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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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.
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Clock drawing by 79-year old male with dementia.

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

Dementia: Clocks gaining interest across the globe

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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.
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Sample clock drawn by dementia patient – primitive demonstrating no planning or problem solving

 

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.
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Clocks chosen for discussion on Australian television program focusing on dementia in 2018
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

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
Name in clock
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?

Construction and Self-monitoring

WESTBOROUGH, MA August 6, 2017 Self-monitoring refers to the capacity to observe one’s own behavior in real time. It is easy to see when someone lacks this important neurocognitive feature. Walk into any middle school and there will be hundreds of boys who act and behave without forethought.  Self-monitoring is a higher-order function that sets us apart from other species – even primates and is thought to mature in the second or third decade of life. It is possible to lose the ability to watch and adjust behavior such as with traumatic brain injury involving frontal lobe structures and in disorders of cognition such as dementia.  How is it possible to lose appreciation for the organization of the task (see drawing on left) and fail to notice one’s errors?
The bicycle task requires a rudimentary capacity to envision the bike and draw it from the image one has in his head.  It requires conceptualization, motor control and visual motor integration for success.  The task is age old – like the clocks frequently featured in these pages. Self-monitoring is a prerequisite for social pragmatics – a fancy term for acting your age. In some cases the failure in self-monitoring results in errors in behavior that can become socially debilitating – especially when the patient demonstrates an indifference to his limitations and does not respond to redirection and feedback.  The task of constructing a bicycle is a screening for higher order deficits.  Like the clock drawing it requires planning, organization, even mechanical awareness.  Muriel Lezak says that regardless of lesion the task requires judgment, organization, conceptual integration, and accurate self-appraisal.  Those with defective self-monitoring often miss important features and omit crucial parts of the bicycle’s mechanism like pedals, chain or both (Lezak, 1995)

 

 

“The capacity to self-monitor and modify one’s behavior is required in an open society or the lack of order would result in people being oblivious to each other and indifferent toward their personal effect on social and interpersonal relationships”    Michael Sefton 2017
In the first bike drawing the patient constructed the bicycle as asked but became confused very quickly.  the two objects extending out from the left and right are wheels that were drawn after I had asked “how does it work?” Interestingly one of the scoring criteria are the correct placement of spokes on the wheels. There are no spokes on the wheels of the second and third drawings. In some cases the concept of perseveration is revealing of decreased self-monitoring.  In a published blog the concept is described.  It is the process of repeating the same response over and over without awareness.

Lezak, M. Neuropsychological Assessment – Third Edition. Oxford Press, 1995.
Sefton, M. (2016) Perseveration, severation, eration, ation, blog post, taken August 8, 2017.

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.