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 early September 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 $425.00 which includes the examination fee 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 firstname.lastname@example.org about becoming a member of the class. Class size will be limited. Additional details about the Academy of Brain Injury Specialists is at https://www.biausa.org/professionals/acbis
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.
WESTBOROUGH, MA March 20, 2018 I am frequently asked about helmets and those that claim to be protective against concussion. As of this publication there are no helmets that unequivocally protect against the forces that impact the brain in the course of an athletic contest. The stunning Ted Talk video below reveals details about the protection offered by helmets today. Concussion is described as occurring in lower brain centers not the surface of the brain as the CDC graphic describes.
“Players are rarely hit by a direct linear force. They are struck from the side or oblique and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.” Sefton, 2018
In fact, there is a newly designed mouth piece that has a built in gyroscope that is capable of measuring g-forces and rotation of the head resulting from head strikes. Researchers now believe it is the rotational force that sends energy into the skull and brain that causes the greatest cognitive and behavioral changes in the event of a concussion. Players are rarely hit by a direct linear force. They are struck from the side or oblique and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.
WESTBOROUGH, MA March 15, 2018 Serious and chronic headaches are a frequent complaint of those recovering from mild traumatic brain injury. “Headache is one of the most common symptoms after traumatic brain injury (often called “post-traumatic headache”). Over 30% of people report having headaches which continue long after injury.” (TBI and Headaches, 2010) They can be quite debilitating. The NCAA Headache Task force listed headaches as among the most debilitating symptoms in the aftermath of concussion. Young women tend to have a higher incidence of post-concussive headaches than males. There is treatment for post-concussive head pain.
Migraine headaches are three times more common in females than males. Rates of emergency room visits related to traumatic brain injury (including concussions) among women almost doubled from 2001 to 2010, according to the Centers for Disease Control and Prevention (CDC). In my own practice here in Massachusetts I have seen more recurring headaches in females than in males. In addition, female athletes generally have a longer recovery course than some of the males I follow. I will say that males are prone to abuse alcohol when recovering from concussion that may also be a confounding variable in the trajectory toward their normal baseline.
Individuals previously treated for headaches are at greater risk of both developing post-concussive headaches and for having chronic headaches following recovery from concussion. These injuries can be caused by not only sports but also falls, car crashes, blunt trauma (getting hit on the head by an object), and assaults as noted in a 2016 Health.com report on women and concussion. I have worked with several high school athletes who had pre-injury headaches and received treatment for chronic headaches who went on to have an increased frequency of headaches after concussion. I worked with a tenured college professor who developed headaches from being hit with a basketball at her daughter’s middle school practice. This was shortly after being diagnosed with concussion from a prior head trauma.
American Olympian Lindsey Vonn suffered with the effects of concussion for months following a skiing accident in 2015 including chronic headaches. The BBC recently featured 22-year old skier Rowan Cheshire who sustained a concussion 4 years ago that kept her from competing in the 2014 Olympic Games. Cheshire had won the World Cup event one month prior to the Olympics in Sochi and suffered a severe concussion in a fall off the halfpipe. It was the first of two subsequent concussions over the next 3 years that caused severe side effects including migraine headaches and panic anxiety. Cheshire worked closely with a sports psychologist during her recovery.
One reason for the difference between men and women in concussions is that women tend to have smaller neck and shoulder muscles allowing for greater whiplash from force striking the upper body. Episodic headaches are usually set off by a single stressful situation or a build-up of stress. These are tension-related headaches which may be unrelated to concussion but whose frequency and intensity change following concussion or when under stressful life conditions. Nevertheless, unchecked stress and tension may contribute to an increased proclivity for head and neck pain and both respond very well to biofeedback and alternative interventions such as acupuncture and progressive relaxation. Daily strain can lead to chronic headaches. Coupled with concussion, stress can become inflammatory in terms of the frequency and intensity of headaches.
“Post traumatic headaches are seriously debilitating in terms of lost school and work days. They are often a late symptom in the recovery from brain injury and concussion” Michael Sefton, 2018
In early childhood there is similarity between boys and girls in symptoms profile. This changes as children enter their growth spurt. “Puberty, which marks a significant developmental fork in the road for males and females, also marks a divergence for concussions. With its onset, females increasingly experience higher incidence of concussions, different and more severe symptoms, and are often slower to recover from the injury.” Treatments for post-concussion range from complete rest to gradual re-exertion, to physical therapy and more. There is a growing trend to slowly increase physical activity once symptoms resolve and I have seen a return of symptoms in cases where physical activity is premature and in cases of second or subsequent concussion.
