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.
Westborough, MA June 6, 2017 The clock of the week is depicted below. It was submitted this week by the Speech Language Pathology service at Whittier Rehabilitation Hospital. I sometimes find it humorous that when I ask a patient to draw a clock they will have already drawn a clock for the speech pathologist. The drawing is used in all aspects of cognitive assessment by pracititioners of all types from neuropsychology to internal medicine to emergency medicine. I typically begin an assessment with the clock drawing because it is nonthreatening and offers a great deal of interesting information about the cognitive capacity of the patient. It was drawn by a 93-year old male with congestive heart
Right handed 93-y/o male with probable dementia
failure and Paget’s disease. It is a disease affecting bone that interferes with the body’s normal recycling process, in which new bone tissue gradually replaces old bone tissue. Over time, the disease can cause affected bones to become fragile and misshapen (Mayo Clinic, 2017). In my experience there is no cognitive deficits associated with Paget’s. This clock is suggestive of what seemed to be a great start – in terms of the initial placement of the numbers although as you can see the numbers 1-6 were drawn on both sides of the circle. This is an unusual finding suggesting decreased problem solving and self-monitoring on behalf of the patient. The SLP drew the circle for the patient. I would suggest that the patient should be allowed to create his or her own circle as this can provide interesting data as well. I once had a patient draw and elaborate grandfather clock fit for a castle. The clock face became secondary and insignificant – for him. The clock is a regular feature here at Concussion Assessment and Management.
Anyone can submit a clock for consideration of the clock of the week. Upload to my email address: firstname.lastname@example.org – No identifying HIPPA protected information please but a brief overview is always helpful.
Westborough, MA May 25, 2017 Cognitive changes are common in patients with dementia. They become increasingly problematic with the disease progression. Some people suffering with dementia have difficulty with even the most basic activity of daily living like dressing themself. Things taken for granted like following directions become a chore as the progression of dementia effects individuals who suffer with the disease. This places a great burden on caregivers who must take over those important functions of daily life.
The clock drawing has been a feature on my blog for several years. It is fun to see people work through the task. Most people complete the task effortlessly. Some are a bit defensive because it seems like such a benign request – “draw a clock…” and I often get “I am not an artist…” in anticipation of failure. I have published over a dozen posts about the clock drawing as a measure of cognitive functioning. Patient with dementia often experience a slow cognitive decline whereby even tasks like constructing a clock become a challenge.
The clocks drawn in this post reflect the effort of a person of 89-years of age who tried very hard to get it right. She had enough preservation of her self- monitoring
3 Clocks drawn in succession by 89-year old female with hypoxia and underlying dementia of Alzheimer’s type – note size in centimeters
that she could tell something was wrong. As you can see the left most circle was the first attempt. It was too small according to the patient and she wanted to try again. The middle clock was her next attempt and shows her disorganization and minimal change in the size of the drawing – approximately 3 centimeters in size. In the center of the drawing there are 2 hands that roughly represent the time 11:10. She told me she needed more space to place the hands so that they could be clearly read and offered to try a third time. On the right is her final attempt. There are two hands (to the right of the number 9 and a second pointing to the number 2). As you can see the circle is only 2 cm in size and was a modest improvement over the first two attempts.
She had fun drawing the clock and did not feel as though she had failed the task. I was encouraging and praised her for staying with the task. At some point she had lost her capacity to plan and execute her visual motor function of crafting the circle. Each attempt was made with the goal of drawing a larger circle. This fine woman was still capable of doing many of her activities of daily living and enjoying her friends and family. She was not at all upset that I had been asked to help with her care.
Dementia requires family support and can be costly to those in need of care. The risk of caregiver fatigue exists in all families. As much as possible, I enourage people to allow the patient to work toward completing their own self-care unless there are risks such as falling due to poor balance. This requires herculean patience and sensitivity because there is often a degree of “awareness” of the cognitive changes experienced by the patient himself. Preserved dignity and sense of independence go a long way toward quality of life in the latter stages of dementia. Most spouses will do whatever it takes to support a loved one with whom they have shared 50 or more years of marriage and experience the decline in functioning as both a personal failure and a heart breaking loss.
WESTBOROUGH, MA May 1, 2017 The return to school following a brain injury should be carefully planned. School nurses tend to be the point person for parents’ whose children are coming back to school after concussion. But let’s not forget the school psychologist. My wife, Mindy Sefton, Psy.D., is trained in concussion management and has crafted some of the best return-to-learn plans I have ever seen. She works closely with the nurse and classroom teachers to be sure no student be placed at risk for failure. At her middle school there is a protocol for re-entry that is specific and tailored for individual students.
Students with acute concussion and those suffering with post concussion syndrome require assistance at school or risk falling behind their peers. Some parents are not aware but it is true that when concussion sidelines and athlete he or she is highly vulnerable for school-related changes as well. Schools or educational teams who are interested in offering a comprehensive concussion education program are encouraged to contact CAMP or Dr. Sefton directly for consultation. Student athletes often require support in school while recovering from concussion. Support protocols like reduced work, extra time for tests, and deferred projects are just three commonly prescribed accommodations.
I am happy to help public schools with their protocols. They are critically important for student success. Individual programs can be integrated slowly on a team by team basis depending upon learning style, specific sport and unique student needs. Dr. Sefton has specialized training in pediatric brain injury, concussion and neuropsychological assessment and is a member of the Academy of Brain Injury Specialists. Training for coaches and trainers is available and recommended to identify updated return-to-play protocols and current standards of care. Both web-based and individualized ImPACT testing is available for preseason and after injury assessment. Return-to-play consultation is available with trainers and team physicians 24/7 at 508-579-0417 and email email@example.com
School districts interested in using CAMP for supporting athletes injured while playing sports can contact Dr. Sefton at 508-579-0417. Parents and physicians may call Dr. Sefton at any time to discuss individual injuries and school and sports re-entry after injury. Post injury testing and neuropsychological consultation is also available.
