Certified Brain Injury Specialist

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
downloadCertified 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.
download 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 msefton@whittierhealth.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

Clock of the Week: 8-15-18

Clock of the Week 8-15-18Scan

Westborough, MA August 15, 2018 The clock of the week is submitted by a Speech Language Pathologist working with patients here at Whittier Rehabilitation Hospital.  The patient who constructed this weeks prize winner is a 64-year old male with bronchiolitis obliterans, a lung disease characterized by fixed airway obstruction. Inflammation and scarring occur in the airways of the lung, resulting in severe shortness of breath and dry cough according to Wikipedia (2018). Just looking at the clock it may be safe to say that there is significant cognitive decline and/or altered mental status depicted in the lack of appreciation for the task demand.  It is not clear to what extent his lung disease may have left him vulnerable to the effects of hypoxia – the lack of oxygen in the blood.  Depending upon how long the brain goes with depleted levels of oxygen and how low the oxygen saturation drops can have a great deal of impact on anoxic brain injury.
Anoxia has a profound impact on cognition and functional independence.  I want to thank the astute speech language pathologist for obtaining this clock drawing in the course of her patient assessment. I am curious as to what treatment options and methods she may be using with this interesting patient. I would welcome other clock submissions.

Clock of the Week: Alzheimer’s

84-Year old female with Alzheimer’s Dementia
WESTBOROUGH, MA August 2, 2018  Here is the clock of the week. It is drawn by Helen, an 84-year old right handed woman suffering from the affects of Dementia of the Alzheimer’s Type – DAT.  I have published weekly or monthly clocks on these pages for the past 3 years.  Recently I have added links to the video taken in our Neuropsychology service at Whittier Rehabilitation Hospital.
All HIPPA compliance rules are followed in terms of patient confidentiality.  I encourage readers to send in clocks for me to publish.  Helen had significant difficulty constructing this clock.  Unlike some of the recent clocks I have published this clock was normal size.  Helen had a resting tremor that closely resembled the movement pattern seen in patient’s with Parkinson’s Disease.

Clock of the Week: July 23, 2018

WESTBOROUGH, MA July 24, 2018 Some people believe that the simple task of drawing a clock is like a window into the brain (Eknoyan,et al. (2012). I have posted reviews of clock drawing over several years.  Edith Kaplan, Ph.D. is credited with teaching me the importance of these neurocognitive protocols in 1985 while I was training at Boston City Hospital. Dr Kaplan saw the clock drawing as a parietal lobe test (Kaplan, 1988) but many debate that focal attribution of the clock drawing may under represent the clinical utility of this perfunctory task.  Tranel and collegues (2008) found that the clock drawing has several potential neuropsychological correlates represent the neuroanatomic underpinnings of the individual clocks scored and rated in their research.
“Documenting the type of clock-drawing errors can contribute to the clinical evaluation of patients with suspected neuropsychiatric disorders and syndromes”  Eknoyan, et al.
Watch the video below and enjoy a complete assessment of a single patient undergoing neuropsychological assessment.  Post your thoughts and let me know what your observations say to the underpinnings of cognition we are seeing.  This patient was cooperative and friendly.  He is only 82 years of age and was undergoing treatment for a recent mechanical fall.
Michael Sefton
Eknoyan, D. et al. (2012) Journal of Neuropsychiatry Clin Neuroscience, 24:3 Summer.

Kaplan, E. (1988) The Process Approach. In Boll T, Bryant, BK, editors. Clinical Neuropsychology and Brain Function. Washington DC, APA.

Tranel, D, et al. (2008) Does the Clock Drawing Test have Focal Neuroanatomical Correlates? Neuropsychology, 22(5) 553-562.

Hearing Loss and quality of life

Abstract Medical And Health BackgroundsWESTBOROUGH, MA July 16, 2018  I have recently been taking care of a couple of men who have experienced significant hearing loss as they aged. The loss of any sensory system contributes to a significant change in independence and satisfaction in life.  In this systematic review and meta-analysis of 36 epidemiologic studies and 20 264 unique participants, age-related hearing loss was significantly associated with decline in all main cognitive domains and with increased risk for cognitive impairment and incident dementia. Increased risks for Alzheimer disease and vascular dementia were not statistically significant.
“Hearing loss may have a profoundly detrimental effect on older people’s physical and mental well-being, and even health care resources,” says senior study investigator and Johns Hopkins otologist and epidemiologist Frank Lin, M.D., Ph.D.
“Our results underscore why hearing loss should not be considered an inconsequential part of aging, but an important issue for public health,” says Lin, an assistant professor at the Johns Hopkins University School of Medicine and the university’s Bloomberg School of Public Health. According to Lin, as many as 27 million Americans over age 50, including two-thirds of men and women aged 70 years and older, suffer from some form of hearing loss.
“Dr Frank Lin says social isolation resulting from hearing loss may explain the physical and mental declines – as well as the cognitive deficits – that afflict older adults. This, in turn, may lead to more illness and hospitalization, he says. His team already has further research under way to see if treating hearing loss with counseling and hearing aids can reduce people’s risk of cognitive decline and dementia”.
Tinnitus is sometimes associated with hearing loss. Tinnitus is also known as ringing in the ears and is described by many as a constant high pitched sound or whistling noise.  It is sometimes attributed to “trauma” from years of employment or working in an industry that required no hearing protection.
I have begun using a new protocol in my biofeedback session for those most bothered by tinnitus.  Neurofeedback is a non- invasive neuromodulation technique which records a subject’s neuronal activity, extracts relevant aspects of brain processes by means of real time signal processing and returns feedback to the subject as visual or auditory stimuli. The aim of neurofeedback is to change behavioral traits or medical conditions associated with altered neural activity as demonstrated for chronic tinnitus.”
“Subjective tinnitus has been described as the constant perception of an auditory sensation that does not correlate to any external acoustic stimulus (Stouffer and Tyler, 1990). It can be perceived as either pitch or noise-like sound and its perception may be unilateral, bilateral or spread out in the whole head (De Ridder et al., 2014b).”