One clear intervention for post-concussion headaches involves a paced-breathing protocol and neurofeedback that I have been using. I teach and practice stress management using biofeedback instruments that have demonstrated reducing duration of headaches, reducing stress, and lowering sympathetic abnormalities including heart rate. The goal of treatment is to reduce the body’s reactivity and normalize the autonomic system. “Fortunately, even if post-concussion headaches don’t get better in the first few weeks after concussion, most are better within 3 months and almost all are better within a year after injury” according to Heidi Blume, M.D., at the American Migraine Foundation.
Sefton, M. (2018) Abnormal Stress response from mTBI often sometimes leads to headaches. Response comment in Emergency Medicine Journal, Volume 34, Issue 12, February 23, 2018
Roehr, B. (2016). Concussions Affect Women More Adversely Than Men: Differences between how females and males experience concussions suggest the need for gender-specific prevention and treatment strategies. Scientific American posted March, 2016. https://www.scientificamerican.com/article/concussions-affect-women-more-adversely-than-men/ Taken February 28, 2018.
Lahz S, Bryant RA (1996). Incidence of chronic pain following
traumatic brain injury. Arch Phys Med Rehabil, 77(9),
Blume, H. (2016). Headaches after Concussion. American Migraine Foundation. https://americanmigrainefoundation.org/understanding-migraine/headaches-after-concussion/ Taken February 28, 2018
“Players are rarely hit by a direct linear force. They are struck from the side or oblique angle and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.” Sefton, 2018
My mother Ann in 2018, she is 89-years old and loves to read but has been less active in past 12 months. She is holding a book given to her by best-selling author Bruce Coffin. She is quite emotionally resilient and enjoys reading and spending time with her children and grandchildren. She does not have dementia.
WESTBOROUGH, MA March 2, 2018 Dementia is the diagnosis given to individuals who have experienced an insidious decline in their neurocognitive functions. Practitioners around the world are using the clock instrument to assess cognitive status among a patient population who presents with cognitive or thinking changes who have insidious decline in their thinking capacity for whatever reason. I have published a great deal about the clock and was surprised this week to be contacted by Nicholas Searles a producer for the Australian television show “Ask the Doctors“. Mr. Searles works for the Austrailian Broadcast Corporation (ABC) wanted to display a clock on the upcoming show that was published on my website as the Clock of the Week in September 2017. These clocks are quite telling as to the cognitive functioning – including problem solving of the patient asked to construct them. See the prior publications of the clock of the week and dementia .
“Take care of yourselves, rest as much as you can, read good books, sing loud songs (when you’re alone…would be best) and read a poem now and then” Ann Sefton, 2015
What is the prominent feature of dementia? By definition dementia is an insidious decline in cognitive functioning over time this includes attention and memory functioning. Insidious change often translates into ‘not every member of the family sees the problem at the same time’. Very often, the patient is the last one to notice that anything is wrong with him or her. This raises considerable fear and sometimes conflict among family members. Everyone handles this particular stress differently. Insidious means that there are subtle but cumulative changes in cognitive functioning among these patients. This included a mixed bag of problems that include both physical and cognitive changes that are slow to present themselves and are sometimes missed by family and even the primary care physician. Sometimes activities of daily living such as bathing and dressing become the first things noticed by members of a caring family and often the source of great conflict. Mom or dad just does not want to “clean up” like they used to – bathing and dressing. Generally they will say “I took a shower this morning” but they may be wearing the same clothes or even undergarments suggesting this may not be the case. Just as frequently, the previously fastidious parent has shown changes in his or her awareness and concern over things that once were carefully controlled. I had one daughter of a dementia patient say that her mom never offers cookies or coffee when people visit and this was something she had done her entire life for visitors which she noticed a big change in her mom’s social behavior.
As a practitioner, when I begin a new patient exam, I make an effort to hear from members of immediate family as to what they have noticed about their loved one? This can be benign or it can be gut wrenching. I try to establish rapport and trust. I do this with empathy and professional concern that may enlist both family and patient in the lengthy process of the examination . Without trust a nervous patient will not be able to participate fully in the examination because of intrusive anxiety over the conflict they may feel about being brought to this office to spend signficant time with someone they do not know.
