title: Fort Sumter

text: Union efforts to retake Charleston Harbor began on April 7, 1863, when Rear Admiral Samuel Francis Du Pont, commander of the South Atlantic Blockading Squadron, led the ironclad frigate "New Ironsides", the tower ironclad "Keokuk", and the monitors "Weehawken", "Passaic", "Montauk", "Patapsco", "Nantucket", "Catskill", and "Nahant" in an attack on the harbor's defenses. (The 1863 Battle of Fort Sumter was the largest deployment of monitors in action up to that time.) The attack was unsuccessful: the Union's best ship, USS "New Ironsides" never effectively engaged, and the ironclads fired only 154 rounds, while receiving 2,209 from the Confederate defenders . Due to damage received in the attack, the USS "Keokuk" sank the next day, off the southern tip of Morris Island. Over the next month, working at night to avoid the attention of the Federal squadron, the Confederates salvaged "Keokuk's" two eleven-inch Dahlgren guns . One of the Dahlgren guns was promptly placed in Fort Sumter.


title: Fort Sumter

text: The Confederates, in the meantime, were strengthening Fort Sumter. A workforce of just under 500 enslaved Africans, under the supervision of Confederate army engineers, were filling casemates with sand, protecting the gorge wall with sandbags, and building new traverse, blindages, and bombproofs. Some of Fort Sumter's artillery had been removed, but 40 pieces still were mounted. Fort Sumter's heaviest guns were mounted on the barbette, the fort's highest level, where they had wide angles of fire and could fire down on approaching ships. The barbette was also more exposed to enemy gunfire than the casemates in the two lower levels of the fort.


title: Fort Sumter

text: A special military decoration, known as the Gillmore Medal, was later issued to all Union service members who had performed duty at Fort Sumter under the command of Major-General Quincy Adams Gillmore.


title: Fort Sumter

text: After the devastating bombardment, both Major General Quincy A. Gillmore and Rear Admiral John A. Dahlgren, now commanding the South Atlantic Blockading Squadron, determined to launch a boat assault on Fort Sumter for the night of September 8–9, 1863. Cooperation between the Army and Navy was poor. Dahlgren refused to place his sailors and Marines under the command of an army officer, so two flotillas set out towards Fort Sumter that night. The army flotilla was detained off Morris Island by the low tide. By the time they could proceed, the navy assault had already been defeated and the army flotilla returned to shore.


title: Fort Sumter

text: The Navy's assault involved 400 sailors and Marines in 25 boats. The operation was a fiasco from beginning to end. Poor reconnaissance, planning, and communication all characterized the operation. Commander Thomas H. Stevens, Jr., commanding the monitor "Patapsco", was placed in charge of the assault. When Commander Stevens protested that he "knew nothing of [the assault's] organization " and "made some remonstrances on this grounds and others." Dahlgren replied, "There is nothing but a corporal's guard [about 6–10 men] in the fort, and all we have to do is go and take possession." . This underestimation of the Confederate forces on Dahlgren's part may explain why he was hostile to a joint operation wishing to reserve the credit for the victory to the navy. Less than half of the boats landed. Most of the boats that did land landed on the right flank or right gorge angle, rather than on the gorge where there was a passable breach. The Union sailors and Marines who did land could not scale the wall. The Confederates fired upon the landing party and as well as throwing hand grenades and loose bricks. The men in the boats that had not landed fired muskets and revolvers blindly at the fort, endangering the landing party more than the garrison. The landing party took shelter in shell holes in the wall of the fort. In response to a signal rocket fired by the garrison, Fort Johnson and the Confederate warship CSS "Chicora" opened fire upon the boats and landing party. A number of the boats withdrew under fire and the landing party surrendered. The Union casualties were 8 killed, 19 wounded, and 105 captured (including 15 of the wounded). The Confederates did not suffer any casualties in the assault.


title: Fort Sumter

text: After the unsuccessful boat assault, the bombardment recommenced and proceeded with the varying degree of intensity, doing more damage to Fort Sumter until the end of the war. The garrison continued to suffer casualties. The Confederates continued to salvage guns and other material from the ruins and harassed the Union batteries on Morris Island with sharpshooters. The Confederates mounted four columbiads, one columbiad rifled, and two rifled 42-pounders, in the left face, bottom tier casemates.


title: Fort Sumter

text: The last Confederate commander, Major Thomas A. Huguenin, a graduate of The Citadel, never surrendered Fort Sumter, but General William Tecumseh Sherman's advance through South Carolina finally forced the Confederates to evacuate Charleston on February 17, 1865, and abandon Fort Sumter. The Federal government formally took possession of Fort Sumter on February 22, 1865.


title: Fort Sumter

text: Anderson, now a major general, returned to Sumter with the flag he had been forced to lower four years earlier, and on April 14, 1865, raised it in triumph over the ruined fort. Henry Ward Beecher was present and subsequently spoke at length about the occasion.


title: Fort Sumter

text: When the Civil War ended, Fort Sumter was in ruins. The U.S. Army worked to restore it as a useful military installation. The damaged walls were re-leveled to a lower height and partially rebuilt. The third tier of gun emplacements was removed. Eleven of the original first-tier gun rooms were restored with 100-pounder Parrott rifles.


title: Fort Sumter

text: From 1876 to 1897, Fort Sumter was used only as an unmanned lighthouse station. The start of the Spanish–American War prompted renewed interest in its military use and reconstruction commenced on the facilities that had further deteriorated over time. A new massive concrete blockhouse-style installation was built in 1898 inside the original walls, armed with two 12-inch M1888 guns, one on a disappearing carriage. Named "Battery Huger" in honor of Revolutionary War General Isaac Huger, it never saw combat. This battery was deactivated in 1947, and in 1948 the fort became Fort Sumter National Monument under the control of the National Park Service.


title: Fort Sumter

text: One hundred and forty-seven years after it was sent, a rolled up telegraphic message was found in a trunk belonging to Col. Alexander Ramsay Thompson of New York and eventually given to a museum in Charleston, S.C. The telegram was dated April 14, 1861 from the Governor of South Carolina to Gazaway Bugg Lamar in New York, reading in part:


title: Fort Sumter

text: In 1966, the site was listed on the National Register of Historic Places. The Civil War Trust (a division of the American Battlefield Trust) and its partners have acquired and preserved of historic land related to the battles at Fort Sumter.


title: Fort Sumter

text: Fort Sumter and Fort Moultrie National Historical Park encompasses three sites in Charleston: the original Fort Sumter, the Fort Sumter Visitor Education Center, and Fort Moultrie on Sullivan's Island. Access to Fort Sumter itself is by a 30-minute ferry ride from the Fort Sumter Visitor Education Center or Patriots Point. Access by private boat is no longer allowed.