Loughrey DG, Kelly ME, Kelley GA, Brennan S, Lawlor BA. Association of Age-Related Hearing Loss With Cognitive Function, Cognitive Impairment, and Dementia A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2018;144(2):115–126. doi:10.1001/jamaoto.2017.2513

Güntensperger D, Thüring C, Meyer M, Neff P and Kleinjung T (2017) Neurofeedback for Tinnitus Treatment – Review and Current Concepts. Front. Aging Neurosci. 9:386. doi: 10.3389/fnagi.2017.00386

De Ridder, D., Fransen, H., Francois, O., Sunaert, S., Kovacs, S., and van de Heyning, P. (2006). Amygdalohippocampal involvement in tinnitus and auditory memory. Acta Otolaryngol. 126, 50–53. doi: 10.1080/03655230600895580

Stouffer, J. L., and Tyler, R. S. (1990). Characterization of tinnitus by tinnitus patients. J. Speech Hear. Disord. 55, 439–453. doi: 10.1044/jshd.55 03.439

Visual Motor Skill and Dementia

WESTBOROUGH, MA July 2, 2018 Simple tasks become more difficult and often are impossible.  Tasks like copying a simple design or making simple line drawings become cognitively onerous


You can see from the drawing above that the 90 year old woman had difficulty initiating and executing the task.  “Draw-a-clock” seems simple enough.  I have been using this technique for over 20 years with very interesting findings.  The
The task relies on existing internal template of clock along with enduring problem solving and self-monitoring. The second drawing was initiated at her own choosing.  When given the choice she asked to draw the bicycle. That drawing is shown below.  Both posts are tiny in size – only 2-3 cm and reveal just how lost the self-monitoring component of cognition has become for this interesting patient.
The most interesting piece of this illustration is the diamond shape.  We had just stopped working on drawing shapes from the Mattis Dementia Rating Scale.  The final shape is a diamond.  Shortly afterward I gave her the standard instructions to draw a clock.  I have published many clocks in these pages to illustrate the complexity of the task.  She initiated the task by constructing another diamond and began putting the numbers in the contour of the diamond – rather than the typical circular drawing.  This is the first time I ever had the clock drawn in a diamond and this is an example of a contaminated response whereas one task intrudes into the next task as I just described.  These types of errors are common in patients with dementia.  I have attached the link to the actual video taken of the task as she created the clock.  Here is the link to the video taken of this clock drawing.
90 DATBicycleScan

Bicycle drawn by same 90 year old patient


Update: Michael Schumacher now living with severe TBI – 4 years on

Westborough, MA June 28, 2018 Michael Schumacher is a former Formula 1 race car driver and champion.  He was severely injuryed in a skiing accident in French Alps near Switzerland 4 years ago in late 2013.  He was treated at a trauma center in Grenoble, France.  His wife and family were on a holiday.  They are devastated by the loss of Michael who is now is a minimally responsive condition that was once called near coma state.  He continues to receive daily therapies including physical and occupational therapy.  Information about Michael is released infrequently because the family is very private.  His care has cost over 20 million Euros since the accident.
Michael Schumacher and wife Corinna in 2013            AFP photo
F1 fans are also still keeping Schumacher close in their thoughts – with the official Ferrari supporters club unfurling a massive 30-metre long banner at pre-season testing in Spain ahead of the 2018 season.
Little is known about the day-to-day condition of this once great Formula 1 athlete except he is no longer able to function at the same level as he once did as a result of the tragic accident in late 2013.  His family stands with him and continues to look for treatment options.  There is some thought to move Michael to Texas in the US where he owns a ranch.  There are recovery services that may be offered to him that may afford Schumacher some improvement in his functioning and provide more hope for his loving and supportive family. Both his son and daughter have gone on to their adult lives and are successful adult athletes.

Gina-Marie Schumacher Photo Splash News


On Father’s Day 2017, his son Mick Schumacher reported “My role model is my dad. Simply because he is the best – my idol.” Meanwhile, his 20-year old daughter Gina-Marie has gone on to a career in the equestrian sport. At the Audi Generation Awards she said “I would like to thank the jury, but especially my parents for the love they give me every day,” she said, after revealing she used to go karting with her legendary father but chose a different career path because “horses are better”.

Clock of the Week – June 21, 2018

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?

Rt Hemisphere_May18Scan

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.