the extent to which they apply to humans is still somewhat unclear.

Diagnosis
Head trauma recipients are initially assessed to exclude a more severe emergency such as an intracranial hemorrhage or other serious head or neck injuries. This includes the "ABCs" (airway, breathing, circulation) and stabilization of the cervical spine, which is assumed to be injured in any athlete who is found to be unconscious after head or neck injury. Indications that screening for more serious injury is needed include 'red flag symptoms' or 'concussion danger signs': worsening headaches, persisting vomiting, increasing disorientation or a deteriorating level of consciousness, seizures, and unequal pupil size. Those with such symptoms, or those who are at higher risk of a more serious brain injury, require an emergency medical assessment. Brain imaging such as a CT scan or MRI may be suggested, but should be avoided unless there are progressive neurological symptoms, focal neurological findings, or concern of skull fracture on exam.

Diagnosis of concussion requires an assessment performed by a physician or nurse practitioner to rule out severe injuries to the brain and cervical spine, mental health conditions, or other medical conditions. Diagnosis is based on physical and neurological examination findings, duration of unconsciousness (usually less than 30 minutes) and post-traumatic amnesia (usually less than 24 hours), and the Glasgow Coma Scale (people with mTBI have scores of 13 to 15). A CT scan or MRI is not required to diagnose concussion. Neuropsychological tests such as the SCAT5/child SCAT5 may be suggested measure cognitive function. Such tests may be administered hours, days, or weeks after the injury, or at different times to demonstrate any trend. Some athletes are also being tested pre-season (pre-season baseline testing) to provide a baseline for comparison in the event of an injury, though this may not reduce risk or affect return to play and baseline testing is not required or suggested for most children and adults.

If the Glasgow coma scale is less than 15 at two hours or less than 14 at any time, a CT is recommended. In addition, a CT scan is more likely to be performed if observation after discharge is not assured or intoxication is present, there is suspected increased risk for bleeding, age greater than 60, or less than 16. Most concussions, without complication, cannot be detected with MRI or CT scans. However, changes have been reported on MRI and SPECT imaging in those with concussion and normal CT scans, and persisting concussion symptoms may be associated with abnormalities visible on SPECT and PET scans. Mild head injury may or may not produce abnormal EEG readings. A blood test known as the Brain Trauma Indicator was approved in the United States in 2018 and may be able to rule out the risk of intracranial bleeding and thus the need for a CT scan for adults.

Concussion may be under-diagnosed because of the lack of the highly noticeable signs and symptoms while athletes may minimize their injuries to remain in the competition. Direct impact to the head is not required for a concussion diagnosis, as other bodily impacts with a subsequent force transmission to the head are also causes. A retrospective survey in 2005 suggested that more than 88% of concussions are unrecognized. Particularly, many younger athletes struggle with identifying their concussions, which often result in the non-disclosure of concussions and consequently under-representing the incidence of concussions in the context of sport.

Diagnosis can be complex because concussion shares symptoms with other conditions. For example, persisting concussion symptoms such as cognitive problems may be misattributed to brain injury when, in fact, due to post-traumatic stress disorder (PTSD).

There are no fluid biomarkers (i.e., blood or urine tests) that are validated for diagnosing concussion in children or adolescents.

Classification
No single definition of concussion, minor head injury, or mild traumatic brain injury is universally accepted. In 2001, the expert Concussion in Sport Group of the first International Symposium on Concussion in Sport defined concussion as "a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces." It was agreed that concussion typically involves temporary impairment of neurological function that heals by itself within time, and that neuroimaging normally shows no gross structural changes to the brain as the result of the condition.

However, although no structural brain damage occurs according to the classic definition, some researchers have included injuries in which structural damage has occurred, and the National Institute for Health and Clinical Excellence definition includes physiological or physical disruption in the brain's synapses. Also, by definition, concussion has historically involved a loss of consciousness. However, the definition has evolved over time to include a change in consciousness, such as amnesia, although controversy continues about whether the definition should include only those injuries in which loss of consciousness occurs. This debate resurfaces in some of the best-known concussion grading scales, in which those episodes involving loss of consciousness are graded as being more severe than those without.

Definitions of mild traumatic brain injury (mTBI) were inconsistent until the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10) provided a consistent, authoritative definition across specialties in 1992. Since then, various organizations such as the American Congress of Rehabilitation Medicine and the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders have defined mTBI using some combination of loss of consciousness, post-traumatic amnesia, and the Glasgow Coma Scale.

Concussion falls under the classification of mild TBI, but it is not clear whether concussion is implied in mild brain injury or mild head injury. "mTBI" and "concussion" are often treated as synonyms in medical literature but other injuries such as intracranial hemorrhages (e.g. intra-axial hematoma, epidural hematoma, and subdural hematoma) are not necessarily precluded in mTBI or mild head injury, as they are in concussion. mTBI associated with abnormal neuroimaging may be considered "complicated mTBI". "Concussion" can be considered to imply a state in which brain function is temporarily impaired and "mTBI" to imply a pathophysiological state, but in practice, few researchers and clinicians distinguish between the terms. Descriptions of the condition, including the severity and the area of the brain affected, are now used more often than "concussion" in clinical neurology.

Prevention
Prevention of mTBI involves general measures such as wearing seat belts, using airbags in cars, and protective equipment such as helmets for high-risk sports. Older people are encouraged to reduce fall risk by keeping floors free of clutter and wearing thin, flat shoes with hard soles that do not interfere with balance.

Protective equipment such as helmets and other headgear and policy changes such as the banning of body checking in youth hockey leagues have been found to reduce the number and severity of concussions in athletes. Secondary prevention such as a Return to Play Protocol for an athlete may reduce the risk of repeat concussions. New "Head Impact Telemetry System" technology is being placed in helmets to study injury mechanisms and may generate knowledge that will potentially help reduce the risk of concussions among American Football players. Mouth guards have been put forward as a preventative measure, and there is mixed evidence supporting its use in preventing concussions but rather has support in preventing dental trauma.

Educational interventions, such as handouts, videos, workshops, and lectures, can improve concussion knowledge of diverse groups, particularly youth athletes and coaches. Strong concussion knowledge may be associated with greater recognition of concussion symptoms, higher rates of concussion reporting behaviors, and reduced body checking-related penalties and injuries, thereby lowering risk of mTBI.

Due to the incidence of concussion in sport, younger athletes often do not disclose concussions and their symptoms. Common reasons for non-disclosure include a lack of awareness of the concussion, the belief that the concussion was not serious enough, and not wanting to leave the game or team due to their injury. Self-reported concussion rates among U-20 and elite rugby union players in Ireland are 45–48%, indicating that many concussions go unreported. Changes to the rules or enforcing existing rules in sports, such as those against "head-down tackling", or "spearing", which is associated with a high injury rate, may also prevent concussions.

Treatment
Adults and children with a suspected concussion require a medical assessment with a doctor or nurse practitioner to confirm the diagnosis of concussion and rule out more serious head injuries. After life-threatening head injuries, injuries to the cervical spine, and neurological conditions are ruled out, exclusion of neck or head injury, observation should be continued for several hours. If repeated vomiting, worsening headache, dizziness, seizure activity, excessive drowsiness, double vision, slurred speech, unsteady walk, or weakness or numbness in arms or legs, or signs of basilar skull fracture develop, immediate assessment in an emergency department is needed. Observation to monitor for worsening condition is an important part of treatment. While it is common advice that someone who is concussed should not be allowed to fall asleep in case they go into a coma, for general cases this is not supported by current evidence. People may be released after assessment from their primary care medical clinic, hospital, or emergency room to the care of a trusted person with instructions to return if they display worsening symptoms or those that might indicate an emergent condition ("red flag symptoms") such as change in consciousness, convulsions, severe headache, extremity weakness, vomiting, new bleeding or deafness in either or both ears. Education about symptoms, their management, and their normal time course, may lead to an improved outcome.

