Breathing, fear, and finding relief from concussion

amygdala-fear-breathing-public-neurosciencenewsWestborough, MA February 10, 2018 The link between breathing and the fear response has recently been highlighted in the Neuroscience News who reviewed a study from Northwestern University.  This study coincided nicely with the ideas I have posted for several years about delayed recovery from post-concussion syndrome (PCS) about the impact of paced breathing on the body’s changing response pattern. The study looked at the link between nasal breathing and the activation of fear and memory centers deep within the brain. Behavioral data in healthy subjects suggest that changing from mouth breathing to nose breathing may have an influence on systems deep within the brain. The discussion presented in the Neuroscience paper findings “imply that, rather than being a passive target of heightened arousal or vigilance, the phase of natural breathing is actively used to promote oscillatory synchrony and to optimize information processing in brain areas mediating goal-directed behaviors” I have seen the results of this firsthand in the biofeedback work I do.  Respiratory sinus arrhythmia (RSA) is a term used to describe the changes in heart rate that are normal with oscillating rates of breathing. In some cases a patient can breath so erratically that his heart rate falls out of synchrony with sympathetic-parasympathetic regulation.
“The breathing systematically influences cognitive tasks related to amygdala and hippocampal functions.” Zelano, C. et. al. 2016

Christina Zelano, Heidi Jiang, Guangyu Zhou, Nikita Arora, Stephan Schuele, Joshua Rosenow and Jay A. Gottfried 
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Clock of the week: February 16, 2018

WESTBOROUGH, MA February 16, 2018 Here is the clock of the week for mid February, 2018.  It is quite unusual as you can see. The clock of the week is sent to me by a speech language pathologist here at Whittier
Name in clock
Rehabilitation Hospital in Westborough, MA.  It was drawn by a 76-year old H.S. graduate with one year of college.  As you can see this patient was provided with standardized directions that I have described in many other posts.  “Draw the face of a clock with all the numbers – set the hands for 11:10.”  It is amazing how the brain operates – or in some cases fails to appreciate the task demands and process the 3 steps of the task as it is given. What is also missing in this creation is an awareness of the errors made relative the task demands.
In this case the speech language pathologist drew the circle because she was using the SLUMS Examination – a V.A. Healthcare screening tool. The SLUMS gives the patient a circle but in general the directions prefer the patient to draw the circle him/herself.
Whatever clock
  The name has been altered for privacy.  What do you make of this clock? Whatever, it’s about
12 before 10? No?

Despair and Self-destruction in elite athletes

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Washington State Tyler Hilinski ESPN photo
WESTBOROUGH, MA February 26, 2018 On January 16 the quarterback of the Washington State Cougars killed himself with a rifle he had taken from a friend.  So far a motive for his suicide has not been published.  Tyler Hilinski was 21-years old and a teammate of the son of former N.E. Patriots quarterback Drew Bledsoe.  One might not expect that an elite athlete is susceptible to depression and even suicidal behavior.  From the outside these athletes have the world by a string and are catered to from early an age.  Elite athletes are among the one percent who become Olympians or high level collegiate athletes, and those who go on to become professional athletes.  But there is a dark side of the business of elite sports when athletes become depressed and too often go without treatment. They suffer in silence sometimes marginalized from teammates and family members.
Much has been published about several high-profile NFL players who have killed themselves and later had their brains autopsied only to be found to have the tell-tale markers of chronic traumatic encephalopathy (CTE) only found post-mortem. Former San Diego Charger Junior Seau died in 2012, Dave Duerson a former Chicago Bear died in 2011, Mike Webster died in 2002 – all were found to have the post-mortem signs of CTE.  CTE is known to contribute to both wide mood swings and expressions of rage and violence as the disease progresses.  I published a post on Hernandez and other professional players earlier this year entitled CTE and its Violent Underpinning.  Recently, former N.E. Patriots player Aaron Hernandez, 27, killed himself in his jail cell and was diagnosed with CTE raising the specter of the role of CTE in the murders Hernandez was accused of committing.
 The case of Tyler Hilinski is different. Drew Bledsoe should be commended for his stand on mental illness and being strong enough to share his experience.  He is correct.  It is important for men to talk about feelings and they rarely do so.  In a Boston Globe interview Bledsoe unabashedly described his early experience with a sports psychologist when he needed someone to talk to.  He described it frankly “If you’ve got a sprained ankle, you go see the trainer. If you’ve got a cold, you go to the doctor. If you’re head’s not quite right, you need to go see someone.” Boston Globe February 4, 2018. An open-minded and resilient opinion in a time where stigma still exists about mental illness as character weakness.
In 2011, Tom Cavanaugh, a local player for the AHL Worcester Sharks ice hockey team jumped to his death after years of psychiatric torment that included several admissions to psychiatric hospitals for depression and ultimately schizophrenia. By outward appearances this Harvard graduate was on the fast track to NHL success.