No easy task, I recently had to bring my mother to the hospital with changes in her cognition that we did not anticipate. Her photograph is posted above. My mother is a resilient and positive woman who is curious and smart. She is kind and gentle. See her comments in the blog I posted a couple years ago called Words to Live by. They are quite kind and endearing. She lost her husband – our father in 1984 and has not remarried. My father was only 56 when he died. My sister alerted me one morning that something was different about our mother. It was upsetting and I admit not wanting to take a close look at the true problem – maybe dementia. I had to bring her to her primary doctor for a quick exam whom then said she needed to be seen at the local emergency department right away. Ugh. I knew what that meant. Many hours of tests, C-T scans, and labs to rule out a cardiac event or an infection, or a cerebral vascular attack – stroke or something else. The entire event was humbling and I grew to appreciate the emergency physicians who deal with these cases daily. The physician who took care of my mother was sensitive and thorough. She listened to my mothers fear and apprehension about being in the hospital. Ultimately, mom was discharged home but still has a struggle with initiation and verbal expression that is unclear to us in terms of where it comes from.
None of us expects to grow old – nor do we expect our parents to ever age or become infirm. But they certainly do and of late, I am faced with the anguish of loosing touch with my mother as a result of her change in cognitive status and I am not sure just why. I am heart-broken when I think about this and she is not diagnosed with dementia. Her change in thinking and problem solving resulted from an infection she developed that came on gradually. The fact remains though that once vulnerable to altered mental status (AMS) one will need to think about possible treatable causes of changes in cognition before anything else. In our case, Mom is at risk for confusion and disorientation whenever she is sick with another condition like urinary track infection, bronchitis, even severe seasonal allergy. And this all means that she is at risk of falls and a host of other age-related problems both accidental and medical. These must be avoided to keep her quality of life and independence.
Dementia a growing problem as baby boomers grow old
I was approached by the Australian Broadcasting Company (ABC) in February 2018 who were interested in the clocks I have published over the years. The ABC somehow found my website and wanted my input on the clocks drawn by dementia patients. The ABC in Australia has a program called “Ask the Doctor” that airs weekly. The clock will be presented as part of the overall change in cognitive functioning when patients slowly become demented. The upcoming program is focused on “Living with Dementia” and will feature a clock that I published offering web site viewers an example of the changes in cognitive functioning when dementia takes hold. I hope to post a link to the program once it is broadcast.
The incidence of dementia is growing dramatically as those individuals born in 1950’s through the mid 1960’s become older. Because of this the medical establishment will soon be asked to modify the standard of care for this growing number of people in need. The assessment of these patients will be tenuous due to volume and lack of clinicians trained in working with geriatric cases. Like never before older American’s and those around the world will begin to show the age-related changes in gait pattern, balance, strength, memory, and problem solving that place them in direct harm for age-related changes in functional capacity. Some will require the services of a neuropsychologist who are on stand-by to provide assessments of patient memory, attention, and other cognitive functions like problem solving, judgment and reasoning that most of us take for granted. I have published clock drawings of some of these patients when of interest. Often they may seem sensational or impossible to believe. When you examine clock-after-clock one can see changes in problem solving and motor skill associated with the demands of the task and can make significant assumptions once the clock is scored. I learned about the clock drawing from Dr. Edith Kaplan in 1984-1986 while a student at Boston City Hospital and V.A. Healthcare in Boston. More importantly, these same problem solving tasks are likely to interfere with individual functional tasks needed by the patient to safely live his or her life. IADL’s are those functional skills such as cooking, cleaning, and making meals that are both automatic and often overlooked.
There are specialists everywhere who are charged with evaluating older patients and determining what is the best course of action for keeping them safe. Falls are a huge problem for older patients everywhere. Of 80 patients in our hospital, I would guess 30-40 percent are admitted secondary to mechanical falls. I will admit my mother has fallen 4 times in 3 years but so far has not bumped her head. That said, falls are a significant risk factor for dementia because an older brain will not tolerate repeated bumps and does not fully recover from falls. There are many people brought to hospital after a fall because of hip fracture or shoulder fracture who are not fully assessed for concussion or worse traumatic brain injury. The first question is always “did you lose consciousness?” and more often than not the patient was not rendered unconscious by the fall but may still have bona-fide neurocognitive changes in functioning.