Rest and return to physical and cognitive activity
Physical and cognitive rest is recommended for the first 24–48 hours following a concussion after which injured persons should gradually start gentle low-risk physical and cognitive activities that do not make current symptoms worse or bring on new symptoms. Any activity for which there is a risk of contact, falling, or bumping the head should be avoided until the person has clearance from a doctor or nurse practitioner. Low-risk activities can be started even while a person has symptoms. Resting completely for longer than 24–48 hours following concussion has been shown to be associated with longer recovery.

Return-to-school
The resumption of low-risk school activities should begin as soon as the student feels ready and has completed an initial period of cognitive rest of no more than 24–48 hours following the acute injury. Long absences from school are not suggested, however, the return to school should be gradual and step-wise. Prolonged complete mental or physical rest (beyond 24–48 hours after the accident that lead to the concussion) may worsen outcomes, however, rushing back to full school work load before the person is ready, has also been associated with longer-lasting symptoms and an extended recovery time. Students with a suspected concussion are required to see a doctor for an initial medical assessment and for suggestions on recovery, however, medical clearance is not required for a student to return to school. Since students may appear 'normal', continuing education of relevant school personnel may be needed to ensure appropriate accommodations are made such as part-days and extended deadlines. Accommodations should be based on the monitoring of symptoms that are present during the return-to-school transition including headaches, dizziness, vision problems, memory loss, difficulty concentrating, and abnormal behavior. Students must have completely resumed their school activities (without requiring concussion-related academic supports) before returning to full-contact or competitive sports.

Return-to-sport
For persons participating in athletics, it is suggested that participants progress through a series of graded steps. These steps include:
 * Stage 1 (Immediately after injury): 24–48 hours (maximum) of relative physical and cognitive rest. This can include gentle daily activities such as walking in the house, gentle housework, and light school work that do not make symptoms worse. No sports activities.
 * Stage 2: Light aerobic activity such as walking or stationary cycling
 * Stage 3: Sport-specific activities such as running drills and skating drills
 * Stage 4: Non-contact training drills (exercise, coordination, and cognitive load)
 * Stage 5: Full-contact practice (requires medical clearance)
 * Stage 6: Return to full-contact sport or high-risk activities (requires medical clearance)

At each step, the person should not have worsening or new symptoms for at least 24 hours before progressing to the next. If symptoms worsen or new symptoms begin, athletes should drop back to the previous level for at least another 24 hours.

Intercollegiate or professional athletes, are typically followed closely by team athletic trainers during this period but others may not have access to this level of health care and may be sent home with minimal monitoring.

Medications
Medications may be prescribed to treat headaches, sleep problems and depression. Analgesics such as ibuprofen can be taken for headaches, but paracetamol (acetaminophen) is preferred to minimize the risk of intracranial hemorrhage. Concussed individuals are advised not to use alcohol or other drugs that have not been approved by a doctor as they can impede healing. Activation database-guided EEG biofeedback has been shown to return the memory abilities of the concussed individual to levels better than the control group.

About one percent of people who receive treatment for mTBI need surgery for a brain injury.

Return to work
Determining the ideal time for a person to return to work will depend on personal factors and job-related factors including the intensity of the job and the risk of falling or hitting one's head at work during recovery. After the required initial recovery period of complete rest (24–48 hours after the concussion began), gradually and safely returning to the workplace with accommodations and support in place, should be prioritized over staying home and resting for long periods of time, to promote physical recovery and reduce the risk of people becoming socially isolated. The person should work with their employer to design a step-wise "return-to-work" plan. For those with a high-risk job, medical clearance may be required before resuming an activity that could lead to another head injury. Students should have completed the full return-to-school progression with no academic accommodations related to the concussion required before starting to return to part-time work.

Prognosis
The majority of children and adults fully recover from a concussion, however some may experience a prolonged recovery. There is no single physical test, blood test (or fluid biomarkers), or imaging test that can be used to determine when a person has fully recovered from concussion.

A person's recovery may be influenced by a variety of factors that include age at the time of injury, intellectual abilities, family environment, social support system, occupational status, coping strategies, and financial circumstances. Factors such as a previous head injury or a coexisting medical condition have been found to predict longer-lasting persisting concussion symptoms. Other factors that may lengthen recovery time after mTBI include psychological problems such as substance abuse or clinical depression, poor health before the injury or additional injuries sustained during it, and life stress. Longer periods of amnesia or loss of consciousness immediately after the injury may indicate longer recovery times from residual symptoms. Other strong factors include participation in a contact sport and body mass size.

Pediatric concussion
Most children recover completely from concussion in less than four weeks, however 15–30% of youth may experience symptoms that last longer than a month.

People aged 65+ with concussion
Mild traumatic brain injury recovery time in people over age 65 may have increased complications due to elevated health concerns, or comorbidities. This often results in longer hospitalization duration, poorer cognitive outcomes, and higher mortality rates.

Repeat concussion
For unknown reasons, having had one concussion significantly increases a person's risk of having another. Having previously sustained a sports concussion has been found to be a strong factor increasing the likelihood of a concussion in the future. People who have had a concussion seem more susceptible to another one, particularly if the new injury occurs before symptoms from the previous concussion have completely gone away. It is also a negative process if smaller impacts cause the same symptom severity. Repeated concussions may increase a person's risk in later life for dementia, Parkinson's disease, and depression.

Post-concussion syndrome
In post-concussion syndrome, symptoms do not resolve for weeks, months, or years after a concussion, and may occasionally be permanent. About 10% to 20% of people have persisting concussion symptoms for more than a month. Symptoms may include headaches, dizziness, fatigue, anxiety, memory and attention problems, sleep problems, and irritability. Rest, a previously recommended recovery technique, has limited effectiveness. A recommended treatment in both children and adults with symptoms beyond 4 weeks involves an active rehabilitation program with reintroduction of non-contact aerobic activity. Progressive physical exercise has been shown to reduce long-term post-concussive symptoms. Symptoms usually go away on their own within months but may last for years. The question of whether the syndrome is due to structural damage or other factors such as psychological ones, or a combination of these, has long been the subject of debate.

Cumulative effects
As of 1999, cumulative effects of concussions were poorly understood, especially the effects on children. The severity of concussions and their symptoms may worsen with successive injuries, even if a subsequent injury occurs months or years after an initial one. Symptoms may be more severe and changes in neurophysiology can occur with the third and subsequent concussions. As of 2006, studies had conflicting findings on whether athletes have longer recovery times after repeat concussions and whether cumulative effects such as impairment in cognition and memory occur.

Cumulative effects may include chronic traumatic encephalopathy, psychiatric disorders and loss of long-term memory. For example, the risk of developing clinical depression has been found to be significantly greater for retired American football players with a history of three or more concussions than for those with no concussion history. An experience of three or more concussions is associated with a fivefold greater chance of developing Alzheimer's disease earlier and a threefold greater chance of developing memory deficits.

Chronic traumatic encephalopathy, or "CTE", is an example of the cumulative damage that can occur as the result of multiple concussions or less severe blows to the head. The condition was previously referred to as "dementia pugilistica", or "punch drunk" syndrome, as it was first noted in boxers. The disease can lead to cognitive and physical disabilities such as parkinsonism, speech and memory problems, slowed mental processing, tremor, depression, and inappropriate behavior. It shares features with Alzheimer's disease.

