WESTBOROUGH, MA March 29, 2018 Whittier Rehabilitation Hospital is proud to announce that they will be offering a Certified Brain Injury Specialist (CBIS) class at its hospital in Westborough, MA. This is a new class and is the first in classroom CBIS program to be offered in over 2 years here in the Boston area. The class is occasionally offered in web-based format. The upcoming class is being planned and will be re-scheduled for October 26-28 2018. The class will be taught by Michael Sefton, Ph.D., who is a
Certified Brain Injury Specialist -Trainer and Director of Neuropsychology and Psychological Services at the Rehabilitation Hospital. This is a new course that provides extensive education in all areas of traumatic and acquired brain injury. The certification comes through the Academy of Brain Injury Specialists and must be renewed annually. Students must pass an online test at the end of the course. Students who receive their certification will receive 1 year of the Journal of Traumatic Brain Injury as part of the certification cost for the first year.
The cost of the course is approximately $500.00 which includes the examination fee, book, and catered lunch both days. The textbook The Essential Brain Injury Guide – 5th Edition was published in 2016 by the Brain Injury Association of America. It is extensive in its revision over the 4th Edition text. It can be purchased on-line or at the class for a discounted price.
Class prerequisites include 500 hours of direct service to patients suffering from the effects of traumatic or acquired brain injury and completed their post baccalaureate training. Others are permitted to take the class and obtain a Provisional certification that may be transferred to full certification once they have completed prerequisite educational requirements.
Contact ACBIS faculty Michael Sefton at 508-870-2222 x 2153 or email@example.com about becoming a member of the class. Interested students may also contact Ms. Beth Pusey, Education Manager at the Brain Injury Association of Massachusetts at 508-475-0032 X 19 for more. Class size will be limited. Additional details about the Academy of Brain Injury Specialists is at https://www.biausa.org/professionals/acbis
WESTBOROUGH, MA June 21, 2018 The clock of the week was drawn by a 74-year old female patient suffering from a right hemisphere cerebral vascular accident (CVA) with a significant number of cognitive behavioral changes from her pre-illness baseline. As you can see from the scanned drawing, it took two attempts for her to be satisfied with the effort. Both drawings are quite small (micrographia) – 1.8 cm in size (0.7 inches). Why?
There are several reasons for micrographia that have to do with visual processing and self-monitoring. When a task is given such as the clock drawing the subject must be able to process the directions using existing linguistic functions. Once done there is an element of planning, e.g. “how do I start this process”?, and finally the initiation and execution of the task from first step through the final drawing. This clock was barely over 1/2 inch in size. The female used the space provided very sparingly and talked her way through the task suggesting a verbal strategy was helpful. However, as you see form the top drawing she was unsuccessful. Immediately afterward, seeing that she failed in the task, she drew the bottom left clock and felt she had done a better job.
It is always interesting to see for yourself how these tasks are completed and to what extent brain injuries interfere with the drawing of common objects like the clock. My interpretation of this clock suggests to me that her frontal feedback loop was decreased in its efficiency. It would have provided her with immediate, on-going feedback and real-time monitoring and adjustment of her work. In the second draft, she may have planned a larger circle and placed the numerals in their correct juxtaposition of one another. Finally, she may have thought for a moment and set the hands correctly for ten past eleven. I have had discussions with speech pathologists with whom I regularly consult about the next generation of patients that are given this task as they get older and may not have learned how to construct the face of a clock when first learning to tell the time. Perhaps at some point we will ask them to draw the face of their cell phone as a screening test of current cognitive functioning.
WESTBOROUGH, MA Here is the “clock of the week” drawn by a well educated 77-year old woman undergoing rehabilitation at the hospital after she sustained a fall and broke some ribs. The clock represents her best effort at completing the 3 step problem I have described so often in these pages. Clocks are interesting and fun. They can be used to put the patient at ease when first getting started. Some patients become quite defensive when they are referred for neuropsychological assessment. It is important to establish rapport prior to initiating the battery of tests so that you may obtain the best possible result.