title: Fort Sumter

text: The Visitor Education Center's museum features exhibits about the disagreements between the North and South that led to the incidents at Fort Sumter. The museum at Fort Sumter focuses on the activities at the fort, including its construction and role during the Civil War.


title: Fort Sumter

text: April 12, 2011, marked the 150th Anniversary of the start of the Civil War. There was a commemoration of the events by thousands of Civil War reenactors with encampments in the area. A United States stamp of Fort Sumter and a first-day cover were issued that day.


title: Fort Sumter

text: On June 28, 2015, in the aftermath of the events of June 17, 2015, when a mass shooting took place at Emanuel African Methodist Episcopal Church in downtown Charleston, South Carolina, the five small flags that were arranged in a semi-circle around the large flagpole flying the 50-star United States flag at Fort Sumter were lowered so that the South Carolina flag could be flown at half staff. Those flown include a 33-star United States flag, a Confederate First National Flag (), a South Carolina State Flag, a Confederate Second National Flag (Stainless Banner), and a 35-star United States flag. This display was added to Fort Sumter National Monument in the 1970s. In August 2015, the flagpoles were removed to create a new exhibit. The four historic national flags now fly on the lower parade ground.


title: Fort Sumter

text: By December 2019, sea level rise led to a Park Service decision to move some of the large rocks "originally installed to protect the fort from the sea," farther from the fort's walls, in order to create a protective breakwater and wetland.


title: Deuce Bigalow: Male Gigolo

text: Deuce Bigalow: Male Gigolo is a 1999 American sex comedy film directed by Mike Mitchell in his feature-length directorial debut, written by Harris Goldberg and Rob Schneider, and starring Schneider in the title role, William Forsythe, Eddie Griffin, and Arija Bareikis. The film tells the story of a hapless fishtank cleaner who goes into business as a male sex worker in an attempt to earn enough money to repair damage he caused while house-sitting. The film is notable for being the first film produced by Happy Madison Productions.


title: Deuce Bigalow: Male Gigolo

text: The film was released on December 10, 1999 by Buena Vista Pictures (through its Touchstone Pictures label). While the film received negative reviews from critics, it was a box office success, grossing $92 million worldwide on a $17 million budget.


title: Deuce Bigalow: Male Gigolo

text: Deuce Bigalow, an insecure fishtank cleaner, is fired for cleaning the tank at a public aquarium while naked. Deuce is unsuccessful in attracting women, so he attempts to keep himself busy at work. On a house call, he meets the Argentinian male prostitute Antoine Laconte. Antoine is going on a business trip, and so asks Deuce to care for his sick lionfish and protect his home while he is away. Deuce accidentally sets Antoine's kitchen on fire when trying to make a grilled cheese sandwich in the toaster, and breaks an expensive fish tank, causing a lot of water damage.


title: Deuce Bigalow: Male Gigolo

text: Fearing Antoine will kill him (Antoine even tells him he will if he messes the place up), Deuce is forced to find a way to pay $6,000 for the damage. Low-rent pimp T.J. Hicks offers to help Deuce make enough money to buy a new fish tank, and convinces Deuce to take over the absent Antoine's role as a gigolo. Deuce decides to make the clients feel better about themselves since he only desires to have sex with beautiful women.


title: Deuce Bigalow: Male Gigolo

text: Deuce meets unusual clients but he still manages to get along with them, despite there being no sex involved, by helping them with certain issues in their lives. The clients include Carol, a woman who is severely narcoleptic; Ruth, who has Tourette syndrome with coprolalia, and therefore is afraid of socializing; Fluisa, a mannish obese woman weighing close to 750 pounds; and Tina, a woman that has a pituitary gland disorder and is extremely tall. Deuce's list of clients gradually increases, with each client being satisfied by much more fulfilling measures due to his personal attention and friendship. However, Deuce falls in love with one of his clients, Kate, who has a prosthetic leg. She later breaks up with Deuce when she finds out that he was a prostitute hired by her friends.


title: Deuce Bigalow: Male Gigolo

text: Meanwhile, Deuce is being stalked by Detective Chuck Fowler, who demands Antoine's "black book" of clients and threatens to take Deuce to jail if he does not comply. Deuce eventually helps Fowler please his wife by stripping and erotically dancing for her, and the two make amends. Deuce is still taken into custody on prostitution charges, as Fowler needs someone to bring in and Deuce refuses to betray his friend T.J. At the hearing, it is revealed that Deuce never slept with any of the clients except for Kate. Since Deuce gave back the money to Kate and was not paid for sex with her, he is cleared of all charges.


title: Deuce Bigalow: Male Gigolo

text: Using the money he made, Deuce restores Antoine's fish tank, although due to time constraints, he is warned that the glass may not be installed properly. Unfortunately, Kate's blind roommate accidentally kills the prize fish in Antoine's aquarium when she starts the mixer in which the fish was being kept. Deuce buys a replacement fish and returns to Antoine's house just before he returns. Antoine taps the new aquarium and the glass shatters. Deuce then reveals his prostituting adventures to the furious Antoine. Enraged, Antoine tries to kill Deuce and at one point shoots a crossbow bolt at him. Fluisa shows up, comes between the two men, and saves Deuce's life (she is not killed because the bolt hits her breasts, between which she has hidden a roast chicken). Antoine is then arrested by Detective Fowler and Deuce marries Kate.


title: Deuce Bigalow: Male Gigolo

text: The end sequences then follow. Deuce's father becomes a male prostitute. Fluisa underwent extensive liposuction and became a model in Victoria's Secret known as Naomi. Ruth opens up an all-girls school for people with Tourette's. Carol manages to fulfill her dream trip to France and dies falling off the Eiffel Tower. T.J. starts his own reality show dedicated to his experiences as a male prostitute. An incarcerated Antoine marries Tina.


title: Deuce Bigalow: Male Gigolo

text: "Deuce Bigalow: Male Gigolo" was the first film released by the Happy Madison Productions film production company. Adam Sandler served as the film's executive producer. Sandler also starred behind the scenes and can be heard yelling the infamous "Freak!' line and other various lines in the background.


title: Deuce Bigalow: Male Gigolo

text: "Deuce Bigalow: Male Gigolo" opened theatrically on December 10, 1999 in 2,154 venues and earned $12,224,016 in its opening weekend, ranking third in the North American box office behind "Toy Story 2" fourth weekend and fellow newcomer "The Green Mile". The film ended its run, having grossed $65,538,755 in the United States and Canada, and $27,400,000 overseas for a worldwide total of $92,938,755. Based on a $17 million budget, the film was a box office success.