Second-impact syndrome
Second-impact syndrome, in which the brain swells dangerously after a minor blow, may occur in very rare cases. The condition may develop in people who receive a second blow days or weeks after an initial concussion before its symptoms have gone away. No one is certain of the cause of this often fatal complication, but it is commonly thought that the swelling occurs because the brain's arterioles lose the ability to regulate their diameter, causing a loss of control over cerebral blood flow. As the brain swells, intracranial pressure rapidly rises. The brain can herniate, and the brain stem can fail within five minutes. Except in boxing, all cases have occurred in athletes under age 20. Due to the very small number of documented cases, the diagnosis is controversial, and doubt exists about its validity. A 2010 Pediatrics review article stated that there is debate whether the brain swelling is due to two separate hits or to just one hit, but in either case, catastrophic football head injuries are three times more likely in high school athletes than in college athletes.

Epidemiology
Most cases of traumatic brain injury are concussions. A World Health Organization (WHO) study estimated that between 70 and 90% of head injuries that receive treatment are mild. However, due to under reporting and to the widely varying definitions of concussion and mTBI, it is difficult to estimate how common the condition is. Estimates of the incidence of concussion may be artificially low, for example, due to under reporting. At least 25% of people with mTBI fail to get assessed by a medical professional. The WHO group reviewed studies on the epidemiology of mTBI and found a hospital treatment rate of 1–3 per 1000 people, but since not all concussions are treated in hospitals, they estimated that the rate per year in the general population is over 6 per 1000 people.

Age
Young children have the highest concussion rate among all age groups. However, most people with a concussion are young adults. A Canadian study found that the yearly incidence of mTBI is lower in older age groups (graph at right). Studies suggest males develop mTBI at about twice the rate of their female counterparts. However, female athletes may be at a higher risk of sustaining a concussion than their male counterparts.

Sports
Up to five percent of sports injuries are concussions. The U.S. Centers for Disease Control and Prevention estimates that 300,000 sports-related concussions occur yearly in the U.S., but that number includes only athletes who lost consciousness. Since loss of consciousness is thought to occur in less than 10% of concussions, the CDC estimate is likely lower than the real number. Sports in which concussion is particularly common include American football, the rugby codes, MMA and boxing (a boxer aims to "knock out", i.e. give a mild traumatic brain injury to, the opponent). The injury is so common in the latter that several medical groups have called for a ban on the sport, including the American Academy of Neurology, the World Medical Association, and the medical associations of the UK, the US, Australia, and Canada.

Workplace
Concussions may also be common and occur in the workplace. According to the US Bureau of Labour Statistics, the most common causes of mTBI-related hospitalizations and deaths from the workplace are falls, force of heavy objects, and vehicular collisions. As a consequence, jobs in the construction, transportation, and natural resource industries (e.g. agriculture, fishing, mining) have more elevated mTBI incidence rates ranging from 10 to 20 cases per 100,000 workers. In particular, as vehicular collisions are the leading cause of workplace mTBI-related injuries, workers from the transportation sector often carry the most risk. Despite these findings, there still remain important gaps in data compilation on workplace-related mTBIs, which has raised questions about increased concussion surveillance and preventive measures in private industry.

History
The Hippocratic Corpus, a collection of medical works from ancient Greece, mentions concussion, later translated to commotio cerebri, and discusses loss of speech, hearing, and sight that can result from "commotion of the brain". This idea of disruption of mental function by "shaking of the brain" remained the widely accepted understanding of concussion until the 19th century. In the 10th century, the Persian physician Muhammad ibn Zakarīya Rāzi was the first to write about concussion as distinct from other types of head injury. He may have been the first to use the term "cerebral concussion", and his definition of the condition, a transient loss of function with no physical damage, set the stage for the medical understanding of the condition for centuries.

In the 13th century, the physician Lanfranc of Milan's Chiurgia Magna described concussion as brain "commotion", also recognizing a difference between concussion and other types of traumatic brain injury (though many of his contemporaries did not), and discussing the transience of post-concussion symptoms as a result of temporary loss of function from the injury. In the 14th century, the surgeon Guy de Chauliac pointed out the relatively good prognosis of concussion as compared to more severe types of head trauma such as skull fractures and penetrating head trauma. In the 16th-century, the term "concussion" came into use, and symptoms such as confusion, lethargy, and memory problems were described. The 16th century physician Ambroise Paré used the term commotio cerebri, as well as "shaking of the brain", "commotion", and "concussion".

Until the 17th century, a concussion was usually described by its clinical features, but after the invention of the microscope, more physicians began exploring underlying physical and structural mechanisms. However, the prevailing view in the 17th century was that the injury did not result from physical damage, and this view continued to be widely held throughout the 18th century. The word "concussion" was used at the time to describe the state of unconsciousness and other functional problems that resulted from the impact, rather than a physiological condition. In 1839, Guillaume Dupuytren described brain contusions, which involve many small hemorrhages, as contusio cerebri and showed the difference between unconsciousness associated with damage to the brain parenchyma and that due to concussion, without such injury. In 1941, animal experiments showed that no macroscopic damage occurs in concussion.

Costs
Due to the lack of a consistent definition, the economic costs of mTBI are not known, but they are estimated to be very high. These high costs are due in part to the large percentage of hospital admissions for head injury that is due to mild head trauma, but indirect costs such as lost work time and early retirement account for the bulk of the costs. These direct and indirect costs cause the expense of mild brain trauma to rival that of moderate and severe head injuries.

Terminology
The terms mild brain injury, mild traumatic brain injury (mTBI), mild head injury (MHI), and concussion may be used interchangeably; although the term "concussion" is still used in sports literature as interchangeable with "MHI" or "mTBI", the general clinical medical literature uses "mTBI" instead, since a 2003 CDC report outlined it as an important strategy. In this article, "concussion" and "mTBI" are used interchangeably.

The term "concussion" is from Latin concutere, "to shake violently" or concussus, "action of striking together".

Research
Minocycline, lithium, and N-acetylcysteine show tentative success in animal models.

Measurement of predictive visual tracking is being studied as a screening technique to identify mild traumatic brain injury. A head-mounted display unit with eye-tracking capability shows a moving object in a predictive pattern for the person to follow with their eyes. People without brain injury will be able to track the moving object with smooth pursuit eye movements and correct trajectory while it is hypothesized that those with mild traumatic brain injury cannot.

Grading systems
National and international clinical practice guidelines do not recommend a concussion grading system for use by medical professionals.

Historical information on grading systems
In the past, the decision to allow athletes to return to participation was frequently based on the grade of concussion. However, current research and recommendations by professional organizations including the National Athletic Trainers' Association recommend against such use of these grading systems. Currently, injured athletes are prohibited from returning to play before they are symptom-free during both rest and exertion and until results of the neuropsychological tests have returned to pre-injury levels. Three grading systems have been most widely followed: by Robert Cantu, the Colorado Medical Society, and the American Academy of Neurology. Each employs three grades, as summarized in the following table: At least 41 systems measure the severity, or grade, of a mild head injury, and there is little agreement about which is best. In an effort to simplify, the 2nd International Conference on Concussion in Sport, meeting in Prague in 2004, decided that these systems should be abandoned in favor of a 'simple' or 'complex' classification. However, the 2008 meeting in Zurich abandoned the simple versus complex terminology, although the participants did agree to keep the concept that most (80–90%) concussions resolve in a short period (7–10 days) and although the recovery time frame may be longer in children and adolescents.

title: Concussion


text:
Bourne End, Buckinghamshire

Bourne End is a village mostly in the parish of Wooburn, but partly in that of Little Marlow in Buckinghamshire, England. It is about five miles (8 km) south-east of High Wycombe and three miles (5 km) east of Marlow, near the boundary with Berkshire and close to where the Buckinghamshire River Wye empties into the Thames.

