Post-Concussion Syndrome: Building Resilience with Biofeedback

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Young woman having peak performance training for cognitive changes from serious TBI taken in 2018.
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.
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“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

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Resilience needed after Concussion

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
APA. Road to resilience. http://www.apa.org/helpcenter/road-resilience.aspx Taken 4-30-18.

TBI, concussion and headaches in females

headache-2-mbhi5p4ess5v9x1kbfpafgnr6lyhkdbydmq67h3pno.jpgWESTBOROUGH, 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

Symptom presentation
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
Levine, H. (2016) The Truth about concussions and women. http://www.health.com/headaches-and-migraines/women-concussions
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),
889-891.
Blume, H. (2016). Headaches after Concussion. American Migraine Foundation.  https://americanmigrainefoundation.org/understanding-migraine/headaches-after-concussion/ Taken February 28, 2018

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 

Neurofeedback: Entrainment options for recovery from concussion

WESTBOROUGH, MA February 28, 2018 There is a growing consensus among providers that a multidisciplinary approach to concussion management is necessary.  Along with heart rate variability neurofeedback helps to reset the sympathetic-parasympathetic mismatch using proven entrainment techniques such as increasing amplitude of sensory motor rhythm (SMR) that has been shown to quiet the body.  I use both neurofeedback and traditional physiologic biofeedback modalities with all kinds of physical conditions from chronic pain to traumatic brain injury with good results. The sensor is placed at the central z-spot or Cz on the 10-20 EEG placement map. A combination of paced breathing, relaxation, and EEG SMR entrainment help bring the body into a more restful coherence and decrease the body’s physical reactivity that causes tension and a host of lingering physical issues.  The emotional and financial cost of these issues is enormous over time. We use the ProComp + and Thought Technology software in our work.

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A Brief Review and Clinical Application of Heart Rate Variability Biofeedback in Sports, Exercise, and Rehabilitation Medicine. Gabriell E. Prinsloo, H.G. Laurie Rauch & Wayne E. Derman  The Physician and Sportsmedicine Vol. 42 , Iss. 2, 2014

Biofeedback: Teaching the body to return to a proper homeostasis

WESTBOROUGH, MA  November 8, 2017  There are several types of biofeedback that are useful when recovering from a concussion.  The first may help with the stress response that sometimes goes into overdrive after TBI or concussion. This involves becoming familiar with the fight-flight mechanism and its useful purpose as an early warning system.  Throughout time the autonomic nervous system (ANS) allowed animals and man to be ready whenever threats to personal safety were present. When we are able to out fox the threat then our sympathetic cascade may slowly return to normal as the parasympathetic breaking mechanism exerts its balancing influence.
There is no way to avoid a stressful life it seems.  Some people are better than others at reducing the impact of stress.  Excercise, healthy eating, regular sleep, and mindfulness reduce the impact of the stress and tension we all experience in our lives.   Michael Sefton 2017
The automatic process of sympathetic arousal ramps us up as if to say “bring it on” – activating us to fight or fly the coop.  The problem all too often is an insidious elevation of normal baseline physiological values that create a sympathetic-parasympathetic mismatch. This results from over active adrenergic fibers largely activated by hormones such a cortisol looking the system.  Over time this leads to heart disease, hypertension, and a host of inflammatory diseases and may prolong those needessly.

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Shown here is the HRV biofeedback screen used for paced breathing and coherence training seen here at Whittier Rehabilitation Hospital

The primary goal of all modalities of biofeedback including psychophysiologic and neurofeedback is to restore the body to its “normal” state.  The process promotes mindfulness and paced breathing to gradually lower respiratory drive, reduce heart rate and blood pressure, and enhance other abnormal physiological readings of skin conductance, finger temperature, and electromyography.  It takes practice and understanding of its value. Not everyone has elevations in each these bodily measures. The specifics of abnormal findings are discussed as part of the treatment plan with the doctor or clinician.
There is a well established link between heart rate and the pace of breathing. Autonomic regulation is the role of the brain stem that maintains the diurnal pattern of arousal for wakeful activity and sleep hygiene.  The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.  The ANS functions as the brain and body’s alarm system signaling the need for fight-flight activation.  When this system is damaged due to traumatic brain injury the recovering subject can have wild swings of autonomic arousal such as elevated heart rate – patients sometimes chug along at 140-160 while autonomic storming.   Paroxysmal changes in blood pressure may pose significant risk, respiratory rate may become tachypnic, patients frequent are febrile and may become excessively sweaty  as a consequence of autonomic dysfunction.
“Autonomic dysfunction must be carefully managed in patients recovering from TBI. This is not conceptually novel although its application to health conditions continues to broaden. Biofeedback may be a useful modality for migraine headaches, anxiety, pain management, concussion, and stress. I have used a combination of physiologic and neurofeedback for patients with failure to thrive, depression, post-concussion syndrome, and severe traumatic brain injury” 2014).  In 2006 I was invited to London, UK to present the findings of a case study with a high school boy who had sustained a severe TBI and was in a minimally conscious state.  The results were remarkable and not entirely the result of the neurofeedback protocol I used with him.  Our team did a good job keeping him moving and gradually he became more functional and regained his independence. It was a fun trip I was able to take with colleague Paul Liquori, MD, medical director at Whittier Rehabilitation Hospital in Bradford.
Relaxation and mindfulness have existed for over 60 years bringing together conscious conscious effort to control bodily system that were once thought to be automatic.  Sefton, 2016