title: Deuce Bigalow: Male Gigolo

text: "Deuce Bigalow: Male Gigolo" received negative reviews from critics. On Rotten Tomatoes, it has an approval rating of 22% based on 76 reviews, with an average rating of 4.01/10. The site's consensus states: "According to critics, "Deuce Bigalow" is just too dumb and filled with old, tired gags." On Metacritic it has a score of 30 out of 100 based on reviews from 26 critics, indicating "generally unfavorable reviews". Audiences surveyed by CinemaScore gave the film a grade B.


title: Deuce Bigalow: Male Gigolo

text: Roger Ebert of the "Chicago Sun-Times" gave the film one-and-a-half out of four stars, stating "It's the kind of picture those View n' Brew theaters were made for, as long as you don't View." Kendall Morgan from "The Dallas Morning News" writes in her review, ""Deuce Bigalow: Male Gigolo" makes "There's Something About Mary" look like "Masterpiece Theatre"."


title: Slipknot discography

text: The American nu metal band Slipknot has released seven studio albums, two live albums, one compilation album, one demo album, twenty-seven singles, five video albums and twenty-seven music videos. Formed in Des Moines, Iowa in 1995, Slipknot originally featured vocalist and percussionist Anders Colsefni, guitarists Donnie Steele and Josh "Gnar" Brainard, bassist Paul Gray, drummer Joey Jordison, and percussionist and backing vocalist Shawn "Clown" Crahan. The original lineup released its first demo "Mate. Feed. Kill. Repeat." in 1996, before undergoing a number of lineup changes over the next few years.


title: Slipknot discography

text: Finalising its lineup as a nine-piece consisting of Corey Taylor (vocals), Mick Thomson, Jim Root (both guitars), Paul Gray (bass), Joey Jordison (drums), Shawn "Clown" Crahan, Chris Fehn (both percussion), Sid Wilson (turntables) and Craig Jones (samples), Slipknot signed with Roadrunner Records and released its self-titled debut album in June 1999. "Slipknot" reached number 51 on the US "Billboard" 200, and has since been certified double platinum by the Recording Industry Association of America (RIAA). The band followed this up in 2001 with "Iowa", which reached number 3 on the "Billboard" 200 and topped the UK Albums Chart. Slipknot also released its first two videos during this period – "Welcome to Our Neighborhood", a collection of music videos and live footage, in 1999, and "Disasterpieces", a live concert recorded in London, in 2002.


title: Slipknot discography

text: After a short hiatus, Slipknot returned in 2004 with its third studio album "", which reached number 2 on the "Billboard" 200. The album was supported by a successful lead single in "Duality", which reached the top 10 of both the US "Billboard" Alternative Songs and Mainstream Rock charts. Later singles "Vermilion" and "Before I Forget" also registered on both charts. The band's first live album, "", followed the next year and reached the top 20 of the "Billboard" 200. Third video album "" was released in December 2006. 2008's "All Hope Is Gone", Slipknot's fourth studio album, was the band's first to top the "Billboard" 200, as well as several album charts in other regions. "Psychosocial", "Dead Memories" and "Snuff" all reached the "Billboard" Alternative Songs top 20.


title: Slipknot discography

text: On May 24, 2010, founding member Paul Gray died of an "accidental overdose of morphine and fentanyl" and in September 2010 the band dedicated its fourth video album "(sic)nesses" to the deceased bassist, which documented their performance at Download Festival in 2009. The release topped the Music Video charts in the US and the UK. A compilation album, "Antennas to Hell", followed in 2012. After returning to touring in 2011 with former guitarist Donnie Steele on bass, Slipknot also parted ways with Joey Jordison in 2013 in controversial circumstances. The group resurfaced in 2014 with Alessandro Venturella on bass and Jay Weinberg on drums, releasing the Gray-dedicated "" in October that year, which followed "All Hope Is Gone" in topping the "Billboard" 200.


title: Slipknot discography

text: The band fired longtime percussionist Chris Fehn after he sued the band for withholding payments from him prior to the release of the band's sixth studio album "We Are Not Your Kind" on August 9, 2019. "We Are Not Your Kind" was the band's third consecutive number one album on the US "Billboard" 200 and was the band's first UK number 1 on the UK Albums Chart in 18 years, since the release of "Iowa". They subsequently replaced Fehn with Michael Pfaff for all future tour dates and recorded his first album with the band for their seventh studio album "The End, So Far" which was released on September 30, 2022 and their last to be released via Roadrunner Records.


title: Vulval vestibule

text: The vulval vestibule (or vulvar vestibule or vestibule of vagina) is a part of the vulva between the labia minora into which the urinary meatus (urethral opening) and the vaginal opening open. Its edge is marked by Hart's line. It represents the distal end of the urogenital sinus of the embryo.


title: Vulval vestibule

text: Structures opening in the vulval vestibule are the urethra, vagina, Bartholin's glands, and Skene's ducts.


title: Vulval vestibule

text: The external urethral orifice is placed about 25–30 millimetres (1–1.2 in) behind the clitoris and immediately in front of that of the vagina; it usually assumes the form of a short, sagittal cleft with slightly raised margins. Nearby are the openings of the Skene's ducts.


title: Vulval vestibule

text: The vaginal orifice is a median slit below and behind the opening of the urethra; its size varies inversely with that of the hymen.


title: Vulval vestibule

text: To the left and right of the vulval vestibule are the labia minora. Anterior to it are the clitoral hood, frenulum clitoridis, and the clitoral glans. Posterior to it is the posterior commissure of the labia minora and the frenulum of labia minora.


title: Vulval vestibule

text: The sides of the vestibule are visible as Hart's line on the inside of the inner lips. Hart's line is the outer edge of the area and marks the change from vulvar skin to the smoother transitional skin of the vulva.


title: Vulval vestibule

text: The prevalence of pain at the vulvar vestibule is relatively common. A study by the University of Michigan found that about 28% of women have experienced vulvar vestibular pain in the past, and about 8% had the pain in the last 6 months.


title: Concussion

text: 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 (LOC); memory loss; headaches; difficulty with thinking, concentration, or balance; nausea; blurred vision; 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. 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.


title: Concussion

text: Common causes include motor vehicle collisions, falls, sports injuries, and bicycle accidents. Risk factors include 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 (such as a physician, physician assistant, or nurse practitioner) is required to rule out life-threatening head injuries, injuries to the cervical spine, and neurological conditions. 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 also be required to rule out severe head injuries. Routine imaging is not required to diagnose concussion.


