Sports specific recovery from Concussion

blurry hockey
Body checking starts at age 11 in most sanctioned ice hockey programs  PHOTO: Mike Sefton
WESTBOROUGH, MA October 9, 2018 Cognitive and emotional symptoms often occur when an athlete sustains a concussion. Individual sports have somewhat different trajectories when it comes to recovery – sometimes because of the nature of the sport and sometimes unique to the athlete and his or her emotional predisposition. Ice hockey is a high speed collision sport. Many athletes play the game on a year round basis chasing a dream of collegiate or professional status. Ice hockey has a high degree of collision-related concussions according to the National Council on Youth Sports.
Contrary to current beliefs, even currently healthy youth hockey players reported higher persisting psychological symptoms among those with a history of concussion. Psychological sequelae appeared unique to a history of concussion as athletes with a history of musculoskeletal injuries did not present with the same persisting psychological symptoms. A study in Pittsburgh looked at the incidence of concussion among younger and older adolescent players from elite hockey programs.  They found a higher rate of concussion among younger players.  In a post last month I presented the notion that size matters when it comes to elite (younger) athletes playing against older and more physically developed athletes.  Concussions tend to be both more frequent and more long lasting.
As with any risk-reward scenario, decisions about physical risk must be considered when a player is invited to play up against older and more developed players. I have seen freshman football players competing at a varsity level and be severely harmed both physically and psychologically by the shear difference in size and strength.  Younger athletes are often misinformed as to the physical demands of a varsity sport and wrongly believe they are athletic failures and weak unless they play through their injuries – including concussion according to Sefton, 2018.
In 2016 the majority college ice hockey player spend one to two years in junior hockey (ages 17-21) allowing them to continue their physical development prior to entering college hockey.  This includes not only Division I scholarship programs but Division II and Division III programs as well.  Very few natural freshmen play college hockey at 18 years of age unless they are highly gifted athletes. Even these players are coached and managed by trainers with ongoing development programs, weight training, and nutritional support to enhance upper body size and strength.    Michael Sefton, 2016
Even though sport concussion is considered a unique subset of MTBI, results suggest that a smaller percentage of youth may be more prone to psychological sequelae following concussion. This means that not all concussions are created equal. Along with colleagues across the country I have been saying this for over 20 years. There is a literature on elite ice hockey players and a co-occurring mood disorder that needs to be addressed as they heal.
When I first started taking an interest in MTBI, also called concussion, physicians did not believe that someone sustained a brain injury unless there was a bonafide loss of consciousness. This remains one of the greatest myths in brain injury rehabilitation and I still hear from people that a son or daughter has a concussion “but he did not get knocked out” as if that minimizes the significance of the injury they sustained. Finally, I am still getting significant push back from the parents of children who are diagnosed with multiple concussions. The recovery from concussion two or three is not the same trajectory as the first. Many wonder why their child hasn’t bounced back like they did the first time around. And common to second concussion irritability and other mood-related changes are common.
I suggest to parents expect the unexpected and try not to attribute changes in school functioning to laziness alone. Plan on working with the school-based support team and athletic trainer as you return to learn and return to play.  Most elite programs offer emotional support for athletes suffering with the effects of concussion. Many feel isolated or marginalized because they may appear normal and walk and talk just like other members of the team. Athletes recovering from concussion are at higher risk of second concussion if they return to play before their injuries heal.  This takes 7-21 days on average.
The Pittsburgh study, published in Pediatrics in 2016, revealed that the population of ice hockey players they studied had a higher preponderance of players who had sustained one or more concussions.  This is what I experienced in looking at junior level ice hockey (typically aged 16-20 years) teams a few years ago.  I was surprised when I asked how many had sustained a prior concussion and most all the players raised their hands. Fighting is first allowed in this level of play and sometimes becomes a handicap for players with sites set on collegiate play.  In many cities across the country junior hockey is the only show in town.  Some cities in the mid-west actually televise games and report scores on local sports programs.
Remember no two concussions are the same. Sports all have their return to play protocol that begins with recognizing the importance of controlled exertion in the setting of concussion and recovery.

Sefton, M. (2016). Body Checking in Hockey: When size matters. Blog post: Taken October 9, 2018

National Council on Youth Sports
. Report on trends and participation in organized youth sports. Available at: Published 2008. Accessed March 17, 2015

Kontos, A. (2016) Incidence of Concussionin Youth Hockey Players PEDIATRICS Volume 137, number 2 , February 2016 :e 20151633 Taken October 9, 2018


Clock of the Week: Alzheimer’s

84-Year old female with Alzheimer’s Dementia
WESTBOROUGH, MA August 2, 2018  Here is the clock of the week. It is drawn by Helen, an 84-year old right handed woman suffering from the affects of Dementia of the Alzheimer’s Type – DAT.  I have published weekly or monthly clocks on these pages for the past 3 years.  Recently I have added links to the video taken in our Neuropsychology service at Whittier Rehabilitation Hospital.
All HIPPA compliance rules are followed in terms of patient confidentiality.  I encourage readers to send in clocks for me to publish.  Helen had significant difficulty constructing this clock.  Unlike some of the recent clocks I have published this clock was normal size.  Helen had a resting tremor that closely resembled the movement pattern seen in patient’s with Parkinson’s Disease.