History
Bourne End's original location differed from today's established village centre, and was a half-mile downstream on the River Thames. The name refers to the end of the river (bourne being an obsolete term for river), and derived from the mouth of the River Wye. Then a hamlet, it appears on Morden's 1722 map of Buckinghamshire as "Born end". It was noted in the 19th century, however, that the name had been corrupted to "Bone End", apparently through local mispronunciation and thence on official maps and documents. In 1858, the vicar of Wooburn succeeded in reversing the change, and the corrected name remains in use today.

The length of the River Wye was the provider of water power for many mills in the valley for hundreds of years, and Bourne End was no exception. There were four on the final stretch of the river: Princes Mill, Jacksons (or Gunpowder) Mill, Hedsor Mill and Lower Mill. These mills were historically the predominant employers in the area, along with the local farms and two wharfs on the Thames.

In the early nineteenth century, the settlement known as Bourne End was a hamlet of Wooburn parish, along with others such as Spring Gardens, Eghams Green, Cores End, Heavens Lea and Upper Bourne End. This changed with the emergence of the Wycombe Railway Company in 1846. By 1854, Isambard Kingdom Brunel had designed and constructed a railway linking Maidenhead to High Wycombe, via Bourne End. The station at Bourne End was originally named Marlow Road; then in 1873 a branch line to Marlow was built, and a year later the station was renamed Bourne End station to avoid confusion with the new station at Marlow town. The railway created more travel opportunities for locals and greatly benefited the mills, and thus Bourne End expanded, on a greater scale than other similar settlements in the surrounding area. See Marlow Branch Line and Marlow Donkey for more information.

The hamlets soon merged into what is now known as Bourne End, as did Well End and Coldmoorholme in the neighbouring parish of Little Marlow. Both a church and school were built at the turn of the century for the residents' convenience. The Parade became established as the focal point of the village for shops and services.

In the 1920s Bourne End became home for two distinguished literary figures; Enid Blyton, a perennially popular children's writer, moved into Old Thatch on Coldmoorholme Lane, and Edgar Wallace, a prolific crime author and dramatist, bought Chalklands off Blind Lane. Another resident at this time was Louis Blériot, the French aviator and aircraft builder, who lived at New York Lodge beside the Thames.

The Royalty Cinema opened in The Parade in 1934. The late 1940s saw extensive development in Bourne End, of the Chalklands estate and the Council Estate north of The Parade. The 1960s saw the building of the Community Centre and Library in Wakeman Road after some years of local campaigning.

The Beeching Axe hit the village in 1969, as it was announced that the line between Bourne End and High Wycombe, which had suffered reduced usage after the direct connection between Wycombe and London by the opening of the Great Western and Great Central Joint Railway in 1899, would be closed. The track bed was lifted soon after closure in 1970. A commercial estate was developed adjacent to the station, though most of the course taken by the railway remains as a footpath between the village and Wooburn.

Locale
Bourne End lies between the M4 and M40 motorways, and retains its railway station on the Maidenhead to Marlow Branch Line. With rail and road accessibility to London, it has become a popular place for commuters to live.

All of the mills along the Wye Valley have now been shut down and demolished, Jacksons Mill in Furlong Road being the last (in Bourne End) in the late 1980s. These have been replaced by houses, offices or industrial estates, which has led to the continuation of the village as an employment centre.

Bourne End remains a distinct settlement, although the continued house-building over the past century means it is threatened by the evident ribbon development, through to High Wycombe. In 1997, when the Local Plan was in preparation, the Residents Associations of Bourne End and Wooburn successfully lobbied to stop Slate Meadow (the field which separates the two settlements) being designated for housing for the time being. Other undeveloped land around the village looks likely to remain so, as it has been specified as Green Belt, an Area of Outstanding Natural Beauty, a Site of Special Scientific Interest, or a combination of the three. In parts, Bourne End is surrounded by farmland. Somewhat further away, Cliveden and Hedsor overlook the village from higher ground to the south east.

Community
Bourne End sustains many businesses and services whilst still retaining a village atmosphere. There is a Community Centre in the centre of the village, with a large hall, function rooms and a bar, which is open for member's use. It is, for many, considered the focal point of village activity.

In the early 2000s, a Twinning Association was established, and subsequently Octeville-sur-Mer, a town on the north coast of France, was chosen to be its twin town. Frequent events are held by members of the association to foster and enhance the relationship between the two settlements.

Administration and services
The local government of the village is made up of two tiers. Wooburn and Bourne End Parish Council (formerly Wooburn Parish Council, until 2005), based in Wooburn; and Buckinghamshire County Council, based in Aylesbury which was established as a unitary authority in 2020. The local police force is Thames Valley Police. Local healthcare services are commissioned by Buckinghamshire Primary Care Trust (PCT); GPs operate from The Hawthornden Surgery in Wharf Lane, and The Orchard Surgery in Station Road. Pound House Surgery at Wooburn Green is part of the same group of practices and nurses and other medical staff operate between all three. There are two dentists, the Bourne End Dental Practice, and Advance Dental Services, both in Station Road.

Leisure
The village has two recreation grounds (Furlong Road and Blind Lane), riverside open space at the marina and Spade Oak Reach, a Junior Sports Club and fitness centre and the long-established Upper Thames Sailing Club. For many residents and visitors alike, the river is the central attraction of Bourne End, and many leisure pursuits involve or revolve around it. The Sailing Club traditionally host a week-long regatta every year in June, known as Bourne End Week.

Bourne End hosts a number of restaurants of varying cuisines. There are also a number of public houses.

Near Bourne End, across the River Thames, is Cock Marsh, an area of common land and floodplain owned by the National Trust. It is a Site of Special Scientific Interest and includes a prehistoric burial mound. Cock Marsh is accessible via the footbridge attached to the railway bridge over the river, and footpaths continue to Cookham, Cookham Dean and beyond.

The Thames Path National Trail follows the River Thames through Bourne End; upstream on the Buckinghamshire side, crossing the river at the footbridge, and downstream through Berkshire.

Education
Bourne End has three schools:
 * Westfield School, on Highfield Road, a special school which was the village First School until 1995.
 * Claytons Primary School, in Wendover Road, the village junior school which was formerly a Middle School and was merged with Westfield.
 * Bourne End Academy, in New Road, an upper school which has specialist Sports College status. Before its amalgamation with Pembroke School, Flackwell Heath, in 1985, this was known as Deyncourt School, and subsequently as Wye Valley School until 2014. From late 2012 to late 2014, the school was suffering from poor results in OFSTED evaluations, and was ultimately placed into Special Measures and given the academy status.

There are a number of pre-schools and nurseries across the village.

Religion
The village currently has three active churches. The Anglican parish church, in Station Road, is dedicated to St Mark. It was built in 1889 as a daughter church of St Paul's, Wooburn. The Roman Catholic church of St Dunstan is in the centre of the village, off Cores End Road. The longest established is the United Reformed Church in Cores End, which was founded as a Congregational Chapel in 1773, as a nonconformist alternative to St Paul's in Wooburn.