title: Concussion

text: Prevention of concussions includes the use of a helmet when bicycling or motorbiking. Treatment includes physical and cognitive 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. Physiotherapy may be useful for persistent balance problems; cognitive behavioral therapy may be useful for mood changes. Evidence to support the use of hyperbaric oxygen therapy and chiropractic therapy is lacking.


title: Concussion

text: 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.


title: Concussion

text: Concussions symptoms vary between people and include physical, cognitive, and emotional symptoms. Symptoms may appear immediately or be delayed. Up to one-third of people with concussion experience prolonged or persistent concussion symptoms, also known as post concussion syndrome, which is defined as concussion symptoms lasting for 4-weeks or longer in children/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.


title: Concussion

text: 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.


title: Concussion

text: 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, another concussion hallmark, 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 mTBI symptoms include changes in sleeping patterns and difficulty with reasoning, concentrating, and performing everyday activities.


title: Concussion

text: 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.


title: Concussion

text: 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').


title: Concussion

text: 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.


title: Concussion

text: 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".


title: Concussion

text: 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/s are estimated to have 25, 50, or 80% risk of mTBI respectively.


title: Concussion

text: 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.


title: Concussion

text: 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).


title: Concussion

text: 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".


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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."


title: Concussion

text: 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.


title: Concussion

text: Head trauma recipients are initially assessed to exclude a more severe emergency such as an intracranial hemorrhage. 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 worsening of symptoms such as headaches, persistent 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, may undergo brain imaging to detect lesions and are frequently observed for 24–48 hours. A brain CT or brain MRI should be avoided unless there are progressive neurological symptoms, focal neurological findings, or concern of skull fracture on exam.


title: Concussion

text: 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 (PTA; 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.


title: Concussion

text: 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 post-concussion syndrome 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.


title: Concussion

text: 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.


title: Concussion

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


title: Concussion

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


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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 (LOC), post-traumatic amnesia (PTA), and the Glasgow Coma Scale (GCS).


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: Adults and children with a suspected concussion require a medical assessment 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. 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.


title: Concussion

text: 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. Low-risk activities can be started even while a person has symptoms, as long as the activity does not worsen existing symptoms or bring on new concussion symptoms. Resting for longer than 24–48 hours follow concussion has been shown to be associated with longer recovery.


title: Concussion

text: 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 school 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 sports.


title: Concussion

text: For persons participating in athletics, it is suggested that participants progress through a series of graded steps. These steps include:


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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 post-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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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 post-concussion syndrome 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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".


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

text: 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.


title: Concussion

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


title: Concussion

text: 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.


title: Concussion

text: 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: 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.


title: Concussion

text: 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:


title: Legacy of Kain

text: Legacy of Kain is a series of dark fantasy action-adventure video games primarily developed by Crystal Dynamics and formerly published by Eidos Interactive, then Square Enix Europe after 2009. The first title, "", was created by Silicon Knights in association with Crystal Dynamics, but, after a legal battle, Crystal Dynamics retained the rights to the game's intellectual property, and continued its story with four sequels. To date, five games comprise the series, all initially developed for video game consoles and later ported to Microsoft Windows. Focusing on the eponymous character of Kain, a vampire antihero, each title features action, exploration and puzzle-solving, with some role-playing game elements.


title: Legacy of Kain

text: The series takes place in the fictional land of Nosgoth—a gothic fantasy setting—and revolves around Kain's quest to defy his fate and restore balance to the world. "" introduced another antihero protagonist, Raziel; the adventures of both characters culminate in "". Themes of destiny, free will, morality, redemption and the hero's journey recur in the storyline, which was inspired by ancient literature, horror fiction, Shakespeare's plays and gnosticism. The "Legacy of Kain" games have enjoyed critical success, particularly receiving praise for high-quality voice acting, narrative, and visuals, and, as a whole, had sold over 3.5 million copies by 2007.


title: Legacy of Kain

text: The "Legacy of Kain" series had been available for external developers to license through the Square Enix Collective service until 2022. That year, Square Enix sold the rights of the series to the Embracer Group, who have expressed interest in developing sequels, remakes and remasters of "Legacy of Kain".


title: Legacy of Kain

text: was created by Silicon Knights under the direction of Denis Dyack, with assistance from publisher Crystal Dynamics, and was released in 1996 on the PlayStation. In 1997, it was ported to Microsoft Windows. Dyack conceived the "vampire project" under the title "The Pillars of Nosgoth" in 1993, and Crystal Dynamics producer Lyle Hall chose this fantasy concept over two other proposals (one of which was "Too Human"). Pursued in hopes of bringing a strong narrative and artistic cinema to consoles, it was built as "a game which adults would want to play", featuring an unconventional hero and gameplay that demanded thought as well as reflexes. Developed as a 2D action-adventure game with role-playing game elements, it debuted to positive critical and commercial reception. Selling points included its 50+ hour length and the wide array of items and abilities the player character commands. "Blood Omen" introduces Nosgoth, a fictional land designed with novel-like complexity, and gives the player control of Kain, a newly resurrected vampire seeking revenge against his murderers and a cure for his vampiric curse.


title: Legacy of Kain

text: Soul Reaver 2 had an accelerated development cycle and was released after two years, despite a switch to sixth generation consoles early in the project. It was initially targeted for release in late 2000 on the PlayStation and Dreamcast, but was reworked and released in 2001 as a PlayStation 2 exclusive, and was ported to Microsoft Windows later that year. The developers' goal was to retain the elements that made its predecessor successful, but they decided to eschew the "complete a level, fight a boss" flow of the previous game in favor of a more narrative-driven approach. The plot serves as a direct sequel to "Soul Reaver", picking up immediately after its ending. The player controls Raziel as he uncovers the mysteries surrounding Nosgoth's distant past and his own destiny. Meanwhile, Kain attempts to subvert fate and restore the world by manipulating history. While "Soul Reaver" was still in development, Crystal Dynamics initiated another project - a successor to "Blood Omen" - and when the "Soul Reaver" team had started work on their follow-up in late 1999, two "Legacy of Kain" games were in simultaneous development.