“We have to get over the stigma associated with asking for help. We need to get to the point where we treat emotional distress the same way we treat other ailments.” The NCAA reports that the incidence of college athlete suicide attempts is quite low.  “There are very few cases of completed suicide. However, we do know what kinds of factors and stressors might lead to an attempted suicide, and we do know that participation in sports can actually protect against some of those stressors.” as reported by David Lester for the NCAA.
“Reaching out for help when we need it is NOT a sign of weakness,” wrote Drew Bledsoe Wednesday on Instagram. “Trusting your friends and asking for help is the ultimate sign of STRENGTH!!”        Former N.E. Patriots Drew Bledsoe, 2018
Male athletes are not alone in their silent grief and torment. Johanna Nilsson, a Swedish born Northern Arizona University athlete killed herself in 2013 after a highly successful career in track and cross-country both at NAU and internationally. There was no specific explanation or warning given off by Johanna Nilsson who was just 30 at the time of her death.  In 2014, Madison Hallorin a 19-year old University of Pennsylvania athlete jumped to her death after a period of depression.
Jim and Stacy Holleran, have launched the Madison Holleran Foundation in an effort to help high school and college students who suffer from depression. The organization’s mission is to “prevent suicides and to assist those in a crisis situation with phone numbers and resources that will assist them during their time in crisis” — building resilience in athletes is important not only for confidence for winning but to help manage the down and out times when even a win can be a downer.

“Madison was the happiest kid, you know, when she was happy. And if that person would understand what they are doing to their family and their friends and their extended friends, they would not choose suicide if they really understood that they would be gone forever.”  Jim Hollerin, 2015

Elite athletes train for their sport every day of their lives and in some cases feel a vague great “missing piece” that can slowly erode their sense of resilience and emotional coping. Drew Bledsoe recognized this and asked a team trainer for a ‘name’ during a time of stress. But it would be important for athletes to become familiar with the routine cognitive behavioral strategies for stress management including HRV – Respiratory Sinus Arrhythmia and paced breathing for peak performance.

The Blaze (2015) Parents Release College Athlete’s Heartbreaking Suicide Note One Year After Her Shocking Death. Blog Post:  https://www.theblaze.com/news/2015/01/22/parents-release-college-athletes-heartbreaking-suicide-note-one-year-after-her-shocking-death Taken February 6, 2018
Lester, D. (2011) Mind, Body and Sport: Suicidal tendencies  An excerpt from the Sport Science Institute’s guide to understanding and supporting student-athlete mental wellness. http://www.ncaa.org/sport-science-institute/mind-body-and-sport-suicidal-tendencies Taken February 6, 2018

Clock of the Week: 1-25-18

Whatever clock
Unusual clock seen store window in Rockland, ME  January, 2018
Westborough, MA February 1, 2018 The video below is the clock of the week for this week in January, 2018. It is an interesting construction by a 81-year old male who is undergoing treatment for respiratory failure and myelodysplastic disease – a blood disorder in errant white blood cell production. He has had difficulty with all of his activities of daily living including dressing, bathing, personal hygiene and toileting.  He is recovering slowly and receiving daily therapy for these physical and occupational deficits.
“Renowned neuropsychologist Dr. Edith Kaplan too had a love affair with clocks (and owls as I recall) and taught us the unique importance of this seemingly simple neuropsychological instrument.” Sefton, 2015
 Clock video
The “clock drawing” task is described throughout the pages of this blog and is widely used by psychologists as a screening for cognitive dysfunction.  I like it because it is not threatening and is not a great challenge to the patient.  That said, I have had many people say ” I am not an artist” when asked to draw the face of a clock.  Interestingly, I suspect those who deny being artistically gifted (drawing a clock) may have some degree of preserved insight into their declining cognitive ability.
Clock of the Week: 1-25-18
https://www.youtube.com/watch?v=5FetKtiEzJE
The video is produced by the Neuropsychology Service at Whittier Rehabilitation Hospital. HIPPA protected.

 


Sefton, M. (2015) All this from a clock? Blog post: https://concussionassessment.wordpress.com/2015/04/29/all-this-from-a-clock-a-cognitive-test-for-the-ages/ . Taken January 26, 2018

