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
WESTBOROUGH, MA April 2, 2018 Much has been written about the incidence of opioid-related death and debility. As of yet I have not directly published my approach to this contagion. 20 years ago we offered a pain management program at the hospital at which I consult.
It was a coordinated and structured rehabilitation program with daily education, physical restoration, mindfulness exercises, aquatics, family support, and nutritional education – including weight management. What happened was referring physicians sent us all their chronic cases and treatment failures. There is no magic to pain management. There is no mysterious gating mechanism to turn off pain receptors in the brain. As soon as people learned this we had difficulty filling the program with those who truly wanted to work at reducing their pain and strive to increase their functional independence. Our medical director cited current rehabilitation statistics from 1999-2002 indicating that if someone is out of work for greater than 6-12 months because of pain, the likelihood of their eventual return to work is almost nonexistent. I found this news to be very discouraging but generally true.
Recently, I was reading the blog post of Vic Crain who is spot on when it comes to many current social issues. He writes from New Jersey and does not hesitate to comment of a range of topics from guns to opioid addiction. I enjoy seeing his writing and try to comment on his posts whenever he touches on an area about which I am knowledgeable or simply an area where we share a common interest. In this case it is the use of pain medicine for chronic pain. Pain management requires both a team approach and a shift in the current zeitgeist guiding the standard of care for those suffering with chronic pain and its psychosocial sequelae. According Harvard University psychologist Dr. Robert Edwards, “patient surveys also show that people with chronic pain care about more than just experiencing less pain. They care about enjoying life more, having a strong sense of emotional well-being, increasing their physical activity, improving sleep and reducing fatigue, and participating in social and recreational activities.” in an article published in 2015.
Each patient has his or her own story to tell and should be allowed the opportunity to express the frustration that is universal among those in pain. At the same time the new standard must include a comprehensive review of medication and modalities that will address the pain from integrated approach that is derived from both the cycle of pain that is coupled with increased functional capacity. Regular education and review of team goals are essential.
There is no shut off switch for severe pain. Patients float from one physician or clinic to another spending thousands of dollars seeking the key to ending their discomfort and debility when often the answer is within their grasp. The internet has allowed many patients to access information about new medications, test procedures, and sometimes obscure treatment methods like never before. Treatment need not be complex but certainly it must include a comprehensive pain management plan.
Reach for the hand of a loved one in pain and not only will your breathing and heart rate synchronize with theirs, your brain wave patterns will couple up too, according to a study published this week in the Proceedings of the National Academy of Sciences (PNAS). Vic Crain, 2018
Using Opioid Medications and Pain Relief
Mr. Crain’s recent post brought into focus the issue of opioid dependence and addiction. Most of us are aware that deaths from opioid overdose have increased exponentially in the past 5 years largely due to physician-related practices – now thought to be over prescribing of pain medication. Recently a study was published findings that indicate chronic pain patients’ are no better off when prescribed opioids or an OTC analgesic. The study followed randomly controlled groups for 12 or more months of treatment. Some patients were functioning even worse after the study period. Mr. Crain also cites a newly released study indicating that the source of underlying pain, know as small fiber polyneuropathy, may require alternative therapies and not respond to the typical opioid therapy (2017). These syndromes are directly linked to the long-term impact of poorly controlled diabetes mellitus, circulatory problems from DVT, poorly controlled cardiac arrhythmia, and more.
A common underpinning of these afflictions and more is elevated inflammation throughout the body and reduced autoimmune functioning. The result is errant ANS functioning. This is an automatic process of sympathetic arousal ramps us up as if to say “bring it on” – activating us to fight or fly the coop if needed to survive. The problem is that over time an insidious elevation of normal baseline physiological values that create a sympathetic-parasympathetic mismatch adds to patient experience of pain and tension. A key component to recovery is movement – regular exercise and a routine of progressive mindfulness coupled with a goal of increased functioning. This is a hard sell for many individuals suffering from pain. Many fail to understand that the lack of movement – and lack of regular exercise, physical therapy, aquatic therapy, yoga, and or other treatments, is far worse than the initial injury they may have sustained sometimes years ago.
What people often do not know is that opioid medication is only one small piece of the pain management puzzle. I am particularly interested in biofeedback protocols designed to reduce pain and the co-morbid conditions that are linked to it like irritability, tension, shortness of breath, and autonomic dysfunction. I have had patients tell me they have tried “everything” to reduce their discomfort and often respond with incredulity when I suggest regular use of ice and 20 minutes of walking each day. Biofeedback may be a useful modality for migraine headaches, anxiety, pain management, concussion, and stress. I have used a combination of physiologic biofeedback and neurofeedback for patients with chronic pain, failure to thrive, depression, post-concussion syndrome, and severe traumatic brain injury” (2014). The results often bring down levels of stress and tension and have a corresponding lowering of physiological arousal – even blood pressure, pulse rate, and improved sleep and mood.