title: Legacy of Kain

text: Blood Omen 2's "creative seeds were sown" in 1999, and the finished product was released in 2002, six months after "Soul Reaver 2", for the PlayStation 2, Xbox, Microsoft Windows and GameCube. It was not produced with the involvement of the "Soul Reaver" crew, instead being created by a new team at Crystal Dynamics under the direction of Glen Schofield. A key point of focus for the developers was the main character, Kain; Crystal Dynamics had "a huge investment in Kain as a character". Shifting the focus of gameplay towards action, gore and combat instead of puzzle-solving, it retains several of the qualities which made the previous games popular, but was criticized for lacking innovation. Despite middling critical reception, it was released on four platforms and sold well. The setting, an enormous industrial city, is a departure for the series. While the game was released after "Soul Reaver 2", the events of the game actually happen after "Blood Omen" but before the events of "Soul Reaver", in an alternate timeline created from the "Soul Reaver 2" events. In "Blood Omen 2" players control a younger Kain after an unsuccessful campaign to conquer Nosgoth, as he is opposed by traitorous vampires and a new enemy.


title: Legacy of Kain

text: , the most recent entry in the series, was released in 2003 on the PlayStation 2, Xbox and Microsoft Windows. First conceptualized as "Soul Reaver 3", it represented a combined effort from the "Soul Reaver 2" and "Blood Omen 2" teams to consolidate and re-balance the storytelling, puzzle-solving and combat aspects of its predecessors, fusing elements from the two sub-series into one game. They chose a new title under the "Legacy of Kain" banner to reflect this new focus. The player alternates between control of Raziel and the "Soul Reaver 2" incarnation of Kain in each of the game's chapters, under the premise that only one of the two will survive—emphasis was placed on cinematic presentation. The story concludes on a hopeful note, but without full resolution; during production, Hennig departed Crystal Dynamics to work for Naughty Dog, and "Defiance" did not meet Eidos' sales expectations. Following its release, Eidos placed the series on hold. Former Eidos North America CEO Bill Gardner and Eidos Life President Ian Livingstone expressed interest in reviving the franchise, but Crystal Dynamics stated that they were not working on a continuation.


title: Legacy of Kain

text: Nosgoth, a multiplayer game, was formally announced by Square Enix London Studios community manager George Kelion to be in development in June 2013, in response to a series of internet leaks and resultant speculation. According to Kelion, it was to be set in the same universe as previous "Legacy of Kain" titles, but would not be "a traditional or even single-player LoK experience". The game was intended to be viewed as "very much on a separate branch to both the Soul Reaver and Blood Omen series", and Crystal Dynamics were not involved in its development. Kelion stated that "Nosgoth" would be more formally announced and revealed at a future date, sometime beyond the Electronic Entertainment Expo 2013. However, "Nosgoth" was never officially released, but began open beta in January 2015. The game officially shut down its servers on May 31, 2016.


title: Legacy of Kain

text: The "Legacy of Kain" games fall into the action-adventure genre, utilizing a balance of action, puzzle-solving and exploration. Starting from "Soul Reaver", the series also features platforming elements from a 3D, third-person perspective. Whereas "Blood Omen" and "Soul Reaver" employ an open world system in the style of "The Legend of Zelda" or "Super Mario 64", the latter three games are divided into chapters, and are more linear in progression. As the player solves pivotal puzzles or defeats bosses, they receive new weapons and abilities, such as telekinesis, shapeshifting, mind control and magical spells. The main character's health constantly declines in each game—Kain must consume blood to sustain his strength, whereas Raziel requires souls—prompting combat, which focuses on hack and slash techniques, and allows the player to kill and feed from enemies.


title: Legacy of Kain

text: "Blood Omen 2" and "Defiance" include experience point systems, and in the "Soul Reaver" games and "Defiance", the player must shift between the material and spectral planes of existence to progress – both realms have unique physical laws, geometry and enemies. The Soul Reaver sword, a recurring ultimate weapon and soul-devouring blade inhabited by a ravenous entity, appears in all five titles. Dialogue in the series is florid and Elizabethan in style, inspired by period pieces such as "Becket", "The Lion in Winter" and "A Man for All Seasons", and each game was scripted in the manner of a stage play, with monologues, asides and cutscenes interspersing gameplay. During "Blood Omen"'s production, Silicon Knights hired classically trained actors to deliver voice talent, a precedent which Crystal Dynamics continued in successive games.


title: Legacy of Kain

text: Simon Templeman and Michael Bell voice protagonists Kain and Raziel respectively. Supporting cast members include Paul Lukather as Vorador, Anna Gunn as Ariel, Richard Doyle as Moebius, and René Auberjonois as Janos Audron. Tony Jay played Mortanius in "Blood Omen", and returned as The Elder God in subsequent games; in "Defiance", Mortanius was recast as Alastair Duncan. Gordon Hunt and Kris Zimmerman provided voice direction from "Soul Reaver" and onward. The developers coordinated the actors by ensuring they were involved as collaborators, recording their dialogue together rather than in isolation, and thus established techniques which would later carry over to Naughty Dog's "Uncharted" series.


title: Legacy of Kain

text: The health of the land of Nosgoth is inextricably tied to nine edifices known as the Pillars of Nosgoth. The Pillars are preserved by an oligarchy of sorcerers known as the Circle of Nine, each of whom serves as the guardian of an individual Pillar. When a guardian dies, a new one is born to take their place. In the prologue of "Blood Omen", Ariel, the guardian of balance, is killed, and the resulting chain of events leads to the spiritual corruption of the Pillars and their guardians. Thirty years later, Kain, a young nobleman, is murdered by brigands, and resurrected as a vampire by a necromancer, Mortanius. Directed by Mortanius and the specter of Ariel, he tracks down and kills the guardians in hopes of attaining revenge and a cure to his vampirism, but slowly begins to embrace his new powers. While hunting Moebius, the guardian of time, he defies the advice of Vorador (a senior vampire), and travels back in time. Using the Soul Reaver, he prevents a tyrant king from coming to power, but the temporal paradox which this causes results in a new timeline where Nosgoth's humans have hunted the vampires to extinction. Kain discovers that Mortanius — the guardian of death —orchestrated his murder to purge the Circle and kills all but one of the remaining guardians. Kain realizes that he himself is the final corrupt guardian, born as Ariel's successor, and is left to decide between sacrificing himself to restore the world (but destroying the vampire race), or ruling Nosgoth in its damnation. "Soul Reaver" establishes that Kain, disgusted by the humans' machinations, chose the latter option and embraced vampirism as a blessing. He raised a cadre of vampire lieutenants to conquer Nosgoth's human kingdoms, establishing an all-powerful empire under his control while the land decays.