These data are turned into the report that physicians will use to access services and needed intervention to assist with return to functional independence whenever possible. In this case, the woman had had two prior CVA’s one on the
Right middle cerebral artery – effecting her visual motor integration and spatial awareness and the second stroke effecting her language area – including verbal fluency and word choice during free speech. I have also added a sample of her written language. Patients are all asked to “write a sentence” that I dictate to them. I have used the same 2 sentences for over 20 years and find them useful.
“Baseball players are tough”
The sentence reads Baseball players are tough. It illustrates the impact of CVA on written language. This interesting lady could no longer write checks or sign her name. Graphic formulation of words requires both the left and right sides of the brain for success. The frontal lobe is also brought in automatically to initiate, plan, and execute the verbiage and organize the thoughts into a coherent message.
During the hours of assessment I learned that this patient had sustained a fall just 5 months earlier resulting in a head strike and 3-5 days of concussion-like symptoms that slowly evaporated returning her to her baseline. This leaves her more vulnerable to cognitive change with any illness including infection or pain syndrome from fractured ribs.
Westborough, MA May 20, 2018 Biofeedback has been the subject of my posts for a few years and I am excited to publish this paper on using the Heart Rate Variability (HRV) protocol together with EEG Neurofeedback to reduce the duration and severity of symptoms of post-concussion syndrome (PCS). “Sometimes vague physical symptoms create an overwhelming emotional response that comes from the lingering resentment patients feel when seeing doctors who seem unable to understand their needs. Sometimes the outward appearance of lingering concussion may appear to be solely a psychiatric condition rather than someone who is recovering from a brain injury. This can leave a patient with feelings of embitterment and confusion. Some physicians unfairly believe prolonged symptoms may be linked to ongoing litigation.” as posted in a concussion blog by Michael Sefton in 2015.
Biofeedback is not new nor is it still considered a novice, untested treatment. There are scores of peer reviewed papers on both physiologic and neurofeedback for a variety of clinical syndrome including epilepsy, chronic pain, hypertension, alcoholism, ADHD, and concussion among others. The key for those suffering with the effects of concussion is early referral into treatment rather than referring as a last resort after three years of chronic suffering. Happily I can report that only a tiny percentage of people who sustain a concussion have symptoms that last greater than 6 months. Nevertheless, the number of post-concussion sufferers is substantial and all too often are overwhelmed by symptoms months after their injury. There are a number of reasons why this seems to occur and many of these relate to the response of the body to stress and its associated physical sequelae. The photograph shows a TBI patient working on peak performance training using both EEG neurofeedback and physiologic biofeedback for HRV and paced breathing. Given the extent of her brain injury, she has done very well and is improving.
“Relaxation and mindfulness have existed for over 60 years bringing together the conscious effort to control bodily systems that were once thought to be automatic and “not correctable.” Research into chronic stress illustrates how damaging it can be on physical functioning and longevity. Concussion is described as an invisible injury yet it has an undeniable impact on sleep, concentration, and emotional well being.” Michael Sefton, 2016
One key indicator for how a person recovers from concussion closely relates to their prototypic response to other stressful events in their lives. According to the American Psychological Association “resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress — such as family and relationship problems, serious health problems or workplace and financial stressors. It means “bouncing back” from difficult experiences.Psychological resilience is required when “knocked down” by a concussion and to bounce back into a fully functioning, integrated person. Where are all of these people right? When this fails and symptoms are prolonged for 6 months or more the likelihood of returning to full employment drops precipitously. Heart rate variability training (HRV) can assist with lowering feelings of pain and tension that make the recovery from concussion more complex. Coupled with this is training to reduce the post-concussive embitterment often described going from doctor to doctor looking for discovery and validation for what has befallen them.
“Resilience is not a trait that people either have or do not have. It involves behaviors, thoughts and actions that can be learned and developed in anyone.” APA The biofeedback I am offering helps patients reduce autonomic overload while helping build resilience. When individual goals are attained using biofeedback people see for themselves that they have control and can learn to lower the tension and pain they feel.