Bourne End had a Methodist Church in Furlong Road, which closed in 2002. Well End once had a Congregational mission hall, in the late 19th and early 20th centuries; this is now a residential house named The Chapel.

Bourne End also has the only UK branch of the Ramakrishna Mission, situated at the Vedanta Centre.

Shopping
Bourne End continues to support a bustling array of shops, chiefly in The Parade. Community events focused on the village centre, such as "Fun Night" in December, have attempted to turn residents' attention to upholding local trade and businesses. There is a small parade of shops in Furlong Road, including the main Post Office.

Noted Inhabitants
Sir Arthur Harden, FRS (1865–1940), Nobel Prize-winning biochemist

Beatrix Lehmann, (1903–1979), British actress, theatre directress, writer and novelist.

John Lehmann, (1907–1987), poet, publisher, man of letters.

Rosamond Lehmann, (1901–1990), novelist and translator

Enid Blyton ,(1897-1968),English children’s writer

Louis Blériot,(1872-1936), French aviator, inventor, and engineer.

Bud Flanagan, (1896 – 1968) British music hall and vaudeville entertainer and comedian)

Bernard Chacksfield (1913 – 1999) was a senior Royal Air Force officer in the 1950s and 1960s and later a chief commissioner of The Scout Association and chairman of the Burma Star Association.

Renée Houston 1902 – 1980) Scottish comedy actress and revue artist

Edgar Wallace (1895 - 1932) Crime writer, war correspondent, journalist, novelist, screenwriter, and playwright.

license: Creative Commons - Attribution Share-Alike - https://creativecommons.org/licenses/by-sa/4.0/

title: Bourne End, Buckinghamshire


text:
Emir of Kuwait

The emir of the State of Kuwait (أمير دولة الكويت) is the monarch and head of state of Kuwait, and is the country's most powerful office. The emirs of Kuwait are members of the Al Sabah dynasty.

Sheikh Mishal Al-Ahmad Al-Jaber Al-Sabah became the emir of Kuwait on 16 December 2023, following the death of Nawaf Al-Ahmad Al-Jaber Al-Sabah.

Rules and traditions of succession
Succession to the throne of Kuwait was limited to the descendants of Mubarak Al-Sabah. The position of emir was also traditionally alternated between the two main branches of the Al Sabah family, the Al-Ahmed and Al-Salem branches. The reigning emir must appoint an heir apparent within one year of his accession to the throne; the nominee for consideration as crown prince has to be a senior member of the Al Sabah family. The prime minister is appointed by the emir.

Compensation
Annual compensation for the emir was defined. The annual compensation was set to 50 million KWD as of 2017.

title: Emir of Kuwait


text:
Winterbourne, Gloucestershire

Winterbourne is a large village in South Gloucestershire, England, situated just beyond the north fringe of Bristol. The village had a population of 8,965 according to the 2011 census. This has risen to 10,250 at the 2021 Census. The Civil Parish of Winterbourne is centred on the village and includes the neighbouring communities of Winterbourne Down, Hambrook and Frenchay. To the north-east is the village of Frampton Cotterell and to the west lies the new town of Bradley Stoke.

Winterbourne was recorded in the Domesday Book as Wintreborne, meaning 'Winter Stream'. The village is believed to have derived its name from the nearby Bradley Brook as much of medieval Winterbourne was originally built up around St Michael's Church, which is situated near the river.

The modern village is largely built on top of a hill, with woodlands and fields encompassing its urban features. The River Frome flows through a valley between the village and nearby Frampton Cotterell, continuing on towards Frenchay, and eventually draining via Mylne's Culvert, into the tidal Bristol Avon New Cut, to the east of what is now Gaol Ferry Bridge. The Bradley Brook divides Winterbourne from Bradley Stoke and Stoke Gifford to the west, before flowing into the Frome at Hambrook. Since the 1960s, the M4 motorway has bypassed the village to the southwest.

The Huckford Viaduct carries the Great Western Railway over the River Frome. Beneath the viaduct is the abandoned Huckford Quarry, a public nature reserve. Winterbourne is known for its large duck pond, which overlooks the Frome Valley and is a common spot for fishing and feeding the ducks and swans.

The parish church is St Michael's, a building dating from the 12th century, which celebrated its 800th anniversary in 1998. St Michael's sits amid fields, flanked by cottages, with its prominent spire visible for miles around. At the altar is a stone depiction of the Last Supper, based on the painting by Leonardo da Vinci. Winterbourne Court Farm Barn is immediately adjacent to the church. This is a grade II* listed 14th century tithe barn and is an outstanding example of its type.

Winterbourne has a number of pubs including the George and Dragon, the Swan and the Mason's Arms. In recent years, a number of the village's pubs have become restaurants; two of which now serve Indian cuisine. The village has three social hubs: St Michael's Rooms, Fromeside Community Centre and Greenfield, which host clubs, functions and other public events.

Winterbourne contains branches of the Co-op and Tesco Express, a chemist, optician, a handful of dental practices and a library. Other village amenities include a bakery, butcher and a Post Office serving the community. Horses and cattle are a common sight in the fields, including in the Cloisters area, which has views of the Frome Valley and the Huckford Viaduct.

As well as being the centre of a large civil parish, Winterbourne contains the hamlet of Watley's End, located on the border between Winterbourne and Frampton Cotterell. Nowadays, it is regarded as an area of Winterbourne, but a few decades ago it was considered to be a village in its own right. Some people in Watley's End continue to refer to the busy, uphill part of the village as 'Winterbourne Hill'. Salem, the local Methodist church, is in Watley's End.

Governance
An electoral ward in the same name exists. This ward stretches from Winterbourne in the north west to Hambrook in the southeast. The total population of the ward taken at the 2011 census was 6,994.

Schools
Winterbourne contains several schools. The main primary schools are Elm Park and St Michael's, with most students going on to attend the nearby secondary school, Winterbourne Academy, originally named The Ridings High School when formally opened by Tony Benn in 1957. Silverhill School and Day Nursery is an independent preparatory school for children aged 6 months to 11 years. St Michael's was founded in 1813 by the abolitionists and educational reformers, Hannah More and William Wilberforce. The original school was located upstairs in the George and Dragon pub. Larger rooms were then provided in Bourne House, where the school remained until a permanent building was erected on the High Street. St Michael's present location on Linden Close was opened in 1970. St Michael's alumna, J. K. Rowling, is reputed to have based much of her character, Albus Dumbledore, on Alfred Dunn, who was headmaster during her studies.

Notable residents

 * Tim Bowles, politician and first Mayor of the West of England.
 * James Bracey, Gloucestershire and England Lions cricketer.
 * Edward Colston, merchant, slave trader and Member of Parliament, is believed to have spent much of his childhood in Winterbourne.
 * Joe Fry, racing driver, was born in Winterbourne in 1915.
 * Harry Grindell Matthews, inventor, was born in Winterbourne in 1880. His childhood home was located at what is now The Grove Residential Home for the Elderly on the High Street where there is a blue plaque commemorating this link.
 * Dan Norris, MP and second Mayor of the West of England.
 * J. K. Rowling, author of the Harry Potter books, lived in Winterbourne until she was nine years old. Potter's surname originated from some of her friends in the village.