title: Legacy of Kain

text: 1500 years after the events of "Blood Omen", Raziel, his first-born follower, transgresses against Kain, and is consequently executed. A demiurge-like entity known as The Elder God resurrects Raziel, who quickly confronts Kain. Kain strikes Raziel with the Reaver, but it shatters against him, and the captive spirit formerly within the blade binds itself to Raziel's arm. Raziel murders his lieutenant brethren, and discovers that Kain resurrected them all from the corpses of the Sarafan, an ancient vampire-hunting spiritual brotherhood. Infuriated at this revelation, he pursues Kain to Moebius's long-abandoned time machine, and Kain lures him into the past. In "Soul Reaver 2", Raziel conspires with Moebius to destroy Kain, but—after realizing that Kain wishes to restore the Pillars, and learning that Moebius secretly serves The Elder God—his lust for vengeance is tempered by a higher quest for enlightenment and freedom from the ensnarement of predestination. On advice from Vorador, he seeks Janos Audron, an infamous, long-dead vampire who holds the key to his destiny. Raziel assists Kain in triggering another paradox which changes Kain's fate, prolonging his life, and travels Nosgoth's history. Beginning to unearth the secrets of his past, he briefly meets with Janos in the era of the Sarafan, but realizes that his own, human former self murdered the ancient vampire. He slaughters the Sarafan lieutenants, and murders his former self, becoming the catalyst of Kain's future empire and his own history. In a final epiphany, he discovers that he is the ravenous spirit destined to become imprisoned in the Reaver—that the cycle of his destiny will never end. At the last minute, Kain saves Raziel from this fate and takes the empty Reaver, but the paradox that this causes changes history for the worse.


title: Legacy of Kain

text: "Soul Reaver 2", "Blood Omen 2" and "Defiance" expand the backstory of the series. Initially, alongside the humans, two other major races existed in Nosgoth's distant past: the ancient vampires and the Hylden. The Vampires exalted the spiritual and the wheel of fate, whereas the Hylden were technologically inclined beings. Though the vampires worshiped The Elder God, the Hylden rejected his doctrine, and the vampires declared war in response to this blasphemy. Using incredible magic, the vampires erected the Pillars, banishing the Hylden into another dimension, and forged the Reaver as a safeguard. The Hylden retaliated by afflicting the vampires with a blood curse, which transformed them into immortal, sterile predators of humankind. Divorced from the wheel of fate and their god, many vampires turned to suicide, and as their race died out, the humans of Nosgoth seized control of the Pillars. Over the centuries, the Hylden strained against the barriers of their prison, seeking to topple the Pillars. Kain's spiritual corruption hinders him from realizing his role as the balance guardian—he seeks to somehow resolve the dilemma he faced at the end of "Blood Omen" by both restoring the Pillars and returning them to vampire rule. Raziel's execution was necessitated—his unique, cyclic destiny affords him free will, enabling Kain to create paradoxes and defy history. "Blood Omen 2" pursues a younger Kain in the altered timeline created at the end of "Soul Reaver 2", depicting his war against the leader of the Hylden. Eventually, Kain kills The Hylden Lord, and departs, to eventually establish his empire from "Soul Reaver".


title: Legacy of Kain

text: "Defiance" covers earlier points in the same timeline, directly after "Soul Reaver 2". Kain and Raziel each discover evidence that the ancient vampires and Hylden had prophesied two champions—one representing each race—who would decide the fate of Nosgoth. Whereas Raziel is bent on resurrecting Janos to escape his destiny, Kain strives to stop him, and the two are drawn into battle. Raziel learns from Mortanius that Kain was raised using Janos' heart, and rips this from Kain's chest in their last battle, ostensibly killing his former master. Though disillusioned, Raziel resurrects Janos, who guides him to a final trial. Though he succeeds, receiving spiritual powers, Raziel witnesses the collapse of the Pillars. The resulting breach enables The Hylden Lord to possess Janos (facilitating his invasion in "Blood Omen 2"), and Raziel is defeated in the ensuing battle, trapped by The Elder God. He concludes that the Elder, sustained by the souls of Nosgoth, is the ultimate cause of all the conflict and strife throughout history, and realizes that he, himself, was both the Vampiric and Hylden champions; Kain was neither. His free will, and his destiny to enter the Reaver (consuming himself), ensures that neither champion can win. Later, Kain miraculously awakes, despite the loss of his heart. He encounters Raziel, and they reconcile; Raziel enters the Reaver willingly, but first uses his spiritual powers to cleanse Kain of the corruption he had inherited at birth as a member of the Circle of Nine. Thus healed, Kain is able to perceive The Elder God for the first time. They skirmish briefly, and Kain wounds the Elder with the Reaver, but is unable to destroy him. As he looks out over Nosgoth, Kain contemplates Raziel's sacrifice, and the first bitter taste of hope it has given him.


title: Legacy of Kain

text: Each of the "Legacy of Kain" games concerns distinct themes and dilemmas, but their overarching philosophical topic involves fatalism and man's struggle for free will. "Blood Omen" was intended to ask "what is evil? Perhaps it is merely a perspective", and to "address morals, evil and good, propaganda and fate in ways that have never been explored in a computer game before". Other latent issues included trust, manipulation and betrayal, which carried over into Crystal Dynamics' sequels. In "Soul Reaver" and "Soul Reaver 2", Amy Hennig identified "the question of free will in a universe apparently ruled by fate" as the core of the story. Gnosticism, in which "the material world is an illusion, a lie perpetrated by a false and malignant god whose aim is to keep the human soul in darkness and ignorance" and the hero's goal is "knowledge, enlightenment, and the exposure of the truth", helped to formulate Raziel's arc. Themes of despair, hope and illumination in the works of T. S. Eliot and James Joyce influenced the story.


title: Legacy of Kain

text: The developers also attempted to subvert the monomyth and other tropes within literature and gaming. Silicon Knights conceptualized Kain, a vampire antihero inspired by Clint Eastwood's "Unforgiven", as an atypical "gray" protagonist, neither good nor evil, despite being advised in 1993 that such a character would not appeal to gamers. Similarly, Hennig developed Raziel as a "self-righteous little twit" with villainy, seeking redemption and transcendence through knowledge, in contrast to an idealistic hero. Drawing from Joseph Campbell's ideas, she felt it would be interesting to see how players interpret morality in this context, and argued that "the only way a hero can ever succeed is by following his own path. As long as he's following a path laid out by someone else, ultimately he's going to fail". "Defiance" portrayed Kain and Raziel as Sophoclean Oedipus-like figures, "being railroaded by fate". Hennig said that "they are heroes because they refuse to submit, even when all the odds are stacked against them".


