WESTBOROUGH, MA Here is the “clock of the week” drawn by a well educated 77-year old woman undergoing rehabilitation at the hospital after she sustained a fall and broke some ribs. The clock represents her best effort at completing the 3 step problem I have described so often in these pages. Clocks are interesting and fun. They can be used to put the patient at ease when first getting started. Some patients become quite defensive when they are referred for neuropsychological assessment. It is important to establish rapport prior to initiating the battery of tests so that you may obtain the best possible result.
These data are turned into the report that physicians will use to access services and needed intervention to assist with return to functional independence whenever possible. In this case, the woman had had two prior CVA’s one on the
Right middle cerebral artery – effecting her visual motor integration and spatial awareness and the second stroke effecting her language area – including verbal fluency and word choice during free speech. I have also added a sample of her written language. Patients are all asked to “write a sentence” that I dictate to them. I have used the same 2 sentences for over 20 years and find them useful.
“Baseball players are tough”
The sentence reads Baseball players are tough. It illustrates the impact of CVA on written language. This interesting lady could no longer write checks or sign her name. Graphic formulation of words requires both the left and right sides of the brain for success. The frontal lobe is also brought in automatically to initiate, plan, and execute the verbiage and organize the thoughts into a coherent message.
During the hours of assessment I learned that this patient had sustained a fall just 5 months earlier resulting in a head strike and 3-5 days of concussion-like symptoms that slowly evaporated returning her to her baseline. This leaves her more vulnerable to cognitive change with any illness including infection or pain syndrome from fractured ribs.
WESTBOROUGH, MA April 1, 2016 The Neuropsychology Service at WRH has added both physiologic and EEG biofeedback to the service for those afflicted with concussion, TBI, and trauma. The protocol involves heart rate variability and controlled or paced breathing as a means of gaining enhanced resonance in the autonomic nervous system. Autonomic storming is a common reaction to traumatic brain injury and can be debilitating over and above the structural changes that impact condition and behavior. It is not new and has utility in treating anxiety and other stress-related conditions. The protocol is designed to activate the body’s parasympathetic function as a “quieting mechanism” – to put the brakes on for relief and a variety of physical symptoms including pain, irritability, and depression. The “protocol quickly assists in helping patients find a balance or resonance between sympathetic and parasympathetic systems in their body using controlled, paced, breathing and prototypic progressive relaxation” according to Michael Sefton, Ph.D., Director of Psychological and Neuropsychological services at Whittier Rehabilitation Hospital in Westborough, MA. 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 certified in biofeedback including neurofeedback and is a Certified Brain Injury Specialist. Contact Dr. Sefton for more information of this protocol or an appointment 508-871-2077.
This clock was constructed by a cooperative and friendly 77-year old experiencing the debilitating symptoms of dementia – diagnosed 2 years previously. It is very poor and somewhat atypical this early on after diagnosis. He was diagnosed with urinary track
infection that has the capacity to render him completely impaired with his cognitive functions as measured by the clock task. Click here for the clock of the week.
Westborough, MA August 18, 2015 Schools across the country are preparing student athletes to return to the fall sports gridiron. This week each year I visit several public and private high schools to inform the parents’ of student athletes about the individual concussion programs that each school offers. Most schools have policies that require physician guided return to play. As a neuropsychologist and certified school psychologist I want to point out that there is so much more to recovery than just getting back on the field of play. A school re-entry plan should be put in place after a student athlete sustains a concussion. This usually means one to three days off from school to allow the brain to heal.
Since July 2010 the MIAA – Massachusetts Interscholastic Athletic Association – the governing body for pubic school athletics has required concussion education for coaches, parents, referees, and athletes themselves. The idea is to inform everyone about the signs and symptoms of concussion. Emphasis is now being placed on the athletes themselves to report a concussion before they risk greater injury by returning to play while still experiencing the symptoms of concussion. The symptoms of concussion have been well described elsewhere including on this website and most parents have taken the online test that is mandated by the MIAA.
As a neuropsychologist in practice in Westborough I have been fortunate to work with excellent athletic trainers, school nurses, and pediatricians as a team providing baseline ImPACT testing, assessment of post-injury concussion, and carefully designed return-to-learn programs, and clearance for return-to-play. I have assisted several Massachusetts and Rhode Island school districts with writing individual concussion policies that have addressed current “best practice” for dealing with student athletes who suffer head injuries in sport.