Sport and leisure
Winterbourne has a Non-League football club Winterbourne United F.C. who play at Parkside Avenue and a popular village cricket club that fields 5 senior sides - Winterbourne CC - who share the same ground. Winterbourne Down Border Morris performs during the year at events such as wassailing, and especially on Boxing Day when they perform a Mummers play.

title: Winterbourne, Gloucestershire


text:
Talk:History of Seattle 1900–1940

Untitled
Imaginably, we might want to juggle the organization of this and History of Seattle before 1900, making the gold rush rather than 1900 the divide. That might actually make more sense. However, I'm done for a while with major structural work here, and I leave that to someone else to think about. -- Jmabel 23:34, 12 Dec 2003 (UTC)

Map of Seattle park/open space coverage--why I changed comment about where parks are lacking. Niteowlneils 20:48, 8 Apr 2004 (UTC)

External links modified
Hello fellow Wikipedians,

I have just modified 2 external links on History of Seattle 1900–40. Please take a moment to review my edit. If you have any questions, or need the bot to ignore the links, or the page altogether, please visit this simple FaQ for additional information. I made the following changes:
 * Added archive https://web.archive.org/web/20100607192530/http://www.seattle.gov/neighborhoods/preservation/ContextQueenAnneStatement2005.pdf to http://www.seattle.gov/neighborhoods/preservation/ContextQueenAnneStatement2005.pdf
 * Added archive https://web.archive.org/web/20080609021534/http://www.smithtower.com/History.html to http://www.smithtower.com/History.html

When you have finished reviewing my changes, you may follow the instructions on the template below to fix any issues with the URLs.

Cheers.— InternetArchiveBot  (Report bug) 22:20, 4 November 2017 (UTC)

title: Talk:History of Seattle 1900–1940


text:
Talk:Punter

Untitled
From VFD:

 * Punter Was a redirect to John (prostitution), which is clearly inappropriate. The vastly more common meaning is someone who bets on horse races (indeed, the local prostitution meaning is probably derived from this one), and it can also mean one who poles a boat in shallow water. None of these meanings are worthy of an encyclopedia entry. This is, after all, not a dictionary. Tannin 13:20, 12 Dec 2003 (UTC)
 * Delete Rossami 14:50, 12 Dec 2003 (UTC)
 * Just wanted to add that, to Americans, a punter is somebody who kicks a football. :) It could be redirected to Glossary of American football.  RickK 16:37, 12 Dec 2003 (UTC)
 * or made into a kind of disambiguation page to all of these various meanings. Gentgeen 16:38, 12 Dec 2003 (UTC)
 * Opposition, for the reason Gentgeen mentioned. It has become a pretty standard disambiguation page now. I was, however, surprised that nobody added the actual meaning of punter: Someone who punts ;-) -- Timwi 16:56, 12 Dec 2003 (UTC)
 * Keep, it has now become a good dismbig page. Tempshill 18:47, 12 Dec 2003 (UTC)
 * Keep. Angela. 21:41, 12 Dec 2003 (UTC)

Now a pointless but harmless disambiguation page: call for deletion withdrawn. Tannin 23:35, 12 Dec 2003 (UTC)

British English
There are three important uses of the word punter in British English, now listed. All three are in common usage and at least one links here from Hillman Hunter, as a cockney rhyming slang term.

Can we please RETAIN the British uses for punter this time?! looking through the history, this has been deleted more than once - it is a VERY common word! - br

The word punter is used under horse racing - betting and should be cross referenced

 * Just because they're common words doesn't mean they have a place on a disambiguation page. Wikipedia is not a dictionary. Disambiguation pages link only to other articles, and don't contain dictionary definitions. — Timwi 16:11, 6 November 2005 (UTC)

If WIKI is not a dictionary, what is it. Define the use of the word dictionary. Define encyclopedia. Let the PUNTERS decide ! —Preceding unsigned comment added by 24.67.216.199 (talk) 13:58, 10 May 2008 (UTC)

Irish Origin?
Could it be some sort of Anglo-Irish derivative, based on the old Irish currency? http://en.wikipedia.org/wiki/Irish_punt

Punt = Money Punter = Person with Punts to spend (e.g. an Irish person at Cheltenham!)? —Preceding unsigned comment added by 211.31.24.2 (talk) 08:06, 10 November 2010 (UTC)

Eddy Groves
This was the first instance of Eddy Groves appearing on this page. I am highly doubtful that this name should appear on this page, however.--Filll (talk | wpc ) 21:33, 13 October 2011 (UTC)

Ship type?
Is "punter" really a ship type? I've found one page that uses it that way, but one could easily be just an error. The article Dutch barge makes no mention of the word. --Dan Wylie-Sears 2 (talk) 20:00, 6 August 2013 (UTC)

It means "customer of a prostitute"
Just today, in reporting by a widely-respected organization:

http://www.bbc.com/news/uk-england-london-35920299 — Preceding unsigned comment added by 97.104.88.146 (talk) 08:24, 9 July 2016 (UTC)

title: Talk:Punter


text:
Child harness

A child harness (alternative: child tether, walking harness, British English: walking reins) is a safety device sometimes worn by children when walking with a parent or carer. Child harnesses are most commonly used with toddlers and children of preschool age, though they may also be used with older children, especially if they have special supervisory needs such as ADHD or autism. Various types exist, though all are worn by the child and have a lead (tether) or rein which is held by a parent or caregiver. As child harness designs and purposes have evolved with cultural norms and parenting techniques, they have become subject to common debate.

Use and purpose
Child harnesses are designed to provide safety for a child when walking by preventing them from being separated from their parent or caregiver. Additionally, some may be used to help keep a child safely seated in a stroller or high chair. Typically used for children between one and four years of age, the use of child harnesses depends on a variety of factors including the age and maturity of the child, as well as any perceived dangers such as busy roads, large crowds, and potential distractions. Other factors such as neurological and health conditions may also be considered, particularly for older children with unique supervisory requirements.

Pre-1900
While there is little documentation on child harnesses before the twentieth century, they may have emerged from leading strings used during the seventeenth and eighteenth centuries. In the late nineteenth century, evidence suggests they were mostly considered as items of clothing, primarily worn by young children learning to walk. The "Baby-Exercising Corset" patented in New Jersey in 1874 aimed to "enable them to learn to walk much sooner, and much more readily, than they could with out its use."

Early 20th century
After 1900, designs evolved from a type of garment into dedicated safety harnesses most commonly "in the form of a waist belt, shoulder straps connecting the waist belt...and a suspending strap for a person to sustain the weight of the child." While earlier patent applications for child harnesses mention protection from potential dangers, designs beginning in the twentieth century were "particularly directed to the prevention of injury.",     With the transition towards safety as the main priority, designs changed "to provide a readily applicable harness for retaining a child in standing position in a chair, go-cart, or the like, and thereby obviating the danger of the child falling.". Harnesses at this time were usually made of leather, and some designs also had small bells attached.

1940s–1980s
By the 1940s in the United Kingdom, child harnesses were fairly common. Designs in the United Kingdom and the United States began to change in the 1950s with the straps being made of webbing instead of leather, and purposely designed fittings to make the harnesses easier to use for parents and caregivers.

In the mid-1950s, various local campaign groups in the United Kingdom began to recommend the use of child harnesses as part of road safety campaigns. In addition to recommendations, the campaigns also focused on abolishing the thirty percent sales tax payable on child harnesses, arguing removing the tax would be "a sign that the Government was sincerely interested in the safety of young children." The debate around possible legislation for child harnesses continued into the 1960s, with the British Standards Institute issuing new safety standards. The "stringent specifications" sought to address the "harnesses on the market which were not sufficiently strong to restrain a bouncing baby in a pram, or to take the weight of a falling toddler," with all designs after November 1964 being subject to "rigorous performance tests" for both design and materials.