CTE and its violent underpining

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Google images – CTE
WESTBOROUGH, MA January 20, 2018 More is becoming known about Chronic Traumatic Encephalopathy or CTE.  It is now able to be diagnosed prior to the death of the patient by identifying unique protein markers in the blood of those who have sustained multiple brain injuries.  Former professional wrestler Chris Benoit was found to have CTE after killing his wife and son before killing himself in 2007. But murder or other violence against others has not typically been associated with CTE until recently.  As recently as summer, 2017, the brain of former N.E. Patriots star Aaron Hernandez was also found to have signs of severe CTE raising the specter of its possible impact on his violent life and eventual death by suicide. I have posted post-mortem photos of his brain first published on the Boston University site in a prior blog on my Concussion site (Sefton, 2017).  See that post by clicking here.  It is now understood that an athlete need not have sustained numerous concussions in his career to be found to have CTE at time of death.  More so, the accumulation of repeated blows to the head – subconcussive force – is being implicated in the etiology of this complex disease process. So contact sports like football, rugby and ice hockey are being closely scrutinized by experts in concussion, athletic training and sports medicine.  Researchers at BU School of Medicine have reported that a protein known as CLL11 may be elevated in the brain and spinal fluid of athletes with a history of brain injury.  It holds some promise of being able to diagnose athletes before death.  This protein leads to elevate Tau protein a known cause of progressive brain damage associated with dementia.
In 2014, The K.C. Star reported that analysis of Belcher’s brain after he’d been exhumed revealed a key signature of chronic traumatic encephalopathy, best known as CTE, a degenerative brain disease found to cause dementia, confusion, depression and aggression). “Belcher’s murder-suicide is the worst possible example of domestic violence, and these findings come as the NFL is under attack for its handling of domestic violence.” (Mellinger, 2014 Kansas City Star). 
“CTE has been found to cause erratic and sometimes tragic behavior by some NFL players, perhaps most notably Hall of Fame linebacker Junior Seau, who killed himself last year. The disease, only recently diagnosable before death, has often been found in former and longtime football players.” Mellinger, 2014 K.C. Star
 Riding a bicycle is a leading cause of brain injury in childhood. Recently, CTE has not been diagnosable before death. It has been found over and over in former and longtime football players. Domestic violence behaviors cut across all socioeconomic strata.  They germinate in an environment of secrecy often early in courtship.  During this time abusive spouse slowly isolates his intimate partner from her support – family, friends, finances.  “In doing so there is a subtle but undeniable manipulation of control – usually coupled with threats and intimidation.  There is growing awareness that red flag behaviors precede DV and domestic violence homicide.  Things like pathological jealousy, forced sexual contact, manipulating friendships, detachment from members of immediate family and others are the early signs of domestic violence.” (Sefton, 2012)  Some believe that the most significant pre-incident red flag is whether or not the victim truly believes she is going to be killed by her intimate partner one day and that these victims are at most risk of death.

Sefton, M (2012) Athletes and Celebrities Not Immuned: Kansas City Chief’s player kills wife and self in act of DVH, Blog post December 1, 2014, taken December 28, 2017. 
Sefton, M. (2017). Brain and Behavior: B.U. scientist says Aaron Hernandez had CTE. Blog post, Nov 19, 2017 Taken December 28, 2017
Read more here: http://www.kansascity.com/sports/nfl/kansas-city-chiefs/article2296030.html#storylink=cpy
Read more here: http://www.kansascity.com/sports/spt-columns-blogs/vahe-gregorian/article187534063.html#storylink=cpy

CTE found in teenage brains by B.U. team

WESTBROUGH, MA January 18, 2018 The scientists studying the damaged brains of older athletes have had the opportunity to study brain damage in athletes who died from other causes.  In 4 such cases, there was evidence of chronic traumatic encephalopathy (CTE) that was not commensurate with the degree of brain trauma that was observed during their athletic careers according to Felice Freyer of the Boston Globe. This recent study was published in the journal Brain illustrates that the onset of CTE may be closer to onset of brain injury than first thought not much later in life.
“The report, published Thursday in the journal Brain, also provides what Goldstein called “the best evidence to date” supporting the theory that CTE is caused not just by concussions, but rather by any blow to the head, including mild impacts. Instead of diagnosing and responding to concussions, he said, coaches would do better to protect children from all hits to the head.” Felice Freyer – Boston Globe 1-8-18
The possibility of younger athletes developing CTE and the symptoms associated with this progressive disease is quite worrisome especially to parents.  It was always thought that CTE would develop later in life if at all. With the prospects of the disease having a much earlier onset the cost of CTE over a lifetime is incalculable in terms of medical costs and neuropsychological sequelae that may evolve in time. The true impact of this and the consequence for repeated, subclinical blows to the head is only now becoming clear.
Like dementia of the Alzheimer’s type the build up of tau protein underlies the changes associated with CTE. “Chronic traumatic encephalopathy is a condition bringing forth progressive tauopathy that occurs as a consequence of repetitive mild traumatic brain injury. We analysed post-mortem brains obtained from a cohort of 85 subjects with histories of repetitive mild traumatic brain injury and found evidence of chronic traumatic encephalopathy in 68 subjects: all males, ranging in age from 17 to 98 years (mean 59.5 years), including 64 athletes, 21 military veterans (86% of whom were also athletes) and one individual who engaged in self-injurious head banging behavior” according to the journal Brain. McKee, A. et. al. 2017

McKee, A. et. al. (2017) The spectrum of disease in chronic traumatic encephalopathy. Brain, Volume 136, Issue 1, 1 January 2013, Pages 43–64, https://doi.org/10.1093/brain/aws307

Once common treatment of concussion

Head injuries at the time were treated as mere nuisances. Players reacted to violent head blows by trying to blink away their blurred vision, shake the ringing from their skulls, and trundle back to their huddles, unless they were flagged by sideline doctors. Even then, they generally returned quickly to action.  Boston Globe October 2017