The MIAA has begun to allow non-physicians to play a larger role in the return-to-play decisions. The MIAA website has all of its concussion policies that are here on this link. This will permit other practitioners with specialized training in concussion management the opportunity to develop return-to-learn plans and to clear an athlete for competition when they are ready. Physician Assistants, Neuropsychologists, Nurse Practitioners, and some ATC Trainers can now write return to play plans with the appropriate training and careful consideration of each student’s needs.
Congratulations for all those student athletes who worked all summer at captain’s practices – running, skating, playing summer soccer, etc. Good luck and be safe. Contact me at Whittier Rehabilitation Hospital for consultation after injury. My policy is to have injured players seen within 72 hours for updated neurocognitive testing and post-injury planning. When symptoms exceed 7-10 days further assessment and consultation may be needed. I encourage everyone to see Dr. Evans video posted below to learn more about recovery from concussion. It takes a care team to help a student athlete get back to school and back to play in a safe way. Stay in touch with team trainers, physicians, and your school nurse.
Concussion Video released August, 2014 that is interesting and funny by Dr. Mike Evans, a Canadian Internist
Check out Dr. Mike Evans Concussion 101 video – click here
WESTBOROUGH, MA June 7, 2015 In response to questions I have received from visitors to the web site I have decided to add a wider genre of content to include neuropsychology in general. I have had a tab labeled neuropsychology since the beginning and it has been linked to topics of importance such as traumatic brain injury, cardiac arrhythmia, and dementia. These topics effect everyone at some point especially those people working in the medical field – brain injury, stroke, pain management, and more.
Neuropsychology is the study of the relationship between brain and behavior. When you think about it that includes just about everything from acquired injury, substance abuse to autism. The topics I will post are those in which I am involved here at Whittier and in my practice. I am adding to the content published here and will continue to work with those afflicted with concussion and post-concussion syndrome and their families. I am very excited to add biofeedback and EEG biofeedback to my practice. While I have limited assessment openings – biofeedback has been a demonstrated modality to enhance functioning.
On my other site I have included posts about domestic violence, the “active shooter”, juvenile fire setting and more that also effect many of us who work with people. That site may be reached at http://www.msefton.wordpress.com
Westborough, MA April 5, 2015 The spring try-out has all but been completed. Most varsity teams have their rosters set and the games have begun. In terms of collision sports men’s lacrosse and women’s softball both have high incidence of concussion. As seasons have gone by, I have seen an elevated rate of girls being injured during softball while sliding into their base or from player on player collisions. Arguably, fast pitch softball has a high incidence of batters being hit by pitch resulting in concussion. Men’s baseball also has a high incidence of concussion from wild pitches hitting batter helmets to outfield collisions.
Every spring I mail out reminder cards to the schools I take care of reminding athletic director’s to have their athlete’s sign on and take the pre-season baseline test – if they have not done so in the fall. Most of the time I try and encourage trainers to refer cases of concussion for neuropsychological assessment early rather than later when symptoms have become chronic. Early referral to a trained neuropsychologist can have a positive impact on successful return to play – including providing support for a step-by-step return to play plan. I have said over and over that no player should go from zero play to game play without first going through a supervised return to play protocol. No matter what you might think, the return to play protocol is the safest way to introduce an athlete back to sport and offers the least likely chance of an athlete being diagnosed with post-concussion syndrome – a chronic set of symptoms that can include headaches, poor attention, decreased short-term memory, depression, and more. Yet I am still seeing physician’s who release student athletes for “game” play with only 5-7 days of rest. Many believe this is inadequate.
Here in Massachusetts the MIAA has required that athletes be cleared by their primary physician before they are eligible to return to play. Since the inception of the MIAA requirements the MIAA has broadened the definition of clinician that may clear an athlete for play to include clinical neuropsychologists and nurse practitioners with documented training in concussion management. I am finding that some schools have allowed athletes to return to play prior to being officially cleared by their doctors – sometimes by the team trainer with some training in concussion. This falls outside of the letter of the law set forth in the MIAA mandate and places athletes at risk.