Sefton, M (2014) Blog post: https://concussionassessment.wordpress.com/consultation/topics-in-neuropsychology/tbi/autonomic-dysfunction/ Taken 11-13-17.
Sefton, M (2016) Blog post: https://concussionassessment.wordpress.com/2016/04/01/biofeedback-for-post-concussion-syndrome/ Taken 11-13-17

Brain, Concussion and Stress: Health effects and post-concussion syndrome

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Amygdala highlighted is over active when stress exists and raises the body’s threat level as shown in this BBC graphic
WESTBOROUGH, MA January 15, 2107 The human cost of stress has been well-studied and the effects of stress are a well-known cause of cardiovascular illness including heart attack and stoke.  It is now known that the brain plays a big role in all of this. The human stress response elevates heart functioning – especially blood pressure and normal heart rhythms in unhealthy ways.  Stress activates the amygdala in the brain by tricking it – as if some great threat exists.  People believe that the body’s autonomic nervous system can be thrown off after a concussion slowly becoming irregular resulting from an abnormal stress response. There is a deactivation of inhibitory neurons in the brain resulting in greater sympathetic activity. This involves progressive relaxation and guided imagery that can slowly lower the tension felt in the body.
Symptoms of concussion are known to elevate the sympathetic nervous system over time. Known as the fight-flight mechanism, stress activates the mechanism in the brain that prepares us each for battle.  This level of tension can only last for so long without needing a break. That is where the parasympathetic system comes in putting the brakes on the body allowing it to rest. The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.
Study: Overactive system of emotional drive
Many believe that an overactive system in the brain results in the elevation of the autonomic nervous system. A Harvard study followed 300 patients for several years and found that those with an overactive amygdala were more likely to have cardiovascular disease and be at greater risk for stroke and heart attack. The amygdala is a tiny organ responsible for the emotions such as fear or pleasure.  It also plays a role in the systemic inflammatory response that may prolong the symptoms associated with concussion. “Heart experts said at-risk patients should be helped to manage stress” according to a BBC publication taken from Lancet.
The protocol I use involves paced breathing and heart rate entrainment as a way of putting the brakes on stress. But it takes time and American’s want instant fixes. Mindfulness requires self-monitoring and personal reflection.  If more people understood the health cost of stress and were able to identify high stress lifestyles then they might make behavioral changes that can lower the risk for cardiovascular disease later on.

The protocol quickly assists in helping patients find a balance or resonance between sympathetic and parasympathetic systems in the body using controlled, paced, breathing and prototypic progressive relaxation” according to Michael Sefton, Ph.D., Director of Psychological and Neuropsychological services at Whittier Rehabilitation Hospital in Westborough, MA.

In several blog posts I have illustrated the potential negative health effects of high stress and physical functioning for which I am providing biofeedback at Whittier Rehabilitation Hospital in Massachusetts. This process helps put the brakes on the stress response and quiet the body.  The effects of concussion slowly elevate autonomic response adding to tension and physical malfunctioning. The biofeedback protocol helps lower the human cost of stress and the body’s inflammatory response and may lower feelings of tension and anxiety.  In doing so a rise in physical and emotional well-being may be expected.

BBC report http://www.bbc.com/news/health-38584975, taken January 14, 2017
WebMD post,  http://www.webmd.com/brain/news/20170111/stress-ball-in-your-brain-may-be-key-to-heart-risks#2, taken January 14, 2017
Sefton, M. (2016) Coincident stress may contribute to post concussion symptoms, blog post, https://concussionassessment.wordpress.com/2016/09/26/coincident-stress-may-contribute-to-pcs/, taken January 14, 2017