Coincident Stress and Trauma
In the Journal of Neurology, Neurosurgery, and Psychiatry, a 2011 study suggested that pre-incident trauma may confound the recovery from concussion. “Several potentially life-altering stressful events were endorsed by at least 25% of participants as having been experienced prior to injury. The incidence of stressful life events was a significant predictor of all four outcome variables.” I have started taking data from people I see asking about trauma occurring at the same time e.g. loss of job, divorce, major health scare, family trouble.
There needs to be secondary care for the emotional loss and stress associated with PCS to reduce the impact of an abnormal emotional or psychological response to concussion. Especially when symptoms go on and on. “Cognitive behavioral therapy works best along with both physiologic feedback and EEG neurofeedback for reduced sympathetic arousal – from stress hormones that have gone into overdrive” from my recent blog post in which I cite Sonia Coelho Mosch, Ph.D. A re-exertion plan along with physical therapy, aquatics, and mindfulness are components of a complete plan of action for recovery from concussion and reduced feelings of helplessness.
I sometimes see patients who exhibit such embitterment about what they believe they have “lost” they cannot move on. It is these cases who are involved in litigation and cannot allow themselves to move on with their lives. They become emotionally stuck – reliving their loss and growing bitter about having lingering symptoms whether it is headaches, sensitivity to sound or light, inability to multi-task, or other cognitive change. Education at the time of injury may mitigate the long-term effects of concussion.
Resilience affords the patient greater coping skill and the underlying confidence that they will get better. Patients must take responsibility for their recovery and avoid being overburdened by bitterness and resentment. Moderate physical activity and physical support is essential following a concussion. Biofeedback can help reduce the autonomic overload that slowly rises when patients feel constant tension, stress, and pain. Certainly, by obtaining greater control over the unbridled fight-flight imbalance athletes and patients alike learn to balance their parasympathetic system with the unappreciated physical and cognitive threat associated with post-concussion syndrome. “Bitterness is a prolonged, resentful feeling of disempowered and devalued victimization. Embitterment, like resentment and hostility, results from the long-term mismanagement of annoyance, irritation, frustration, anger or rage. ” according to Steven Diamond, Ph.D. who publishes on the Psychology Today website.
The APA article says several additional factors are associated with resilience, including:
The capacity to make realistic plans and take steps to carry them out.
Skills in communication and problem solving.
A positive view of yourself and confidence in your strengths and abilities.Skills in communication and problem solving.
The capacity to manage strong feelings and impulses.
All of these are factors that people can develop in themselves and lead to improved coping and may reduce the impact of concussion.
APA. Road to Resilience. http://www.apa.org/helpcenter/road-resilience.aspx. Taken May 12, 2018
Diamond, S. (2009) Anger Disorder (Part Two): Can Bitterness Become a Mental Disorder? Can Bitterness Become a Mental Disorder? PT blog https://www.psychologytoday.com/us/blog/evil-deeds/200906/anger-disorder-part-two-can-bitterness-become-mental-disorder. Taken May 13, 2018
Sefton, M. (2016) Coincident Stress may prolong symptoms of Concussion. https://concussionassessment.wordpress.com/2016/09/26/ Taken May 13, 2018
Westborough, MA May 10, 2018 Clock of the week for May 10, 2018. Here is an interesting clock drawn by a 79-year old right handed male. He is a nursing home resident who is suffering with the effects of dementia. This clock is interesting because the subject was working quickly and until he reached the number placement. This is a good clock overall but fails appreciably in the self-monitoring needed for success.
He had been both efficient and spatially accurate. Ultimately his performance was negatively effected by the problem solving element of the three-step command required for success.
WESTBOROUGH, MA May 2, 2018 At a meeting of the Sports Neuropsychology Society held in early May each year the topic of “resilience” emerged as a term referring to the physical and emotional response to adverse events. According to Sonia Coelho Mosch, Ph.D., “your body and mind can choose how to respond to the event with ‘I’m really screwed’ or you can change what you say to yourself with the expectation that you are going to overcome it” on Forbes.com. Patients who obsess over every symptom may be those who go on to experience post-concussion syndrome.
“Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress — such as family and relationship problems, serious health problems or workplace and financial stressors” according to the American Psychological Association.
Dr. Mosch believes people who take responsibility for their injury and focus on intermediate goals for restoring themselves often recover quickly “as long as they do not focus on small symptoms and pathologize every internal feeling state. She works with NHL pro hockey players as well as clinic patients who are referred for any number of possible injuries causing concussion e.g. car accident. Positive outcomes are linked to handling the stressful event with positivity and the expectation for a positive outcome. The pro athletes more often than not express a strong willingness to do “whatever is necessary” to get back to work and take responsibility for their recovery. “Resilience is not a trait that people either have or do not have. It involves behaviors, thoughts and actions that can be learned and developed in anyone” according to APA site.
At Whittier Rehabilitation Hospital we are often working with people who have been symptomatic for months or even years. They come to Whittier not expecting to get better and believing they are truly sick and no one understands what they are going through. When told they must alter their expectations and begin to work towards better management of stress, physical mobility and light exercise, and nutritional health and well-being they sometimes become disenchanted and move on.
In the first meeting, I have had a patient tell me that he believed that he was dying and had started telling his friends as much. These cases are very difficult to treat and require both physical and emotional support for successful outcome. Cognitive behavioral therapy works best along with both physiologic feedback and EEG neurofeedback for reduced sympathetic arousal – from stress hormones that have gone into overdrive. A re-exertion plan along with physical therapy, aquatics, and mindfulness are components of a complete plan of action for recovery from concussion.
Wagner, R Neuropsychologist shares pro hockey players’ secrets to resilience. Forbes.com taken April 30, 2018
WESTBOROUGH, MA April 2, 2018 Much has been written about the incidence of opioid-related death and debility. As of yet I have not directly published my approach to this contagion. 20 years ago we offered a pain management program at the hospital at which I consult.
It was a coordinated and structured rehabilitation program with daily education, physical restoration, mindfulness exercises, aquatics, family support, and nutritional education – including weight management. What happened was referring physicians sent us all their chronic cases and treatment failures. There is no magic to pain management. There is no mysterious gating mechanism to turn off pain receptors in the brain. As soon as people learned this we had difficulty filling the program with those who truly wanted to work at reducing their pain and strive to increase their functional independence. Our medical director cited current rehabilitation statistics from 1999-2002 indicating that if someone is out of work for greater than 6-12 months because of pain, the likelihood of their eventual return to work is almost nonexistent. I found this news to be very discouraging but generally true.
Recently, I was reading the blog post of Vic Crain who is spot on when it comes to many current social issues. He writes from New Jersey and does not hesitate to comment of a range of topics from guns to opioid addiction. I enjoy seeing his writing and try to comment on his posts whenever he touches on an area about which I am knowledgeable or simply an area where we share a common interest. In this case it is the use of pain medicine for chronic pain. Pain management requires both a team approach and a shift in the current zeitgeist guiding the standard of care for those suffering with chronic pain and its psychosocial sequelae. According Harvard University psychologist Dr. Robert Edwards, “patient surveys also show that people with chronic pain care about more than just experiencing less pain. They care about enjoying life more, having a strong sense of emotional well-being, increasing their physical activity, improving sleep and reducing fatigue, and participating in social and recreational activities.” in an article published in 2015.
Each patient has his or her own story to tell and should be allowed the opportunity to express the frustration that is universal among those in pain. At the same time the new standard must include a comprehensive review of medication and modalities that will address the pain from integrated approach that is derived from both the cycle of pain that is coupled with increased functional capacity. Regular education and review of team goals are essential.
There is no shut off switch for severe pain. Patients float from one physician or clinic to another spending thousands of dollars seeking the key to ending their discomfort and debility when often the answer is within their grasp. The internet has allowed many patients to access information about new medications, test procedures, and sometimes obscure treatment methods like never before. Treatment need not be complex but certainly it must include a comprehensive pain management plan.