Clock of the Week: July 23, 2018

WESTBOROUGH, MA July 24, 2018 Some people believe that the simple task of drawing a clock is like a window into the brain (Eknoyan,et al. (2012). I have posted reviews of clock drawing over several years.  Edith Kaplan, Ph.D. is credited with teaching me the importance of these neurocognitive protocols in 1985 while I was training at Boston City Hospital. Dr Kaplan saw the clock drawing as a parietal lobe test (Kaplan, 1988) but many debate that focal attribution of the clock drawing may under represent the clinical utility of this perfunctory task.  Tranel and collegues (2008) found that the clock drawing has several potential neuropsychological correlates represent the neuroanatomic underpinnings of the individual clocks scored and rated in their research.
“Documenting the type of clock-drawing errors can contribute to the clinical evaluation of patients with suspected neuropsychiatric disorders and syndromes”  Eknoyan, et al.
Watch the video below and enjoy a complete assessment of a single patient undergoing neuropsychological assessment.  Post your thoughts and let me know what your observations say to the underpinnings of cognition we are seeing.  This patient was cooperative and friendly.  He is only 82 years of age and was undergoing treatment for a recent mechanical fall.
Michael Sefton
Eknoyan, D. et al. (2012) Journal of Neuropsychiatry Clin Neuroscience, 24:3 Summer.

Kaplan, E. (1988) The Process Approach. In Boll T, Bryant, BK, editors. Clinical Neuropsychology and Brain Function. Washington DC, APA.

Tranel, D, et al. (2008) Does the Clock Drawing Test have Focal Neuroanatomical Correlates? Neuropsychology, 22(5) 553-562.

Visual Motor Skill and Dementia

WESTBOROUGH, MA July 2, 2018 Simple tasks become more difficult and often are impossible.  Tasks like copying a simple design or making simple line drawings become cognitively onerous


You can see from the drawing above that the 90 year old woman had difficulty initiating and executing the task.  “Draw-a-clock” seems simple enough.  I have been using this technique for over 20 years with very interesting findings.  The
The task relies on existing internal template of clock along with enduring problem solving and self-monitoring. The second drawing was initiated at her own choosing.  When given the choice she asked to draw the bicycle. That drawing is shown below.  Both posts are tiny in size – only 2-3 cm and reveal just how lost the self-monitoring component of cognition has become for this interesting patient.
The most interesting piece of this illustration is the diamond shape.  We had just stopped working on drawing shapes from the Mattis Dementia Rating Scale.  The final shape is a diamond.  Shortly afterward I gave her the standard instructions to draw a clock.  I have published many clocks in these pages to illustrate the complexity of the task.  She initiated the task by constructing another diamond and began putting the numbers in the contour of the diamond – rather than the typical circular drawing.  This is the first time I ever had the clock drawn in a diamond and this is an example of a contaminated response whereas one task intrudes into the next task as I just described.  These types of errors are common in patients with dementia.  I have attached the link to the actual video taken of the task as she created the clock.  Here is the link to the video taken of this clock drawing.
90 DATBicycleScan

Bicycle drawn by same 90 year old patient


Clock of the Week – June 21, 2018

WESTBOROUGH, MA June 21, 2018 The clock of the week was drawn by a 74-year old female patient suffering from a right hemisphere cerebral vascular accident (CVA) with a significant number of cognitive behavioral changes from her pre-illness baseline.  As you can see from the scanned drawing, it took two attempts for her to be satisfied with the effort. Both drawings are quite small (micrographia) – 1.8 cm in size (0.7 inches).  Why?

Rt Hemisphere_May18Scan

There are several reasons for micrographia that have to do with visual processing and self-monitoring.  When a task is given such as the clock drawing the subject must be able to process the directions using existing linguistic functions.   Once done there is an element of planning, e.g. “how do I start this process”?, and finally the initiation and execution of the task from first step through the final drawing.  This clock was barely over 1/2 inch in size.  The female used the space provided very sparingly and talked her way through the task suggesting a verbal strategy was helpful. However, as you see form the top drawing she was unsuccessful.  Immediately afterward, seeing that she failed in the task, she drew the bottom left clock and felt she had done a better job.

It is always  interesting to see for yourself how these tasks are completed and to what extent brain injuries interfere with the drawing of common objects like the clock. My interpretation of this clock suggests to me that her frontal feedback loop was decreased in its efficiency. It would have provided her with immediate, on-going feedback and real-time monitoring and adjustment of her work.  In the second draft, she may have planned a larger circle and placed the numerals in their correct juxtaposition of one another.  Finally, she may have thought for a moment and set the hands correctly for ten past eleven.

     I have had discussions with speech pathologists with whom I regularly consult about the next generation of patients that are given this task as they get older and may not have learned how to construct the face of a clock when first learning to tell the time.  Perhaps at some point we will ask them to draw the face of their cell phone as a screening test of current cognitive functioning.

June 8, 2018 – Clock of the week

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”

Basball_written- LangScan
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.


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.
Dio ClockScan
Clock drawing by 79-year old male with dementia.