Patients are urged to have at least 10 sessions of HRV biofeedback and may practice at home between sessions. Diet and exercise are important parts of recovery from TBI, concussion, and other pain-related syndromes. Dr. Sefton is a licensed psychologist who is certified in biofeedback including neurofeedback and is a Certified Brain Injury Specialist-Trainer (CBIST).
Edwards, R. (2015) The “right” goal when managing pain. December 18, 2015 Harvard Health Blog https://www.health.harvard.edu/blog/the-right-goal-when-managing-pain-201512188865 takenMarch 12, 2018.
Crain, V. (2017) A New cause and treatment for pain. November 10, 2017 Blog post: https://wordpress.com/read/blogs/69301418/posts/13770 taken March 12, 2018 citing Pavel Goldstein, Irit Weissman-Fogel, Guillaume Dumas, Simone G. Shamay-Tsoory. Brain-to-brain coupling during handholding is associated with pain reduction. Proceedings of the National Academy of Sciences, 2018; 201703643 DOI: 10.1073/pnas.1703643115
Crain, V. (2018) Pain therapy: Holding hands. March 7, 2018 Blog post: https://wordpress.com/read/feeds/21687647/posts/1787094734 taken March 12, 2018
Sefton, M (2014) Blog post: https://concussionassessment.wordpress.com/consultation/topics-in-neuropsychology/tbi/autonomic-dysfunction/ Taken 3-13-18.
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 26-28 2018. The class will be taught by Michael Sefton, Ph.D., who is a
Certified 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 $500.00 which includes the examination fee, book, 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.
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 firstname.lastname@example.org about becoming a member of the class. Interested students may also contact Ms. Beth Pusey, Education Manager at the Brain Injury Association of Massachusetts at 508-475-0032 X 19 for more. Class size will be limited. Additional details about the Academy of Brain Injury Specialists is at https://www.biausa.org/professionals/acbis
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.
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.
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
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.
Head injuries at the time were treated as mere nuisances. Players reacted to violent head blows by trying to blink away their blurred vision, shake the ringing from their skulls, and trundle back to their huddles, unless they were flagged by sideline doctors. Even then, they generally returned quickly to action. Boston Globe October 2017
Westborough, MA December 18, 2017 The British Medical Journal Lancet recently published a series of articles describing the long-term effects of brain trauma. The series is worth a serious read for those who are in the position to take care of trauma patients.
There has been little change in our approach to handling the individual grind of caring for the TBI patient I must sadly admit. Young and old it takes both patience and dedication to achieve the best outcomes with those we bring into our treatment continuum. “Survivors experience a substantial burden of physical, psychiatric, emotional, and cognitive disabilities, which disrupt the lives of individuals and their families, and pose huge costs to society” according the Lancet, 2017. Many readers have read my post Updates in these pages where I have detailed well-known athletes like Formula 1 car driver Michael Schumacher and Mike Towell, the Irish boxer both of whom were seriously injured from TBI. Towell died from injuries linked to second impact syndrome following a match in 2016.
Schumacher remains in a minimally conscious state in Switzerland. He is conscious but does not speak or move about. He requires 24 hour medical care and is living is a special suite adapted in his home that allows him to continue to receive the best care possible while being in his familiar setting surrounded by family and friends. The cost of his care exceeds $ 100,000 per month.
Some reports suggest Mr. Trowell had sustained a brain injury in the early rounds of the fight. “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.” Sefton, 2016 on second impact syndrome and Mike Trowell
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 according to a Autonomic Storming post by Michael Sefton, Ph.D.
Lancet identifies the complexity of TBI and its multifactorial underpinning. A growing number of patients are elderly that contribute to “heterogeneity of outcomes and consider ways forward for targeted management of severe TBI in the intensive care unit” as mentioned in the 2017 Lancet summary. Improved management of TBI in the trauma centers and ICUs bring forth better rehabilitation candidates and better outcomes including return to home and eventually return to preinjury employment for many. Surgical intervention crafted to decrease secondary injury to brain have been enhanced by improved diagnostic accumen, imaging and novel techniques such as radical craniectomy and cranioplasty for management of intracranial pressure and its associated edema.
The series also explains PSH or “autonomic storming” something that I have described in several posts and can be quite serious both in the trauma canter and later in the rehabilitation hospital “Geert Meyfroidt and colleagues provide an overview of paroxysmal sympathetic hyperactivity, a consequence of acute brain injury, and discuss the promise of improved characterization and implications for management”. Damage to the system that regulates sympathetic and parasympathetic functioins due to traumatic brain injury can be unsettling for familiy members and clinicians alike. 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. Patients in our rehabilitation frequently undergo repeated blood cultures and lab studies looking for a source of infection. Many are returned to the trauma centers for additional brain imaging studies and cardiac monitoring that takes hours and is often unneccessary. These procedures delay recovery and add confusion to the patient and his family.
The regulation of the secondary injuries such as paroxysmal sympathetic hyperactivity is essential for patient well-being and outcome measures including returning home and re-entering the work force. The Lancet series is a well written update on current brain injury treatment and management of this serious public health threat.