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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Preventing Concussion whenever possible

WESTBOROUGH, MA March 20, 2018 I am frequently asked about helmets and those that claim to be protective against concussion.  As of this publication there are no helmets that unequivocally protect against the forces that impact the brain in the course of an athletic contest. The stunning Ted Talk video below reveals details about the protection offered by helmets today.  Concussion is described as occurring in lower brain centers not the surface of the brain as the CDC graphic describes.
“Players are rarely hit by a direct linear force.  They are struck from the side or oblique and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.”  Sefton, 2018
In fact, there is a newly designed mouth piece that has a built in gyroscope that is capable of measuring g-forces and rotation of the head resulting from head strikes.  Researchers now believe it is the rotational force that sends energy into the skull and brain that causes the greatest cognitive and behavioral changes in the event of a concussion. Players are rarely hit by a direct linear force.  They are struck from the side or oblique and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.

 

 

 

Link to Dr. Mike Evans Concussion 101 video

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

CTE and its violent underpining

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Google images – CTE
WESTBOROUGH, MA January 20, 2018 More is becoming known about Chronic Traumatic Encephalopathy or CTE.  It is now able to be diagnosed prior to the death of the patient by identifying unique protein markers in the blood of those who have sustained multiple brain injuries.  Former professional wrestler Chris Benoit was found to have CTE after killing his wife and son before killing himself in 2007. But murder or other violence against others has not typically been associated with CTE until recently.  As recently as summer, 2017, the brain of former N.E. Patriots star Aaron Hernandez was also found to have signs of severe CTE raising the specter of its possible impact on his violent life and eventual death by suicide. I have posted post-mortem photos of his brain first published on the Boston University site in a prior blog on my Concussion site (Sefton, 2017).  See that post by clicking here.  It is now understood that an athlete need not have sustained numerous concussions in his career to be found to have CTE at time of death.  More so, the accumulation of repeated blows to the head – subconcussive force – is being implicated in the etiology of this complex disease process. So contact sports like football, rugby and ice hockey are being closely scrutinized by experts in concussion, athletic training and sports medicine.  Researchers at BU School of Medicine have reported that a protein known as CLL11 may be elevated in the brain and spinal fluid of athletes with a history of brain injury.  It holds some promise of being able to diagnose athletes before death.  This protein leads to elevate Tau protein a known cause of progressive brain damage associated with dementia.
In 2014, The K.C. Star reported that analysis of Belcher’s brain after he’d been exhumed revealed a key signature of chronic traumatic encephalopathy, best known as CTE, a degenerative brain disease found to cause dementia, confusion, depression and aggression). “Belcher’s murder-suicide is the worst possible example of domestic violence, and these findings come as the NFL is under attack for its handling of domestic violence.” (Mellinger, 2014 Kansas City Star). 
“CTE has been found to cause erratic and sometimes tragic behavior by some NFL players, perhaps most notably Hall of Fame linebacker Junior Seau, who killed himself last year. The disease, only recently diagnosable before death, has often been found in former and longtime football players.” Mellinger, 2014 K.C. Star
 Riding a bicycle is a leading cause of brain injury in childhood. Recently, CTE has not been diagnosable before death. It has been found over and over in former and longtime football players. Domestic violence behaviors cut across all socioeconomic strata.  They germinate in an environment of secrecy often early in courtship.  During this time abusive spouse slowly isolates his intimate partner from her support – family, friends, finances.  “In doing so there is a subtle but undeniable manipulation of control – usually coupled with threats and intimidation.  There is growing awareness that red flag behaviors precede DV and domestic violence homicide.  Things like pathological jealousy, forced sexual contact, manipulating friendships, detachment from members of immediate family and others are the early signs of domestic violence.” (Sefton, 2012)  Some believe that the most significant pre-incident red flag is whether or not the victim truly believes she is going to be killed by her intimate partner one day and that these victims are at most risk of death.

