Return to school: Psychologists also working in the trenches after concussion

CONCUSSION-SCHOOL LIAISON 2017
WESTBOROUGH, MA May 1, 2017 The return to school following a brain injury should be carefully planned.  School nurses tend to be the point person for parents’ whose children are coming back to school after concussion.  But let’s not forget the school psychologist.  My wife, Mindy Sefton, Psy.D., is trained in concussion management and has crafted some of the best return-to-learn plans I have ever seen.  She works closely with the nurse and classroom teachers to be sure no student be placed at risk for failure. At her middle school there is a protocol for re-entry that is specific and tailored for individual students.
Students with acute concussion and those suffering with post concussion syndrome require assistance at school or risk falling behind their peers.  Some parents are not aware but it is true that when concussion sidelines and athlete he or she is highly vulnerable for school-related changes as well.  Schools or educational teams who are interested in offering a comprehensive concussion education program are encouraged to contact CAMP or Dr. Sefton directly for consultation. Student athletes often require support in school while recovering from concussion. Support protocols like reduced work, extra time for tests, and deferred projects are just three commonly prescribed accommodations.
 I am happy to help public schools with their protocols.  They are critically important for student success.  Individual programs can be integrated slowly on a team by team basis depending upon learning style, specific sport and unique student needs.  Dr. Sefton has specialized training in pediatric brain injury, concussion and neuropsychological assessment and is a member of the Academy of Brain Injury Specialists.  Training for coaches and trainers is available and recommended to identify updated return-to-play protocols and current standards of care.  Both web-based and individualized ImPACT testing is available for preseason and after injury assessment.  Return-to-play consultation is available with trainers and team physicians 24/7 at 508-579-0417 and email msefton@qmail.qcc.edu

School districts interested in using CAMP for supporting athletes injured while playing sports can contact Dr. Sefton at 508-579-0417.  Parents and physicians may call Dr. Sefton at any time to discuss individual injuries and school and sports  re-entry after injury. Post injury testing and neuropsychological consultation is also available. 

HeadacheReturn-to-Learn Care Plan
Some students who are injured playing in school sports may require a return to school care plan.  Dr. Sefton will consult with student, parents, and school personnel to assist with short-term accommodations in school that can assure for continued success in academic domains.  Not all children require changes in their educational programs but careful consideration of the child’s school functioning is essential.
Classroom teachers should be advised to monitor the student athlete for the following signs:
  • Increased problems paying attention/concentrating
  • Increased problems remembering/learning new information
  • Longer time required to complete tasks
  • Increase in physical symptoms (e.g., headache, fatigue) during schoolwork
  • Greater irritability, less tolerance for stressors
Advertisements

What happens to the brain when concussed? See for yourself in CDC video just published

WESTBOROUGH, MA April 21, 2017  There has been a great deal of research published recently about the cumulative impact of concussion.  Every athlete who experiences a concussion has a unique trajectory toward recovery.  It is well-known that athlete’s who experience  a second or third concussion may be at risk for long-term cognitive symptoms unless they rest until the symptoms are fully resolved. It is now expected that each recovery is different and should be tailored for the presenting symptom profile and the athlete’s medical history. A combination of rest and controlled exertion seems to work best for recovery.  Balance and vestibular changes from concussion require physical therapy in the days after injury. We offer these services at Whittier Rehabilitation Hospital. In cases of second or third concussion the recovery can be very different and often prolonged.
There are dozens of You Tube videos that I have posted in these pages illustrating the brain as it becomes concussed. On my first website nearly 20 years ago I purchased a .gif program to illustrate the movement of the brain during a concussion – like the one below.  It cost me nearly $100 to download and post on my website.  Now they are available free of cost and easily posted to social media.
A concussion is a traumatic brain injury resulting from force causing energy to pass through the brain resulting in the brain shaking within the skull.  A study published in January 2016 in the Journal of Pediatrics suggests that preadolescent boys are at higher risk of concussion when playing on varsity ice hockey teams.  The study at Hasbro Children’s Hospital in Providence, RI also suggested that girls playing ice hockey who are heavier may be at greater risk for concussion.  On average, the preadolescent boys in the study took 54 days to become symptom free.
Here is a link to another very useful video produced by a Canadian physician Dr. Mike Evans. I often have families watch this 10 minute video before initiating our conversation.  The point is that the brain is seriously impacted by energy pulsating through the skull from whatever cause.  I have seen several snow boarders this winter. Spring sports usually see an uptick of concussions in lacrosse and girl’s softball.  Concussion can be expected to effect all cognitive functioning including concentration, speed of mental processing, problem solving, memory, and behavior.