title: Legacy of Kain

text: During and after the completion of "Dark Legions", Silicon Knights spent several months working on the design of "Blood Omen" without a particular platform in mind. Major inspirations behind the project included "The Wheel of Time", "Necroscope" and Shakespeare's plays, while the concept of the Pillars of Nosgoth was derived from cover art for "The Pillars of the Earth". Crystal Dynamics agreed to publish the game in 1993, and although there was indecision as to whether it should be produced for the 3DO Interactive Multiplayer or the Sega Saturn, both parties settled on the PlayStation once Sony announced its impending launch. The game took over three years to develop, undergoing a substantial expansion mid-process which required Silicon Knights to increase its workforce—Crystal Dynamics sent several staff to assist them, including Amy Hennig and Seth Carus. Following "Herculean efforts", "Blood Omen" was released in late 1996. After its success, Silicon Knights contemplated creating a sequel in what they described as the "Blood Omen" series, but their relationship with Crystal Dynamics dissolved in 1997. Crystal Dynamics began developing "Soul Reaver" internally, and were acquired by Eidos Interactive during its production.


title: Legacy of Kain

text: In 1998, Silicon Knights filed a suit against Crystal Dynamics for rights to the "Legacy of Kain" IP, requesting an injunction to prevent Crystal Dynamics from marketing the sequel. The two studios settled their legal dispute privately, and Crystal Dynamics and Eidos retained rights to the "Legacy of Kain" franchise, provided that "Soul Reaver" acknowledge Silicon Knights as the series' original creator. "Paradise Lost" was the original inspiration behind the concept, and sources such as Rabbinic lore, vampire mythology, Eastern myth and mysticism were also key influences. Visual cues were borrowed from films such as "The City of Lost Children" and "The Cabinet of Dr. Caligari", and H. P. Lovecraft's Cthulhu Mythos. "Soul Reaver" was highly anticipated despite several delays, and was promoted on the covers of over ten game industry magazines, but schedule pressures forced Crystal Dynamics to cut content from the ending sequence. They intended to integrate the removed material into the sequel. "Soul Reaver 2" was inspired by time travel fiction and Kurt Rudolph's research into Gnosticism. It was slated to include more of "Blood Omen"'s role-playing game aspects and a wider breadth of acquirable abilities, though the team was handicapped by the release of the PlayStation 2.


title: Legacy of Kain

text: The "Soul Reaver 2" project was produced for the PlayStation for a short time, but, after creating a proof-of-concept demo, the developers were given approval to scrap their work and switch to the newer console. With "remarkable dedication, and sickening hours", the game was developed in 17 months; as with "Soul Reaver", several features were cut in order to meet the release deadline. "Blood Omen 2" was concurrently developed by an independent Crystal Dynamics team with creative autonomy, extrapolating from the 19th century steampunk aesthetic of "Soul Reaver" to settle on a Victorian feel. Its crew was wary of relying too strongly on the original "Blood Omen" as an influence, and expanded on the franchise's backstory in hopes of starting a new series. However, inconsistencies raised by its plot left the "Soul Reaver 2" team to reconcile the storyline in the next game. "Defiance" represented "a whole new approach" to the franchise, with more focus on drama, an overhauled combat system, and scripted, cinematic camera angles. After fan speculation that it would become the last "Legacy of Kain" title, Crystal Dynamics unofficially confirmed on their forums that another game was being worked on, though no announcement followed, and, in 2005, their next project was revealed to be "". In 2008, it emerged that a sixth game, "Legacy of Kain: The Dark Prophecy", had briefly been in development at Ritual Entertainment in 2004 before being canceled. Later, in 2013, Square Enix confirmed allegations that Climax Studios had worked on another new "Legacy of Kain" title, for the PlayStation 4—""—until this project's cancellation in 2012.


title: Legacy of Kain

text: In October 2015, Crystal Dynamics' senior designer, Michael Brinker, stated that there was "a 50/50 chance" of a sixth "Legacy of Kain" single player game releasing during the eighth generation of video game consoles. In November 2017, Square Enix Europe's director of indie publishing, Phil Elliott, confirmed that the company had no specific plans for "Legacy of Kain", but would consider licensing the property to external developers through its Square Enix Collective service. In April 2019, Elliott stated that no such projects were in production as no team had come forward with a credible proposal, but that the Collective program would remain open to future "Legacy of Kain" submissions.


title: Legacy of Kain

text: In 2022, the Embracer Group acquired "Legacy of Kain" intellectual property alongside other assets of Square Enix Europe, including the development studio Crystal Dynamics for $300 million. The deal was closed in summer. Embracer Group (before the acquisition was complete) expressed interest in sequels, remakes and remasters in "Legacy of Kain" franchise among others. On November 2022, Embracer, after sending a survey in October to see if the fans are still interesed in the IP, said during an earnings call that they recived more than 100,000 responses and hear very clear to the fans and preparing something for the series according to CDE Enterteinment CEO Phil Rogers.


title: Legacy of Kain

text: Music from both "Soul Reaver" and "Soul Reaver 2" was released on a promotional soundtrack in 2001. For "Soul Reaver", Amy Hennig selected Kurt Harland of synthpop band Information Society to compose the score. According to Harland, a colleague introduced the "Soul Reaver" team to his work through "Ozar Midrashim", a track from Information Society's 1997 album "Don't Be Afraid". This track went on to feature in "Soul Reaver" as the opening theme. Harland worked with audio engineer Jim Hedges in the creation of an adaptive audio system for "Soul Reaver" which allowed the music to change based on in-game context. This approach became a mainstay of subsequent games in the series.


title: Legacy of Kain

text: Following the release of "Soul Reaver", action figures of the characters Kain and Raziel were created by Blue Box Interactive and the National Entertainment Collectibles Association in partnership with Eidos. A single-issue promotional comic by Top Cow Productions was released in October 1999 to promote the release of "Soul Reaver", starring the vampire Raziel and serving as a prequel to the game's events. Top Cow collaborated with Crystal Dynamics to produce a second comic in early 2004, recapitulating the series' backstory, to coincide with the release of "Defiance". Both Kain and Raziel also feature as playable characters in downloadable content for 2010's "Lara Croft and the Guardian of Light".


title: Legacy of Kain

text: By 2007, the "Legacy of Kain" series had collectively sold over 3.5 million copies, but its commercial success has varied with each game. "Blood Omen" surpassed Crystal Dynamics' expectations, with reported sales figures ranging from 320,082 units to 2 million copies, whereas "Soul Reaver" sold over 1.5 million copies, and was included on Sony's "Greatest Hits" list. "Soul Reaver 2" and "Blood Omen 2" also performed well, selling in excess of 500,000 copies each and becoming Greatest Hits titles. "Defiance" sold between 500,000 and 1 million units, but failed to live up to Eidos's sales targets.