Sefton, M (2012) Athletes and Celebrities Not Immuned: Kansas City Chief’s player kills wife and self in act of DVH, Blog post December 1, 2014, taken December 28, 2017. 
Sefton, M. (2017). Brain and Behavior: B.U. scientist says Aaron Hernandez had CTE. Blog post, Nov 19, 2017 Taken December 28, 2017
Read more here: http://www.kansascity.com/sports/nfl/kansas-city-chiefs/article2296030.html#storylink=cpy
Read more here: http://www.kansascity.com/sports/spt-columns-blogs/vahe-gregorian/article187534063.html#storylink=cpy

Neurological trauma and enduring change in survivors

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.

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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.

 Lancet Neuology (2017) Jun;16(6):452-464. doi: 10.1016/S1474-4422(17)30118-7. Traumatic Brain Injury. Taken 12-18-2017.

Brain and Behavior: B.U. scientist says Aaron Hernandez had CTE

Westborough, MA November 18, 2017 The NFL has some explaining to do. Why are former athletes killing themselves and in some cases other people? As students studying the brain it was something special when you could make a correlation between an identified brain lesion and the behavior you are seeing.  I was in China in early November 2017 at a conference on RNA targeted therapy for cancer.  As the non-scientist in the group I was referred to as the clinician who saw the phenotype rather than the genotype – referring to the innumerable genetic underpinnings of cellular biology and changing science of modified nucleotides.  I understood this to have some meaningful interest to the faculty that consisted of 3 prior Nobel laureates and leading scientists in RNA targeted therapy.  So after sitting through hours of presentations I realize the importance of not making a rush to judgment about the cause of some predicted outcome. As a neuropsychologist we are asked to make assumptions about brain integrity after CNS infarcts and make educated predictions about the functional implication of focal lesions in brain.
Recently the scientists at Boston University announced the results of the post-mortem analysis of the brain of Aaron Hernandez, former N.E. Patriots receiver and convicted murderer.  Hernandez had his conviction expunged after he died while his case was on appeal. The 27-year old brain was highly suggestive of having the tell tale signs of chronic traumatic encephalopathy or CTE thought to be the result of repeated concussions and now realized as the result of hundreds – perhaps thousands of sub-concussive blows to the head that accumulate over time.  Hernandez’s brain was the youngest of the donated brains to be identified with advanced CTE. Hernandez played football for 17 years starting when he was a young boy. The question remains did the brain damage that was identified in the post-mortem analysis cause behavior change in Hernandez and could the murder of Odin Lloyd be attributed to the build up of dangerous tau protein in his brain?
“While no one can prove a causal link between Hernandez’s brain damage and his actions, there is little dispute that he displayed CTE symptoms associated with behavioral problems, such as aggressiveness, explosiveness, impulsivity, and suicide.”
Boston Globe Bob Hohler November 9, 2017
By history Aaron Hernandez was an angry, impulsive and violent teenager that his mother reported began when his father died suddenly. Coupled with this was a biological proclivity toward degenerative brain disorders such as Alzheimer’s Disease and CTE.  Both are diagnosed only after the death of the victim. We know that brain-behavior relationships exist from research in stroke and traumatic brain injury where focal injuries result in specific and expected changes in behavior.  These often result from a disconnection between functional centers of the brain including limbic structures that link centers for emotional regulation and the frontal system that exerts inhibitory control over those emotions. The athlete’s who have donated their brain’s upon their death have almost universally exhibited changes in behavior including poor impulse control, depression, and anger.

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BU Medical School and WCVB images 2017

Clock of the Week

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Dr. Michael Sefton at Boston Museum of Fine Arts
WESTBOROUGH, MA September 15, 2017  Much has been published about the utility of the clock drawing in making preliminary assumptions about the cognitive health of an individual who may be referred for neuropsychological assessment.  I use it all the time and those of you who have submitted clocks for publication here agree with my assumptions.  The photograph at the left was taken at the Boston Museum of Fine Arts by a colleague Dr. David Kent, a neuropsychologist from Worcester, MA. There are several posts that identify some of the literature behind the assumptions I make about clock drawing and cognition.  Here is another link: Clocks and cognition

 

 

Click and see the interesting “Clock of the week