It is prudent to have student athletes see a primary care physician and or another practitioner who can set forth a comprehensive return to play plan that allows for 7-10 days of rest followed by an active plan to return the athlete to the field of play as soon as safely possible. Early referral to a specialist may be warranted whenever recovery takes an unexpected turn.
WESTBOROUGH, MA November 3, 2014 Visual processing is a key component to living a healthy and independent life. Visual perception refers to the sensory processing of visual information including language i.e. reading and abstraction i.e. shapes and designs. Visual spatial deficits are common after traumatic brain injury, stroke, or tumor. Stroke that impacts the right side of the brain can result in sometimes profound visual perceptual deficits. The right middle cerebral artery supplies much needed blood to a large distribution of the right side of the brain – usually in the parietal lobe. When sensory receptors are damaged they are no longer available to process information using visual pathways. The right side of the brain controls the left side of the body. The negative impact of lesions in this region can be dramatic when it comes to vision, processing abstract stimuli, and and visual perception.
Perhaps the most profound thing we do as humans that requires rapid visual processing is to operate a motor vehicle. Driving requires fluid visual processing that quickly adapts to whatever circumstance it encounters – like potholes, other cars, and people walking. Without the use of the right hemisphere one might not efficiently process all aspects of the visual information being seen. In fact, there is a high likelihood that some individuals fail to look to the left often missing large bits of visual information.
Neuropsychological aspects of the right middle cerebral artery
This is the drawing made by a patient who was shown the complex figure above. The brain is called upon to see and interpret the figure. As it does this it becomes organized in some manner depending upon the cognitive style of person who is copying it. As you can see from the figure on the left there is a loss of appreciation of the outer configuration as well as a paucity of detail.
The right hemisphere is thought to play a role in processing non-linguistic information, abstract stimuli and attention. But there are many other things that can go wrong when someone suffers a stroke in the right side of their brain – like appreciation for music, expressing emotion in speech, and initiating a plan. It is not uncommon that I am asked to consult on a case of right hemisphere CVA that is suddenly always crying or even laughing! This is called pseudobulbar affect. It is a common occurrence after stroke and often a sign of emotional “release” due to decreased emotional control following stroke. It can be a bit unnerving if you have not worked with it before. Another common problem found after stoke affecting the right side of the brain is called perseveration. This refers to the tendency to keep producing the same response even when you are told that the task has changed or you have moved on to something different. I have seen this is someone’s writing. For example someone might be writing a sentence like “Baseball players are tough”. They produce perseverative responses like “baseball ball ball players are tufffff.” You can see the perseveration in what is produced in the written language.
Visual illusions – not hallucinations
Some patients experience changes in how they interpret visual information making them appear quite idiosyncratic – sometimes like a psychiatric patient to an untrained observer. The right hemisphere syndrome sometimes results in visual illusions as a result of the misidentification of a complex visual array. Remember a book written by Oliver Sacks, M.D. entitled The man who mistook his wife for a hat” – now 30 years old? It is largely about visual misidentification or agnosia – an inability to identify common objects. “The world can become a complex and dangerous place when visual perception is corrupt due to stroke or some other affliction” according to Michael Sefton, Ph.D.. “More than a few times I have been asked to consult on a patient having hallucinations when in fact the patient has misidentified objects in his visual field and called it something else that it could not be” according to Sefton. For example, a patient with a prominent left neglect had been doing much better undergoing physical rehabilitation. Some bed linens had been placed on the bedside table on his left. In the periphery of his vision he sensed that something was there but could not spontaneously look to the left and identify what it was. He became quite anxious and suspicious that someone was standing to his left watching him. He mistook the pile of linen for a small person who was silently standing and felt threatened. By moving the extra stuff in his room and lighting the environment we were able to lessen the disruptive anxiety he exhibited. It takes time to assess the systems of the brain especially a complex system that is interconnected with attention, language, and spatial relations.
Michael Sefton – Whittier Rehabilitation Hospital
Capruso, D. et al. (2009) Clinical Evaluation of Visual Perception and Construction Ability. In Clinical Neuropsychology, Second Edition. Snyder, P. (Ed). APA.