Chronic Stress – The unbridled malignancy that effects us all

WESTBOROUGH, MA January 31, 2017 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.  These behaviors are being taught to children who experience stress just like their parents in many schools. Meanwhile, concussion and more serious brain injuries result in changes in the autonomic nervous system that are sometimes life threatening.  The behavioral response of these afflictions include marked restlessness, anxiety, changes in sleep hygiene, abnormal pain response, and pervasive tension.
In cases of severe brain injury one might see autonomic storming as described in a prior blog. Autonomic storming results from trauma to regions of the brain that control primitive bodily functions like respiration, heart rate, and emotional regulation. This includes profuse sweating, elevated heart rate, rapid changes in body temperature and motor restlessness. These functions are comprised in the autonomic nervous system and are known as the fight-flight mechanism.  The sympathetic nervous system elevates blood pressure, respiratory drive, and gets us ready to fight or run.  Meanwhile, the parasympathetic system puts the brakes on these functions allowing the body to return to its normal resting rate.

“Eventually, chronic stress could be treated as an important risk factor for cardiovascular disease, which is routinely screened for and effectively managed like other major cardiovascular disease risk factors.” Ahmed Tawakol, Harvard Medical School

Ostensibly, stress has the capacity to change this normal resting heart rate and slowly raise our levels making it difficult to truly relax. In the long term, external stress can change our heart functioning including hypertension and cardiac arrhythmia and put us at risk for cardiovascular illness including heart attack and stroke. Lifestyle changes are necessary to avoid long-term health problems from stress. Mindfulness includes deep, regular breathing, guided imagery, and progressive relaxation. It is being introduced in some public schools so that it may become part of the coping mechanisms used by kids when stress sets them off – as it undeniably will do.

Sefton, M. (2015). Heart rate variability: Biofeedback options for post-concussion syndrome,  https://concussionassessment.wordpress.com/2015/08/03/heart-rate-variability-biofeedback-options-for-post-concussion-syndrome/
WebMD (2017) Brain ‘stress ball’ may be key to heart risks. http://www.webmd.com/brain/news/20170111/stress-ball-in-your-brain-may-be-key-to-heart-risks#2, taken January 14, 2017

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

_93357606_c0036850-amygdala_in_the_brain_artwork-spl
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

What is post-concussion syndrome?

“The syndrome consists of musculoskeletal pain, headaches, sensitivity to sound and light, sleep disturbance, changes in memory and balance, anxiety and depression. The emotional impact of this leaves patients feeling alone and frustrated” Sefton, 2016

The likelihood of getting a concussion while playing sports is between 10-30 percent of high school and college athletes.  As many as 29 percent of these injured players may go on to experience post-concussion syndrome. It is important for team physicians, trainers, and primary care doctors to understand and treat people with lingering symptoms of concussion.

brain_pictureIn a blog post published in September it is noted that concussion is an invisible injury and recovery takes time – generally 2-3 weeks. The consequence to individual athletes or others recovering from car crash, falls, and any brain trauma can be debilitating and effect a few bodily systems. The emotional stress of lingering symptoms should not be underestimated. Whether it is a professional, elite student athlete or a salesman injured in a car crash there is an experience of stigma associated with the invisible injury of concussion. The emotional impact of this marginalizes patients often leaving them feeling alone and frustrated.

