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.

Resilience needed after Concussion

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
APA. Road to resilience. http://www.apa.org/helpcenter/road-resilience.aspx Taken 4-30-18.

TBI, concussion and headaches in females

headache-2-mbhi5p4ess5v9x1kbfpafgnr6lyhkdbydmq67h3pno.jpgWESTBOROUGH, MA March 15, 2018 Serious and chronic headaches are a frequent complaint of those recovering from mild traumatic brain injury.  “Headache is one of the most common symptoms after traumatic brain injury (often called “post-traumatic headache”). Over 30% of people report having headaches which continue long after injury.” (TBI and Headaches, 2010) They can be quite debilitating. The NCAA Headache Task force listed headaches as among the most debilitating symptoms in the aftermath of concussion.  Young women tend to have a higher incidence of post-concussive headaches than males.  There is treatment for post-concussive head pain.
Migraine headaches are three times more common in females than males.  Rates of emergency room visits related to traumatic brain injury (including concussions) among women almost doubled from 2001 to 2010, according to the Centers for Disease Control and Prevention (CDC). In my own practice here in Massachusetts I have seen more recurring headaches in females than in males. In addition, female athletes generally have a longer recovery course than some of the males I follow.  I will say that males are prone to abuse alcohol when recovering from concussion that may also be a confounding variable in the trajectory toward their normal baseline.
Individuals previously treated for headaches are at greater risk of both developing post-concussive headaches and for having chronic headaches following recovery from concussion.  These injuries can be caused by not only sports but also falls, car crashes, blunt trauma (getting hit on the head by an object), and assaults as noted in a 2016 Health.com report on women and concussion. I have worked with several high school athletes who had pre-injury headaches and received treatment for chronic headaches who went on to have an increased frequency of headaches after concussion. I worked with a tenured college professor who developed headaches from being hit with a basketball at her daughter’s middle school practice. This was shortly after being diagnosed with concussion from a prior head trauma.
American Olympian Lindsey Vonn suffered with the effects of concussion for months following a skiing accident in 2015  including chronic headaches.  The BBC recently featured 22-year old skier Rowan Cheshire who sustained a concussion 4 years ago that kept her from competing in the 2014 Olympic Games.  Cheshire had won the World Cup event one month prior to the Olympics in Sochi and suffered a severe concussion in a fall off the halfpipe. It was the first of two subsequent concussions over the next 3 years that caused severe side effects including migraine headaches and panic anxiety.  Cheshire worked closely with a sports psychologist during her recovery.
One reason for the difference between men and women in concussions is that women tend to have smaller neck and shoulder muscles allowing for greater whiplash from force striking the upper body.  Episodic headaches are usually set off by a single stressful situation or a build-up of stress. These are tension-related headaches which may be unrelated to concussion but whose frequency and intensity change following concussion or when under stressful life conditions. Nevertheless, unchecked stress and tension may contribute to an increased proclivity for head and neck pain and both respond very well to biofeedback and alternative interventions such as acupuncture and progressive relaxation. Daily strain can lead to chronic headaches. Coupled with concussion, stress can become inflammatory in terms of the frequency and intensity of headaches.
“Post traumatic headaches are seriously debilitating in terms of lost school and work days.  They are often a late symptom in the recovery from brain injury and concussion” Michael Sefton, 2018

Symptom presentation
In early childhood there is similarity between boys and girls in symptoms profile. This changes as children enter their growth spurt. “Puberty, which marks a significant developmental fork in the road for males and females, also marks a divergence for concussions. With its onset, females increasingly experience higher incidence of concussions, different and more severe symptoms, and are often slower to recover from the injury.” Treatments for post-concussion range from complete rest to gradual re-exertion, to physical therapy and more. There is a growing trend to slowly increase physical activity once symptoms resolve and I have seen a return of symptoms in cases where physical activity is premature and in cases of second or subsequent concussion.
One clear intervention for post-concussion headaches involves a paced-breathing protocol and neurofeedback that I have been using.  I teach and practice stress management using biofeedback instruments that have demonstrated reducing duration of headaches, reducing stress, and lowering sympathetic abnormalities including heart rate.  The goal of treatment is to reduce the body’s reactivity and normalize the autonomic system. “Fortunately, even if post-concussion headaches don’t get better in the first few weeks after concussion, most are better within 3 months and almost all are better within a year after injury” according to Heidi Blume, M.D., at the American Migraine Foundation.