Reach for the hand of a loved one in pain and not only will your breathing and heart rate synchronize with theirs, your brain wave patterns will couple up too, according to a study published this week in the Proceedings of the National Academy of Sciences (PNAS). Vic Crain, 2018
Using Opioid Medications and Pain Relief
Mr. Crain’s recent post brought into focus the issue of opioid dependence and addiction. Most of us are aware that deaths from opioid overdose have increased exponentially in the past 5 years largely due to physician-related practices – now thought to be over prescribing of pain medication. Recently a study was published findings that indicate chronic pain patients’ are no better off when prescribed opioids or an OTC analgesic. The study followed randomly controlled groups for 12 or more months of treatment. Some patients were functioning even worse after the study period. Mr. Crain also cites a newly released study indicating that the source of underlying pain, know as small fiber polyneuropathy, may require alternative therapies and not respond to the typical opioid therapy (2017). These syndromes are directly linked to the long-term impact of poorly controlled diabetes mellitus, circulatory problems from DVT, poorly controlled cardiac arrhythmia, and more.
A common underpinning of these afflictions and more is elevated inflammation throughout the body and reduced autoimmune functioning. The result is errant ANS functioning. This is an automatic process of sympathetic arousal ramps us up as if to say “bring it on” – activating us to fight or fly the coop if needed to survive. The problem is that over time an insidious elevation of normal baseline physiological values that create a sympathetic-parasympathetic mismatch adds to patient experience of pain and tension. A key component to recovery is movement – regular exercise and a routine of progressive mindfulness coupled with a goal of increased functioning. This is a hard sell for many individuals suffering from pain. Many fail to understand that the lack of movement – and lack of regular exercise, physical therapy, aquatic therapy, yoga, and or other treatments, is far worse than the initial injury they may have sustained sometimes years ago.
What people often do not know is that opioid medication is only one small piece of the pain management puzzle. I am particularly interested in biofeedback protocols designed to reduce pain and the co-morbid conditions that are linked to it like irritability, tension, shortness of breath, and autonomic dysfunction. I have had patients tell me they have tried “everything” to reduce their discomfort and often respond with incredulity when I suggest regular use of ice and 20 minutes of walking each day. Biofeedback may be a useful modality for migraine headaches, anxiety, pain management, concussion, and stress. I have used a combination of physiologic biofeedback and neurofeedback for patients with chronic pain, failure to thrive, depression, post-concussion syndrome, and severe traumatic brain injury” (2014). The results often bring down levels of stress and tension and have a corresponding lowering of physiological arousal – even blood pressure, pulse rate, and improved sleep and mood.
Patients are urged to have at least 10 sessions of HRV biofeedback and may practice at home between sessions. Diet and exercise are important parts of recovery from TBI, concussion, and other pain-related syndromes. Dr. Sefton is a licensed psychologist who is certified in biofeedback including neurofeedback and is a Certified Brain Injury Specialist-Trainer (CBIST).
Edwards, R. (2015) The “right” goal when managing pain. December 18, 2015 Harvard Health Blog https://www.health.harvard.edu/blog/the-right-goal-when-managing-pain-201512188865 takenMarch 12, 2018.
Crain, V. (2017) A New cause and treatment for pain. November 10, 2017 Blog post: https://wordpress.com/read/blogs/69301418/posts/13770 taken March 12, 2018 citing Pavel Goldstein, Irit Weissman-Fogel, Guillaume Dumas, Simone G. Shamay-Tsoory. Brain-to-brain coupling during handholding is associated with pain reduction. Proceedings of the National Academy of Sciences, 2018; 201703643 DOI: 10.1073/pnas.1703643115
Crain, V. (2018) Pain therapy: Holding hands. March 7, 2018 Blog post: https://wordpress.com/read/feeds/21687647/posts/1787094734 taken March 12, 2018
Sefton, M (2014) Blog post: https://concussionassessment.wordpress.com/consultation/topics-in-neuropsychology/tbi/autonomic-dysfunction/ Taken 3-13-18.