Clock of the Week – May 10, 2018

Westborough, MA May 10, 2018  Clock of the week for May 10, 2018.  Here is an interesting clock drawn by a 79-year old right handed male. He is a nursing home resident who is suffering with the effects of dementia.  This clock is interesting because the subject was working quickly and until he reached the number placement.  This is a good clock overall but fails appreciably in the self-monitoring needed for success.
He had been both efficient and spatially accurate.  Ultimately his performance was negatively effected by the problem solving element of the three-step command required for success.
Dio ClockScan
Clock drawing by 79-year old male with dementia.
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Certified Brain Injury Specialist

FOR IMMEDIATE RELEASE – RESCHEDULED
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 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 $525.00 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.
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 Beth Pusey at the Brain Injury Association of Massachusetts at 508-475-0032 for more. Class size will be limited. Additional details about the Academy of Brain Injury Specialists is at https://www.biausa.org/professionals/acbis

Mitigating the impact

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“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

Living with Dementia

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Clock drawing of 78-year old male with advanced dementia
WESTBOROUGH, MA February 23, 2018 Dementia is an affliction that slowly robs patients of their capacity to remember new information. Meanwhile their personal history remains readily available to them. That is why so many are able to share stories sometimes over and over. The cost of living with dementia for those so diagnosed is not a singular phenomena.  It effects the entire family and the wider community in which the patient lives. For many living with dementia is a lonely experience with sometimes  overwhelming sadness seeing a loved one slowly transform into child-like dependency.  Caregivers are at high risk for burn out when they care for a loved one day-after-day.  For many living with a person who has dementia can be an unforgettable challenge that often evokes guilt, resentment and despair.
There are many myths associated dementia that are worth pointing out.  First, old age and dementia are not synonymous.  Patients always say to me “what do you expect I am 82 years old” when I first begin the assessment process.  Research according to the APA, has shown in the right environment memory should not fail solely on the basis of age.
Part of this post was first publish nearly 3 years ago in 2015 and remains a timely addition to the literature on dementia, its assessment and impact on quality of life for those involved.  I have made some changes to the post from 2-1-2016 to update it and introduce another post that will be published shortly about dementia.  Pleased stay tuned to this blog and learn all about the affliction of dementia and more on the use of clocks for the assessment of cognitive changes.  I have added a person story that is compelling and has to do with this topic.  Thanks – I hope you like the upcoming posts.

“For many living with a person who has dementia can be an unforgettable challenge that evokes guilt, resentment and despair.” Michael Sefton 2018

The assessment of dementia is often stressful and the diagnosis is difficult to make.  The stress comes from the rare times that psychologist must give “bad news” to families of patients suffering with changes in their mental faculties. Unlike our physician brethren, psychologists rarely  have to give family members bad news or news that reflects a change in life expectancy.  One might expect this as normal from a physician who specializes in cancer or tumor treatment.  But in general, our discipline is not called upon to provide such subjective prognostic diagnoses very often. Dementia is one of those conditions primarily diagnosed by neuropsychological testing that has obvious impact on the life expectancy and the overall quality of life of those afflicted with it.
This clock above was drawn by a 78-year old man who was referred for outpatient neuropsychological assessment to determine the extent of change in dementia from his initial testing 24 months earlier.  You can learn quite a bit from the drawings of people thought to be suffering from dementia.  In this case, the patient was friendly and compliant.  He put forth a good effort and worked with diligence and earnest.  The task is the same for all cases – “draw a clock, put all the numbers on it and set the hands for 11:10.”
This clock effectively demonstrated the decline in the gentleman’s neurocognition.  It was poorly organized.  There was some neglect of the left hemi-space.  He had no self-monitoring or internal executive capacity to guide his construction.  He seemed surprised when I pointed out his work.  The numbers were not correctly placed. The slash marks were meant as minute marks and not number 11.  However, there were repeated numerals and reversals.  No hands were placed.
I learned about cognitive testing while an intern at Boston City Hospital – now B.U. Medical Center in the South End.  I loved my time there.  I wrote a blog about clocks and the utility of the clock drawing about a year ago called “All this from a Clock”.  If interested in the clock drawing take a look at the link I posted.  There is growing from clinicians around the world about dementia and using the clock as a screening tool.  The ABC in Australia recently chose one of the clocks recently published to feature on an upcoming program on dementia it is not clear when the program will be broadcast in Australia but I will post a link to the show once it is ready for broadcast. Stay tuned to http://www.concussionassessment.wordpress.com and Michael Sefton for further details.

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 

Clock of the week: February 16, 2018

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

Despair and Self-destruction in elite athletes

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

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

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

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

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