Designs advanced further in the 1960s with Roland Cheetham (W.H. Cheetham & Sons Limited) inventing the first terylene webbing harness in 1961. Going on sale in 1962, the new webbing material had "a high resistance...to abrasion and moisture" with the company claiming the design was "virtually ever-lasting." The new materials were lighter than previous versions, and the company also claimed the material was more hygienic as the harness could be washed and dried in five minutes. The new design and was awarded the certificate of the Royal Institute of Public Health and Hygiene. The design also featured improved fittings "so that the mother does not have to bother with buckles" and could "vary the size easily." The harness was sold in four different colors with a suggested retail price of twelve shillings and sixpence.

Child harness designs remained largely unchanged between the 1970s and 1990s, the most significant change being the replacement of metal parts with plastic parts. The most notable exception, patented in 1987, was the "wrist link" or "wrist strap" which dispensed with the chest harness section, instead consisting of a length of webbing with a loop at each end. One loop secures around the wrist of the child, while the other is held by the parent or caregiver. The idea was to address how parents and/or caregivers could find it "very impractical to use one hand to hold the child at all times" and thus "leaves the parent's hands free." The wrist link/strap design was also noted to be "adaptable to children of any size or age". Other hands-free adaptions to the established designs of child harnesses were also developed in the late 1980s.

Post-1990
In the United Kingdom, following the 1993 James Bulger murder case, sales of child harnesses "dramatically increased" and some stores sold out when "trying desperately to meet demand." Two years later, child harnesses were recommended by the Child Accident Prevention Trust as part of their "Seven Steps for Safety Campaign."

In 2005, after a largely standardized design for forty years, an alternative design for child harnesses was created which merged the basic strap elements with a soft toy. The new design, developed by Goldbug, Inc. in the United States, evolved into "a backpack...in the form of a novelty character of animal or human form" which also included a "storage pouch" with "the shoulder and waist straps of the harness representing the limbs or extremities of the character, and a tether attached to the harness in the form of a character tail." The alternative designs, which included a variety of popular soft toys such as monkeys, giraffes, and teddy bears, were developed and marketed as "Harness Buddies" to discourage any objections of a child to wearing a safety harness through providing more comfort, padding, and overall novelty.

In 2007, Scottish primary school teacher Elaine Stephen, MBE launched the Walkodile harness. The design, developed in partnership with The Design Unit at De Montfort University, was the first child harness which could be used for multiple children, allowing for two or more children to walk together side-by-side. Each child has their own simplified safety belt which can be attached to any connection point located on an extendable modular section which is located between the parallel rows of children.

In May 2014, British retailer Boots was criticized for its range of child harnesses as some felt the colors and designs reinforced traditional gender roles. The company sold two harnesses; a blue version with the words "Train Driver" and another pink version which featured the words "Little Cupcake" specifically labelled as a "Girls Walking Rein and Harness". After a consumer photo of the harnesses went viral, the retailer responded by promising to change the packaging to demonstrate their "commitment to prevent gender stereotyping."

Standard harness
The standard design usually consists of a waist or chest strap and two shoulder straps forming a simple chest harness, most commonly with the closure behind the child. A walking lead, tether, or rein attaches at the back or sides of the chest harness and is held by the parent or caregiver behind the child. This design is sometimes used to safely secure a child in a stroller or high chair as well as for walking. The most historically established design, standard style child harnesses are made of either leather or webbing and are primarily sold for children between four years of age or younger.

Character harness
Character harnesses integrate the functions of the standard child harness and a soft toy. Some designs are based around simple generic soft toy characters such as monkeys, teddy bears, or bunnies; while others are based around well-known children's entertainment characters. Character harnesses share the same basic features as standard child harnesses, but often have a front closure and are designed to be more appealing for the child, parent, and/or caregiver via additional comfort and novelty. Some also feature small storage pockets.

Backpack harness
Backpack harnesses integrate the functions of a standard child harness and a backpack. Designs are generally based around a basic backpack, suitably sized for a child with a connection for a lead or tether. Like character harnesses, backpack harnesses usually feature closures at the front of the harness and are marketed as an alternative to standard child harnesses for a similar age group.

Wrist link
A wrist link (sometimes called a wrist strap or wrist rein), is a simple length of webbing with two loops; one at each end. One loop is worn on the child's wrist and the other is held by the parent or caregiver. Usually, the loops are adjustable for size and the strap often features an elastic section to prevent injury by absorbing shock from any sudden movements. Some wrist links use a strong coiled line instead of webbing or elastic. Wrist links are sometimes marketed as suitable for those in the "junior" age range and are occasionally worn by children who may have outgrown the standard or backpack style child harnesses.

Special needs harness
For older children and adolescents who have special supervision requirements due to health or behavioral conditions, larger, and sometimes bespoke, versions of child harnesses are available. These designs vary, but often include features atypical of standard child harnesses designed for younger kids such as support handles, lockable closures, and additional straps to prevent removal.

Sports/recreational harness
While not designed for everyday use, some specialist child harnesses exist for specific recreational purposes such as hiking or skiing. These types of harnesses feature unique elements such as longer leads to assist children in sports training techniques.

Common debate
There is some disagreement about the use of child harnesses which focuses on a number of aspects including safety, physical health, mental development/behavior, as well as parenting philosophies and styles. Opinion is divided among parents (and non-parents) but also among childcare and educational professionals.

Safety
Those who use or suggest using child harnesses say that they provide more safety for the child, especially for more active children. Parents and caregivers who advocate using child harnesses cite the impulsivity of toddlers or young children to unknowingly put themselves in danger as a main reason for their use. Some childcare professionals cite the preventative principle of child harnesses to help avert situations where the child might place themselves at risk. A 1991 report in the Archives of Disease in Childhood journal stated that six childhood fatalities which occurred within the Greater London and Birmingham areas of the United Kingdom could have been prevented by the use of child harnesses (reins). For those involved in childcare who believe that "care and safety is their number one priority," harnesses can be "the best option" in some circumstances.

Others contend that the safety benefits of child harnesses are minimal, or at least unknown according to studies. In 2019, Benjamin Hoffman, the Chair of the Injury Prevention Council at the American Academy of Pediatrics stated that there was no "data on injuries associated with [safety] leashes" and that there was a "lack information about why parents use them, and what any benefit might be," adding that "from an injury standpoint" there are potential concerns over entanglement or choking similar to the cords on window blinds and that "there's also the risk of accidentally tripping your child with the tether." Other medical professionals have also stated that certain designs of child harnesses such as the wrist link/strap maybe potentially dangerous for children as they do not provide adequate physical support when needed and also require a degree of cooperation from the child which maybe intermittent.

Physical health
Those who use, or agree with the use of child harnesses, often contend that they improve the physical health of child by allowing them to walk and thereby provide opportunities for exercise. These arguments are especially prevalent when the use of child harnesses is compared to the time a child might otherwise spend in a stroller and thus not able to walk (or jog or run). A 2001 textbook aimed at students studying for the Child Development GCSE states that "walking reins with a safety harness are essential for toddlers, as they can experience walking skills while remaining under the control of an adult." The 2019 OCR handbook for the Cambridge National qualification in Child Development lists child harnesses as a "key factor" in considering the right equipment to "promote the well-being and development" of children aged between one and five years.

