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.

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

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

Delirium: sudden onset often lingering emotional impact

Patients with ICU delirium are less likely to survive and more likely to suffer long-term cognitive damage if they do.  STAT Boston Globe taken 10-17-2016
Try as he might a patient with delirium cannot complete simple tasks according to Sefton.

Clock of the Week – Sept 30

WESTBOROUGH, MA September 30, 2016  The clock of the week is drawn by a 77-year-old male with Parkinson’s Disease.  It is representative of his execution of the internal

Clock of 77-year old male

ized concept of “clock” with the given task of setting the hands to read 10 past 11. Many people discredit the utility of the clock drawing because on the outside it appears to lack psychometric rigor. I disagree and have used the clock drawing for many years as a tool to screen motor control, visual spatial capacity, problem solving, self-monitoring, and other frontal controls.  The particular clock above is not a complete disaster.  As you can see there is a circle.  The next feature illustrated is the presence (or absence) of all the numbers,  In this case it is clear that all 12 numerals are represented on the face of the clock.  Admittedly the numbers fail to appreciate the contour of the circle but they are grossly appropriate.  Finally, the task requires the patient to set the clock so that the time is set for 11:10 (intentionally vague).  The errors produced often provide grist for the diagnostic mill in terms of the types of mistakes, e.g. missing numbers, broken gestalt of circle, numbers crowded to one side of the clock, time set in error.  In the past several months I have published clocks drawn by patients here at Whittier.  Many people have expressed an interest in the clock drawing and I find that everyone is using the clock as a cognitive screening measure.  Here at Whittier our speech pathologists use it with every admission.  I have found it funny when someone says “what another clock?”.  These patients usually check out just fine on the tests we use as a measure of perfunctory neurocognition.

Written language – to dictation

Written Language in PD

Here is a sample of the same patient’s written language .  He is asked to write 2 sentences that are quite easy.  Poor written expression is common in most people who suffer with Parkinson’s because PD is a disease that attacks motor pathways resulting in sometimes wild tremors and poor motor control making them at risk for falls. These sentences do not replect the tremulous motor output often found in the work of patients with PD.  In this case his symptoms are well controlled on his current medication.  He is seen by a neurologist and intenal medicine physician almost daily.  The sentences are: He shouted the warning; and Baseball players are tough.


Perseveration: Often seen in concussion – in short duration before recovery

WESTBOROUGH, MA July 23, 2016 Perseveration results from a change in cognitive status often seen in athletes with concussion. It is most often manifest when an athlete says or does the same thing over and over without realizing it. In some cases the athlete will make an effort to cover for themselves expecting that no one will notice that anything is amiss. Not so fast.  The last one to notice that anything is wrong is the athlete with a concussed brain.  Everyone else notices but not him.  Recently the NFL has made it mandatory for a teammate who suspects that a teammate has sustained a concussion must say something to the coaches or trainer.

In patients with concussion the confusion evaporates quickly generally within minutes to hours.  The video shown here depicts a case of perseveration that is more severe.  It is an older patient who sustained a fall and is quite altered. The video illustrates a case of altered mental status resulting in perseverative drawing in circles.  In general, patients who are older have a slower recovery than younger ones. This video shows the stark lack of self-monitoring as the patient attempts to construct a simple clock.

This video was put together by the Neuropsychology Service at Whittier Rehabilitation Hospital in Westborough, MA USA


July 7 – Clock of the Week

This clock was drawn by a 77-year old male suffering with dementia.  Dementia is defined as a decline in cognitive – mental functioning in memory and activities of daily living

WESTBOROUGH, MA July 7, 2016 The clock drawing is something that I have grown quite fond of using to assess patients who might be impaired in their thinking skills. Here is the clock of the week for early July, 2016. Some patients become suspicious when the neuropsychologist gets involved often saying “What do they think I am crazy?”  No not at all.  But the clock drawing can provide a great deal of important clinical information about their cognitive functioning.  I have written about the clock drawing and other visuospatial functions for a few years now.  As you can see by the clock of the week for July 7th the patient who crafted this clock missed the boat.  I needed to prompt him for everything including placing the numbers around the clock.  The clock is nonthreatening.  Patients sometimes believe that the tests we use in our assessments require a high level of education.  Not true.  I published a post in January about the impact of dementia on caregivers.  Under normal circumstances taking care of a loved one is a stressful endeavor that requires sensitivity and supportive friends and family.

Dementia takes its toll on those whose responsibility it is to care for the failing loved one. The decline in cognitive functioning impacts all mental capacities including written language.  As a bonus this week I am adding a sample of the patient’s written language.  I ask for a writing sample that is always the same.  Two sentences: “He shouted the warning” and “Base ballplayers are tough”.  As you can see from this sample it is neither correct nor legible. The third line is the patient’s signature.  In this case, when asked to show  me his signature the patient asked “What is my full name?”  If you are interested in neuropsychological testing or physical rehabilitation please send me an email.  If you are so inclined send a copy of a clock you have seen and let me have a look. I enjoy posting the drawings that clinician’s send to me on this website.

“No greater sense of despair and futility exists as when the declining husband or wife can no longer remember a devoted caregiver or the memory of a shared life.” according to Michael Sefton at Whittier Rehabilitation Hospital in Westborough, MA.
This writing was made by the same patient whose clock is being honored this week on the Concussion Assessment website.  I ask patients to write simple sentences to screen their motor speed, skill and grammatic efficiency.

Whether it is written language or some other measure of constructional praxis the work I do is very gratifying.  I was once asked by a postdoctoral fellow that I was supervising “can the patient refuse to take the tests?” She was a bright experimental psychologist from Yale University who worried that the tests may be unfair to a patient with severe cognitive impairment –  especially if they were to be used to take away a driver’s license or for placement into a nursing home.  If someone does not wish to complete the testing it is entirely up to them.  I will usually make an attempt to establish rapport prior to any formal testing and rarely encounter resistance. When I do I will back off and leave it up to the patient to approve further testing.  Ultimately the success or failure of the assessment process requires that a ‘trust’ established and that patient dignity and respect be honored. While training to be a paramedic in 2012 the mantra we lived by was to treat the patient as you might want your mother or father to be treated.  That is the least we can do here at the hospital to preserve patient dignity and restore independence as much as possible.