Sefton, M. (2018) Abnormal Stress response from mTBI often sometimes leads to headaches. Response comment in Emergency Medicine Journal, Volume 34, Issue 12, February 23, 2018
Levine, H. (2016) The Truth about concussions and women. http://www.health.com/headaches-and-migraines/women-concussions
Roehr, B. (2016). Concussions Affect Women More Adversely Than Men: Differences between how females and males experience concussions suggest the need for gender-specific prevention and treatment strategies. Scientific American posted March, 2016. https://www.scientificamerican.com/article/concussions-affect-women-more-adversely-than-men/ Taken February 28, 2018.
Lahz S, Bryant RA (1996). Incidence of chronic pain following
traumatic brain injury. Arch Phys Med Rehabil, 77(9),
889-891.
Blume, H. (2016). Headaches after Concussion. American Migraine Foundation.  https://americanmigrainefoundation.org/understanding-migraine/headaches-after-concussion/ Taken February 28, 2018

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

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

Lyme disease, debility and what is wrong with me?

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Distribution of Lyme cases in predominantly 14 northeastern states

 

WESTBOROUGH, MA February 20, 2018 Lyme disease is a disabling condition that comes from a tick bite. Most people are not aware that they have been bitten by a tick at some point in their recent past. The symptoms may not be present until weeks or months after being bitten. Some patients complain of headaches, poor concentration, memory loss, weakness, joint pain and swelling, mood swings. “Lyme disease is predominately a disease of the white matter, while Alzheimer’s is predominately a disease of the gray matter. Memory association occurs in the white matter, while memory is stored in the gray matter. White matter dysfunction is a difficulty with slowness of recall, and incorrect associations” according Robert Ransfield, M.D. In contrast, gray matter dysfunction is a loss of the information which has previously been stored.It can become quite disabling if not diagnosed early. Massachusetts is among 14 states in the United States that have a high number of cases of Lyme annually. The states with the highest incidence of Lyme are predominantly in the northeast according to published data.  For many suffering with symptoms of Lyme who struggle to figure out what is wrong with them. The test for Lyme has a high degree of false negative findings.  This means over 50 percent of patients are found not to have Lyme when in fact they may have the disease. A statistician would say it lacks specificity and may not be valid in terms of the content it seeks to assess.
Why is this so misunderstood.  Some may patients are told they do not have Lyme. While this may be a relief to some, many people tell me they feel confused and misunderstood after going through the examination for Lyme. Testing for Lyme disease is done by taking a sample of blood.  They test is becoming more accurate and physicians are generally updating their examination of Lyme with a more expensive and accurate test.  Patients need to advocate for themselves and push for the two blood tests.  There is currently no C-T scan or MRI to demonstrate the organic signs of Lyme.
“When your body is invaded by the Lyme spirochetes, your immune system makes antibodies to fight the infection. Tests that measure antibody levels are indirect tests. They measure the body’s immune response to infection rather than the actual presence of bacteria.”  Sticker, 2010
Lyme seems to be a diagnosis of last thought. People suffering from Lyme disease often experiencing frustration and anxiety over their personal health especially when their primary physician cannot seem to figure out what is wrong with them. They go through test after test with no definitive answers until finally Lyme is screened.  Unfortunately, the screening test is highly insensitive and fails to accurately identify patients who have Lyme disease. The two-tiered test system misses roughly 54% of patients. (Stricker, R. 2010)
Recently a retired police colleague to me she used to walk 45-60 minutes a day each morning without much stress.  Now, after 6 months with Lyme she has daytime fatigue, muscle weakness, joint discomfort, and memory loss. Yet there seems to be nothing she can do to improved her sense of well-being.  It can be very frustrating for those seeking a treatment plan.  I know my colleague is frustrated as she is a hiking, kayaking aficionado who loves the great outdoors of Maine.


Bransfield, R. Lyme Disease and Cognitive Functioning.  http://www.mentalhealthandillness.com/Articles/LymeDiseaseAndCognitiveImpairments.htm Taken 2-28-2018.
Stricker, R. and Johnson, L., Lyme disease diagnosis and treatment: Lessons from the AIDS epidemic. Minerva Med. 2010; 101: 419-25.)