Using the clock as a cognitive assessment tool – Growing interest around the world
The clocks below are those chosen by the producers at the Australian Broadcasting Company for a show called “Ask the Doctor”. I am told the show may be downloaded in the iTunes library for free or very low-cost. I will post a link when the show is broadcast so check back here if interested. You see the clocks below and may ask yourself “what happened here or why is this so hard for some people?” I had one email last year who asked whether the clock had been drawn by a person suffering form blindness as a reason for its idiosyncratic presentation.
No. In fact, those who are blind are often better at these tasks relying on internal conceptualization and approximate visual spatial configuration. I often say if I blindfolded you I would still expect a successful clock drawing.
When patient slowly loses cognitive function as in those afflicted with dementia their appreciation of performance is often lost and the appreciation for the complexity of the task may become minimized e.g. “I am not an artist”. While drawing the clock many do not self-monitor and do not notice the error pattern until it is all done. Some say “that does not look right..?” while others explain the results because “they are not artists” or the task is too simple for them. The clocks drawn to the left are those that will be discussed in the upcoming Australian Broadcast Company program “Ask the Doctor”
Clock of the week September 1, 2017
Sefton, M. (2015) Words to live by. Blog Post: https://msefton.wordpress.com/2014/12/28/words-to-live-by-trimble/ taken March 2, 2018
WESTBOROUGH, MA February 20, 2018 Lyme disease is a disabling condition that comes from a tick bite. Most people are not aware that they have been bitten by a tick at some point in their recent past. The symptoms may not be present until weeks or months after being bitten. Some patients complain of headaches, poor concentration, memory loss, weakness, joint pain and swelling, mood swings. “Lyme disease is predominately a disease of the white matter, while Alzheimer’s is predominately a disease of the gray matter. Memory association occurs in the white matter, while memory is stored in the gray matter. White matter dysfunction is a difficulty with slowness of recall, and incorrect associations” according Robert Ransfield, M.D. In contrast, gray matter dysfunction is a loss of the information which has previously been stored.It can become quite disabling if not diagnosed early. Massachusetts is among 14 states in the United States that have a high number of cases of Lyme annually. The states with the highest incidence of Lyme are predominantly in the northeast according to published data. For many suffering with symptoms of Lyme who struggle to figure out what is wrong with them. The test for Lyme has a high degree of false negative findings. This means over 50 percent of patients are found not to have Lyme when in fact they may have the disease. A statistician would say it lacks specificity and may not be valid in terms of the content it seeks to assess.
Why is this so misunderstood. Some may patients are told they do not have Lyme. While this may be a relief to some, many people tell me they feel confused and misunderstood after going through the examination for Lyme. Testing for Lyme disease is done by taking a sample of blood. They test is becoming more accurate and physicians are generally updating their examination of Lyme with a more expensive and accurate test. Patients need to advocate for themselves and push for the two blood tests. There is currently no C-T scan or MRI to demonstrate the organic signs of Lyme.
“When your body is invaded by the Lyme spirochetes, your immune system makes antibodies to fight the infection. Tests that measure antibody levels are indirect tests. They measure the body’s immune response to infection rather than the actual presence of bacteria.” Sticker, 2010
Lyme seems to be a diagnosis of last thought. People suffering from Lyme disease often experiencing frustration and anxiety over their personal health especially when their primary physician cannot seem to figure out what is wrong with them. They go through test after test with no definitive answers until finally Lyme is screened. Unfortunately, the screening test is highly insensitive and fails to accurately identify patients who have Lyme disease. The two-tiered test system misses roughly 54% of patients. (Stricker, R. 2010)
Recently a retired police colleague to me she used to walk 45-60 minutes a day each morning without much stress. Now, after 6 months with Lyme she has daytime fatigue, muscle weakness, joint discomfort, and memory loss. Yet there seems to be nothing she can do to improved her sense of well-being. It can be very frustrating for those seeking a treatment plan. I know my colleague is frustrated as she is a hiking, kayaking aficionado who loves the great outdoors of Maine.
Bransfield, R. Lyme Disease and Cognitive Functioning. http://www.mentalhealthandillness.com/Articles/LymeDiseaseAndCognitiveImpairments.htm Taken 2-28-2018.
Stricker, R. and Johnson, L., Lyme disease diagnosis and treatment: Lessons from the AIDS epidemic. Minerva Med. 2010; 101: 419-25.)