Those who oppose child harnesses on grounds of physical health often cite the risk of injury and/or misuse of harnesses. Such concerns include how some parents or caregivers might "tug on the tether or drag the child.". Additionally, some individuals who oppose the use of child harnesses often contend they function as a "leash" to restrict movement and therefore offer negligible, little, or even reduced physical health benefits compared to children who are able to explore beyond the limits of movement which harnesses create. Furthermore, some opponents contend child harnesses operate as a substitute for rule making which can result in parents generating (albeit knowingly or unknowingly) "more freedom to be less present" and reduce their awareness of their child's behavior in "potentially dangerous places".

Mental development/behavior
Advocates and users of child harnesses argue that harnesses allow a safe range of exploration for the child, as well as being a useful "communication tool and teaching method to help children learn to stay beside their parent or caregiver" and thus assist them in understanding boundaries, recognizing potential dangers, and when exploration maybe unsafe or improper. Proponents claim that when used in the appropriate "manner as a teaching tool" harnesses will "not have a negative effect" on the child. Additionally, some supporters of child harness use have cited their own memories of how wearing a harness could be a form of enjoyment or play. In certain circumstances, child harnesses are also recommended by professionals specializing in the health of special needs children whose supervisory requirements may be different from those of neurotypical children.

Many who oppose child harnesses view them as a tool which delays or restricts learning and mental development about rules and potential dangers. Some contend child harnesses are substitute "babysitters," a way for parents or caregivers to "check out," and equate to a "short-term, Band-Aid" solution which results in parents not teaching children important safety and cultural rules. Some psychologists have argued that child harnesses limit the natural curiosity of young children and prohibit them from acquiring skills in self-control which subsequently reduces their ability to understand and respect rules as they grow older. Additionally, other psychologists contend child harnesses could be a source of embarrassment for the child.

Parenting/caregiver philosophy/style
The advocacy or disapproval of child harnesses is also determined by parenting styles and beliefs.

Parents and caregivers who use child harnesses often cite safety as the primary reason for doing so, fearing losing contact with the child. However, for some the use of child harnesses is only a temporary and/or reserve measure during the education and generation of trust in a child. Once the child has proved they have learned such knowledge "the use of the tether can be faded" showing that "when used short term and in a loving manner as a teaching tool" a harness "should not have a negative effect on the child.”. Some parents and caregivers also claim that the use of harnesses can be more comfortable for the child as having to raise their arm to hold their parent's hand for extended periods can be uncomfortable. Similarly, some parents argue that compared to having their child in a stroller, a using a harness allows for more awareness of their child's needs or wants. Equally, some parents have also observed that their children are more positive and happier during outdoor activity when wearing a harness compared to being a stroller, and that using a child harness "has more to do with how it reflects on us as parents than how it actually affects our children." Additionally, some argue if a "parent experiences a lot of anxiety" to such an extent that "it interferes with them taking their children outdoors or on other events" if "the tether increases the parents' feelings of competence and allows the child to go places...than tethering could be beneficial" for both adult and child.

Those who disapprove of child harnesses argue that their use can be socially degrading for children "like treating a child like a dog or an animal" which results in others possibly perceiving "a parent who can't control her toddler." Such viewpoints claim that making and enforcing appropriate rules is the primary job of the parent and a child harness avoids such responsibilities. Other childcare specialists have also raised concerns over the effect on the confidence of parents and caregivers with the "worst part of using these harnesses and wrist links are the stares that you get from other people who don't understand that they are a safety precaution." Others have expressed similar concerns regarding how such "reactions could negatively impact a child" as well as the parent or caregiver as "the stigma from being stared at...could play a larger role in traumatizing the child than the correct use of a tether." Some have also drawn philosophical parallels between using child harnesses for toddlers and the use of GPS and smartphone tracking apps for older children. These arguments contend that children benefit when having to solve problems alone or by seeking appropriate help, neither of which are possible if the child has a permanent form attachment to their parent or caregiver.

European Union and United Kingdom

Regulations can be traced back to old British Standards for mass-manufactured child harnesses. These British regulations were further developed within the European Union, where the harnesses must comply with the safety requirements as defined in the EN13210:2004 "Children's harnesses, reins and similar type articles" standard. These rules cover a range of attributes such as strength, durability, use of small parts, shapes of components, substances or chemicals used for manufacturing, safety markings, and instructional information on safe use. They also define testing procedures. This European Standard still has the status of a British Standard (BS EN 13210:2004) in the UK.

A new version of the standard is under preparation in the EU; it will split into Part 1 (Children’s harnesses, reins – Safety requirements and test methods) and Part 2 (Children’s harnesses incorporating backpacks and reins – Safety requirements and test methods).

In 2013, the European Child Safety Alliance (Eurosafe) recommended that a child harness approved to the EN13210:2004 safety standard will provide additional safety for children when using a second-hand stroller not yet equipped with a five-point harness.

As of 2019, rule four of the Highway Code of the United Kingdom, recommends that parents or caregivers use child harnesses (reins) for very young pedestrian children when walking alongside or crossing roads as a possible alternative to a pushchair (stroller) to ensure safety.

The use of such child harnesses is sometimes recommended by local authorities in certain areas where risk and potential dangers to children are considered much higher than usual. These include areas such as mountain paths which are steep or unpredictable underfoot thereby posing an increase of slipping or falling to young children or children inexperienced walking on such terrain.

Other regions
In the United States, the standards, safety, and potential recall process for child harnesses is overseen by the United States Consumer Product Safety Commission. In Australia, parallel standards of safety are developed and enforced through the Australian Product Safety System, overseen by the Australian Competition & Consumer Commission.

title: Child harness


text:
Boveney

Boveney is a village and former civil parish, now in the parish of Dorney, in Buckinghamshire, England. It is situated near Windsor, between the villages of Eton Wick in Berkshire, and Dorney and Dorney Reach in Buckinghamshire. Since boundary changes in 1974 and 1995, Boveney is the southernmost village in Buckinghamshire. In 1931 the parish had a population of 630.

Origin of name
The village name is Anglo-Saxon in origin and means "above island". This refers to the island in the River Thames next to the village. The Anglo-Saxon name for the village was Bufanege.

History
Boveney was once a hamlet within the parish of Burnham, though it has long since been considered a separate village, particularly since the urban growth of nearby Slough. It became a separate civil parish in 1866, having been a chapelry before, and was part of Eton Rural District from 1894 to 1934. On 1 April 1934 the parish of Boveney was abolished, under a County Review Order, with the more urbanised part being added to Elton in Eton Urban District, and a larger, less populous part being added to the parish of Dorney.

The Church of St Mary Magdalene is in a remote part of the village by the River Thames. In 1983 the church was declared redundant and vested in the care of the Friends of Friendless Churches, who repair and conserve it for visitors and local people to enjoy. In 2004 a major campaign was undertaken to repair the 14th century timber-framed tower and a further programme of repairs was planned for 2007, so the church was closed to visitors.

Dorney Common, which borders the village, is one of several locations to view Windsor Castle from outside the town of Windsor itself; the large open space affords panoramic views of the castle as well as parts of Eton.

In literature
The village is twice briefly mentioned in Jerome K. Jerome's book Three Men in a Boat (1889).

Filming location
Many TV and film companies use the village as a location.

The Church of St Mary Magdalene was used as a location for many Hammer Horror movies which were made at nearby Bray Studios. The Inspector Morse episode Silent World of Nicholas Quinn and the Kevin Costner movie Robin Hood: Prince of Thieves were partly filmed here. The signpost for the village appeared very briefly in the 1976 Sweeney episode "I Want the Man" as a white Mercedes Benz limousine turns left towards the village (06m 48secs standard Freemantle DVD).

title: Boveney