A multidisciplinary approach is best that allows for restoration of physical activity and acknowledgement of both physical and emotional symptoms. Pain management is a useful intervention including aquatics.  My approach to treatment includes biofeedback, education and psychotherapy.  This helps reduce the autonomic effects of acute stress and the inflammatory impact on the fight/flight response – including blood pressure, sleep, and rate of breathing.

Sefton, M. What is PCS: and why do I care? Blog post: https://concussionassessment.wordpress.com/2016/09/30/what-is-pcs-and-why-do-i-care/. Taken October 1, 2016.

Second Impact Syndrome: rare but often fatal

_91455480_12500219
25-year old Boxer Mike Towell  (BBC photo)
WESTBOROUGH, MA October 8, 2016 Second impact syndrome is a rare but generally catastrophic injury that results from a second blow to the head that immediately follows a concussive injury – often undiagnosed or an injury that was previously diagnosed but not fully healed. The second injury to an already damaged brain results in catastrophic swelling within the brain often incompatible with survival.  Scottish boxer Mike Trowell died of a severe brain injury occurring in a sanctioned boxing match in Glasgow, Scotland on September 29.
Essentially, “second impact syndrome” or SIS results from the brain’s inability to autoregulate cerebral perfusion pressure and swelling as a result of repeated cerebral trauma. This leaves an athlete gravely injured unless immediate neurosurgical intervention can be provided (Bey & Ostick, 2009).  Sadly, even with the best care many patients with SIS succumb to their injuries within a few minutes. Most believe that concussions create a metabolic crisis in the brain that results in a gross change in cerebral efficiency – an inability to match the external cerebral energy demand – especially sporting activity at the elite level.
In general, if the brain fully heals an athlete is at no greater risk of concussion than someone who has never sustained a concussion.  However, when an athlete returns to play before he or she is fully healed they are at high risk for a second or third concussion and at risk for SIS. It is well know that there is a cumulative effect of injury to the brain with repeated trauma. In fact, repeated trauma results in a significant reduction in brain volume that can seriously reduce information processing speed and other neurocognitive functions according to a study in the British Journal of Sports Medicine in 2015. The greater number of fights resulting in more blows to the head has a significant impact on speed of processing. Certainly a well established link between repeated head trauma and dementia, depression, and other signs of neurocognitive decline has been found in U.S. football players.
Boxer fatally injured with second impact that was sustained in a fight in Scotland recently.  Scottish Boxer Mike Towell was critically injured on September 30, 2016 during a fight with Dale Evans in Glasgow, Scotland.  According to the BBC, Towell was knocked to the mat in the first round of a 10 round bout.  He was given a standing 8 count and continued the fight.  Some said he dominated the next two rounds when finally in the fifth round he was again knocked down and the fight was ended.  He was transported to the trauma center in Glasgow ultimately being placed on life support.  He lived 12 hours once the decision had been made to terminate life support.  His partner Chloe Ross reported that Towell had been experiencing headaches in the weeks prior to the fight that were attributed to stress.  Medical authorities may not have allowed Towell to fight had the recent history been known. Towell may have been highly vulnerable to concussion as a result of his boxing history and unique neurocognitive underpinning.  So when he stayed in the fight he unknowingly put himself at risk for lethal injury.
REFERENCES
Bey,T and Ostick, B. Second Impact Syndrome West J Emerg Med. 2009 Feb; 10(1): 6–10 Taken October 1, 2016
Loosemore, M., et al. Boxing injury epidemiology in the Great Britain team: a 5-year surveillance study of medically diagnosed injury incidence and outcome. British Journal of Sports Medicine doi:10.1136/bjsports-2015-094755.

“The last thing you may want…”

“The last thing a person who has been suffering with the effects of a concussion wants is to be told they should go and see a neuropsychologist who will take them all the way back to the beginning – where no one seems willing to go.”  Michael Sefton