title: Legacy of Kain

text: "Legacy of Kain" has been cited as one of the most popular video game intellectual properties associated with vampires. IGN's Douglass C. Perry regarded the series as "a strangely attractive, yet equally obscure one that [had him] torn between loving and hating it". GameSpot's Greg Kasavin was critical of "Blood Omen 2", but praised the "Soul Reaver" games as "great" for their "innovation and surprising drama", voice acting and technical feats. Matt Clemens of "Computer and Video Games" said that the series had engaging narrative, impressive cinematic sequences and fluid combat, calling "Soul Reaver" an "absolute classic". The "Houston Press" described "Legacy of Kain"'s voice cast as "the greatest unrecognized brilliance in video game acting", and compared the dialogue of the series to plays by William Shakespeare. Mikel Reparaz of GamesRadar said that "known for nuanced storytelling, unconventional protagonists, amazing boss fights and rich Shakespearean baritones, the series raised the bar for writing and acting in games". GameSpy's Chuck Osborn complimented the games' storyline as "deep", but described their mythology as convoluted.


title: Legacy of Kain

text: Individually, each title has generally been received well by critics. Metacritic, a video game review aggregator website, determined that the PlayStation version of "Soul Reaver" received a "critical acclaim" score of 91/100, "Soul Reaver 2" received "generally favorable" scores of 80/100 and 77/100 for PlayStation 2 and Microsoft Windows, the Xbox version of "Blood Omen 2" received a "generally favorable" score of 76/100 while the GameCube, PlayStation 2 and Microsoft Windows versions received "mixed or average" scores of 71/100, 67/100 and 66/100, the PlayStation 2 version of "Defiance" received a "generally favorable" score of 75/100 while the Xbox and Microsoft Windows versions received "mixed or average" scores of 74/100 and 70/100. "Soul Reaver" was also Amy Hennig's self-proclaimed greatest achievement. Later games in the series were criticized for repetitive gameplay elements and review scores of subsequent titles trended downward.


title: Design thinking

text: Design thinking refers to the set of cognitive, strategic and practical procedures used by designers in the process of designing, and to the body of knowledge that has been developed about how people reason when engaging with design problems.


title: Design thinking

text: Design thinking is also associated with prescriptions for the innovation of products and services within business and social contexts.


title: Design thinking

text: Design thinking has a history extending from the 1950s and '60s, with roots in the study of design cognition and design methods. It has also been referred to as "designerly ways of knowing, thinking and acting" and as "designerly thinking". Many of the key concepts and aspects of design thinking have been identified through studies, across different design domains, of design cognition and design activity in both laboratory and natural contexts.


title: Design thinking

text: The term design thinking has been used to refer to a specific cognitive style (thinking like a designer), a general theory of design (a way of understanding how designers work), and a set of pedagogical resources (through which organisations or inexperienced designers can learn to approach complex problems in a designerly way). The different uses have given rise to some confusion in the use of the term.


title: Design thinking

text: An iterative, non-linear process, design thinking includes activities such as context analysis, user testing, problem finding and framing, ideation and solution generating, creative thinking, sketching and drawing, prototyping, and evaluating.


title: Design thinking

text: Designing typically deals with ill-defined problems which are "wickedly difficult". Wicked problems have features such as no definitive formulation and no true/false solution. Horst Rittel introduced the term in the context of design and planning, and with Melvin Webber contrasted this problem type with well-defined or "tame" cases where the problem is clear and the solution available through applying rules or technical knowledge.


title: Design thinking

text: Rather than accept the problem as given, designers explore the given problem and its context and may re-interpret or restructure the given problem in order to reach a particular framing of the problem that suggests a route to a solution.


title: Design thinking

text: In empirical studies of three-dimensional problem solving, Bryan Lawson found architects employed solution-focused cognitive strategies, distinct from the problem-focused strategies of scientists. Nigel Cross suggests that "Designers tend to use solution conjectures as the means of developing their understanding of the problem".


title: Design thinking

text: In the creation of new design proposals, designers have to infer possible solutions from the available problem information, their experience, and the use of non-deductive modes of thinking such as the use of analogies. This has been interpreted as a form of Peirce's abductive reasoning, called innovative abduction.


title: Design thinking

text: In the process of designing, the designer's attention typically oscillates between their understanding of the problematic context and their ideas for a solution in a process of co-evolution of problem and solution. New solution ideas can lead to a deeper or alternative understanding of the problematic context, which in turn triggers more solution ideas.


title: Design thinking

text: Conventionally, designers communicate mostly in visual or object languages to translate abstract requirements into concrete objects. These 'languages' include traditional sketches and drawings but also extend to computer models and physical prototypes. The use of representations and models is closely associated with features of design thinking such as the generation and exploration of tentative solution concepts, the identification of what needs to be known about the developing concept, and the recognition of emergent features and properties within the representations.


title: Design thinking

text: A five-phase description of the design innovation process is offered by Plattner, Meinel, and Leifer as: "(re)defining the problem, needfinding and benchmarking, ideating, building, and testing". Plattner, Meinel, and Leifer state: "While the stages are simple enough, the adaptive expertise required to choose the right inflection points and appropriate next stage is a high order intellectual activity that requires practice and is learnable."


title: Design thinking

text: The process may also be thought of as a system of overlapping spaces rather than a sequence of orderly steps: inspiration, ideation, and implementation. Projects may loop back through inspiration, ideation, and implementation more than once as the team refines its ideas and explores new directions.


title: Design thinking

text: Generally, the design innovation process starts with the inspiration phase: observing how things and people work in the real world and noticing problems or opportunities. These problem formulations can be documented in a brief which includes constraints that gives the project team a framework from which to begin, benchmarks by which they can measure progress, and a set of objectives to be realized, such as price point, available technology, and market segment.


title: Design thinking

text: In their book "Creative Confidence", Tom and David Kelley note the importance of empathy with clients, users, and customers as a basis for innovative design. Designers approach user research with the goal of understanding their wants and needs, what might make their life easier and more enjoyable and how technology can be useful for them. Empathic design transcends physical ergonomics to include understanding the psychological and emotional needs of people—the way they do things, why and how they think and feel about the world, and what is meaningful to them.


title: Design thinking

text: Ideation is idea generation. The process is characterized by the alternation of divergent and convergent thinking, typical of design thinking process.


title: Design thinking

text: To achieve divergent thinking, it may be important to have a diverse group of people involved in the process. Design teams typically begin with a structured brainstorming process of "thinking outside the box". Convergent thinking, on the other hand, aims for zooming and focusing on the different proposals to select the best choice, which permits continuation of the design thinking process to achieve the final goals.