Return-to-Learn Care Plan
Some students who are injured playing in school sports may require a return to school care plan. Dr. Sefton will consult with student, parents, and school personnel to assist with short-term accommodations in school that can assure for continued success in academic domains. Not all children require changes in their educational programs but careful consideration of the child’s school functioning is essential.
Classroom teachers should be advised to monitor the student athlete for the following signs:
Increased problems paying attention/concentrating
Increased problems remembering/learning new information
Longer time required to complete tasks
Increase in physical symptoms (e.g., headache, fatigue) during schoolwork
Greater irritability, less tolerance for stressors
WESTBOROUGH, MA April 20, 2017 Whenever I meet someone who comes to me because of a recent concussion they will inevitably ask “what happens if I return to play too soon?” If it isn’t the athlete asking that question it might be their parent. Ever since the era of awareness of concussion began people have been more apprehensive about their return to activity. I recently took care of a basketball coach who was feeling better when she was hit in the back of the head with an errant basketball during the shoot around. Her symptoms returned with intensity and left her on the sideline for over a month. People now accept that the cumulative effects of concussion can have lasting impact.
The consensus currently indicates that some activity during recovery is beneficial rather than 100 % rest as once espoused. That activity would consist of physical therapy, exertion and balance training along with controlled cognitive exercise. It is still recommended that recovering patients not overuse their computers, tablets, game systems, etc. Sleep and rest also remain an important component of the recovery plan especially when re-integrating into school or work. If symptoms persist or worsen than I often suggest lessening the work load. Most schools will write off some work assignments when necessary. Some students get quite anxious about the make-up requirements for classrooms work if they have missed days or weeks of school.
“Concussive injury has the potential to derail the trajectory of normal development and is fully preventable,” according to Michael Sefton, Ph.D., Director of Neuropsychology at Whittier Rehabilitation Hospital in Westborough, MA, US.
WESTBOROUGH, MA April 15, 2017 On March 15th across New England and most of the country high school spring sports take to the fields. Well actually most of the lacrosse and softball teams start out in school gyms or field house. Many actually rent out indoor playing fields to put in the hours needed to begin a rigorous new season. The starting dates are closely watched by members of the Massachusetts Interscholastic Athletic Association – MIAA. It is the same thing with football and fall sports – August 20th the ritual first day of Fall sports practice. In spite of these rituals and scores of other idiosyncrasies that teams share, concussion should not be an expected rite of passage for contact sports. Yet some people are still not taking it seriously.
“The protocol about which I write comes in sequence to the athlete being symptom free. When this happens he or she may begin a return to play protocol that consists of systematic activities designed to slowly stress the athlete in an effort to be certain that no symptoms will return as the athlete exerts himself over a 5-step sequence that ends in a full contact practice.”
I posted a short blog in January 2017 about the role of a stepwise return to play protocol. Most schools expect this protocol and are often surprised when the parent of an injured student marches in with a note authorizing return to full participation by the pediatrician – as if this trumps anything the CDC has implemented as the standard of care. This may now be the standard of care but is not being followed. In the past month I have been asked to write return to play protocols for athletes who had already been cleared to play by their pediatrician. You cannot have it both ways – either a player is held out until he is fully healed or he is at risk of prolonged debility and postconcussion syndrome if injured again during recovery. When it comes to middle or high school students the greater risk is missing days or weeks of school.
Case study – 2017
Just recently I saw a 12-year old middle school boy who had sustained a moderate injury while snowboarding. He had 2-3 weeks of significant symptoms including sensitivity to light and sound, headaches, irritability and changes in sleep pattern. He had taken one week off from school and returned 1-2 hours daily until fully reintegrated with his classmates. By outward appearances he was doing all the right things and had returned to his travel soccer team. Yet he was still having symptoms and should have taken a more focused approach to exerting himself. His school was beginning to push him to complete missing assignments that was adding to his anxiety and irritability. The child had been seen at a local concussion clinic who had cleared him for step 1 of the 5-step protocol. They prescribed the CDC 5 step protocol I have mentioned here but there was no in-school trainer to manage each step. This frequently falls on coaches or the school nurse. But by allowing him to exert himself and practice with his teammates he missed out of steps 2 and 3. His brain had not fully healed and was struggling to keep up with energy demand of school, homework, make-up tests and soccer. Concussion is an energy crisis resulting in less efficient processing and it was clear to me that he had not fully recovered from his moderate injury. He needed to start over and his parents heard this to be a set-back. They were protective of his emotional well-being and wanted him to be with his class and team mates. These are important considerations and must be figured into the recovery equation.
“There should be an understanding that no student may be expected to take tests – even state mandated achievement tests until they are fully recovered from their injuries. The failure to allow full recovery to take place prior to exerting the athlete places him or herself at risk for additional injury from second impact. Some students require a formal 504 support plan for the duration of their symptoms.” Sefton, 2014
In another case from spring soccer that I previously illustrated, a young high school boy was recovering and had still been having headaches. Their question was: could he travel to Portugal and play against an elite high school? They had been planning the trip for nearly a year. His anxiety over missing the trip was palpable but the risk of playing against older and more developed athletes was against my advice. He could attend the trip but not play. I am unsure what they decided to do but I did not see them again. For readers of this post I ask: Does it make sense to have an athlete who is still recovering to play at the elite level where competition is fierce and risk of injury is real? The 5-step protocol should not begin until the athlete is symptom free. Some believe the athlete should be symptom free for one week prior to beginning the return to play protocol. To see the CDC protocol click here.
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.