Multiple Sclerosis: And it’s insidious impact on thinking

WESTBOROUGH, MA May 15, 2017 Multiple Sclerosis is a demyelinating disorder that affects the brain and spinal cord of those so afflicted. MS is a disease that causes the immune system to attack the protective covering around the nerve fibers (Reference.com). Many of the nerves in the brain and spinal cord are covered with a myelin sheath – something like insulation on wire.  This permits the instantaneous transmission of nerve impulses from one part of the body or brain to another. In patients suffering with MS their myelin is deficient sometimes having reduced efficiency or not working at all. It is a condition that for many gets better and gets worse.  As you can see from this image taken from Google images the myelin sheath is the outer layer or membrane of fatty Schwann cells and other neuroglial support cells. MS may be linked to a virus and/or immunological compromise but its true etiology is not known.
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Google images
We see a fair number of persons afflicted with M.S. in the rehabilitation hospital here in Massachusetts. MS is known to be relapsing and remitting in its quality which adds to treatment complexity and frustration for patients. They are a fiercely independent group of people and I can certainly understand why that might be.  On some days they are able to get themselves out and into their cars for the drive to work something we might take for granted.  While on other days, they may have difficulty putting on their their shoes and making lunch.  Many are frustrated and angry that they cannot take care of themselves and sometimes wind up in our hospital getting physical therapy and other restorative therapies.  Aquatic therapy is a great resource we offer at Whittier in Westborough, MA.  I encourage people to become familiar with aquatic programs
M.S._clockScan
Clock drawing by patient with early onset MS
in their area. They can provide support, pain management and effective physical therapy for those who may have limited energy resources.  Fatigue becomes a problem in nearly all patients who suffer with multiple sclerosis.  Cognitive changes are common in patients who experience long-term MS that sometimes make subtle changes in personality and all higher order problem solving, reasoning, and other executive functions.  Some believe there are distinct personality features in those with MS
In addition to frustration and anger, some patients are resistant to restorative solutions suggested by rehabilitation team members who want to help.  Some say “they want to do things their way” and resist rehabilitative suggestions that might offer energy conservation strategies or innovative methods for greater independence.  Medication is used to reduce inflammation associated with MS and prevent relapse.

Reference.com. (2017) https://www.reference.com/health/treatments-multiple-sclerosis-2ed87c70dcd71896. Taken May 6, 2017

Return to school: Psychologists also working in the trenches after concussion

CONCUSSION-SCHOOL LIAISON 2017
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 msefton@qmail.qcc.edu

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. 

HeadacheReturn-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

Chronic Stress – The unbridled malignancy that effects us all

WESTBOROUGH, MA January 31, 2017 There is no way to avoid a stressful life it seems.  Some people are better than others at reducing the impact of stress.  Excercise, healthy eating, regular sleep, and mindfulness reduce the impact of the stress and tension we all experience in our lives.  These behaviors are being taught to children who experience stress just like their parents in many schools. Meanwhile, concussion and more serious brain injuries result in changes in the autonomic nervous system that are sometimes life threatening.  The behavioral response of these afflictions include marked restlessness, anxiety, changes in sleep hygiene, abnormal pain response, and pervasive tension.
In cases of severe brain injury one might see autonomic storming as described in a prior blog. Autonomic storming results from trauma to regions of the brain that control primitive bodily functions like respiration, heart rate, and emotional regulation. This includes profuse sweating, elevated heart rate, rapid changes in body temperature and motor restlessness. These functions are comprised in the autonomic nervous system and are known as the fight-flight mechanism.  The sympathetic nervous system elevates blood pressure, respiratory drive, and gets us ready to fight or run.  Meanwhile, the parasympathetic system puts the brakes on these functions allowing the body to return to its normal resting rate.

“Eventually, chronic stress could be treated as an important risk factor for cardiovascular disease, which is routinely screened for and effectively managed like other major cardiovascular disease risk factors.” Ahmed Tawakol, Harvard Medical School

Ostensibly, stress has the capacity to change this normal resting heart rate and slowly raise our levels making it difficult to truly relax. In the long term, external stress can change our heart functioning including hypertension and cardiac arrhythmia and put us at risk for cardiovascular illness including heart attack and stroke. Lifestyle changes are necessary to avoid long-term health problems from stress. Mindfulness includes deep, regular breathing, guided imagery, and progressive relaxation. It is being introduced in some public schools so that it may become part of the coping mechanisms used by kids when stress sets them off – as it undeniably will do.

Sefton, M. (2015). Heart rate variability: Biofeedback options for post-concussion syndrome,  https://concussionassessment.wordpress.com/2015/08/03/heart-rate-variability-biofeedback-options-for-post-concussion-syndrome/
WebMD (2017) Brain ‘stress ball’ may be key to heart risks. http://www.webmd.com/brain/news/20170111/stress-ball-in-your-brain-may-be-key-to-heart-risks#2, taken January 14, 2017

Is there risk associated with valve replacement surgery?

Aortic valve_clock
Clock drawing of 66-year old patient who was recent recipient of prosthetic aortic valve. Premorbid health was otherwise excellent.

WESTBOROUGH, MA  March 28, 2016 Whenever surgery is recommended there are inherent risks that should be understood. The  fast answer is “yes, there are risks when you replace someone’s aortic valve.” But not so fast.

Cardiac surgery has become almost commonplace in the current medical society.  Here in the Boston area there are several heart centers providing surgical treatments and risks have been greatly reduced in the past 25 years. Procedures are now minimally invasive and require much less recovery time than the former procedures.  Many centers are also using robotic assistance in valve replacement.  There are at least 3 major centers in Boston with excellent surgical teams.  Your physician will discuss these with you but the patient must understand the risk versus reward conundrum.  You can read the list below for a bullet point visual.  This is the case whenever one embarks on treatment – “what are the risks of taking one drug over another?” or “is there a risk when I undergo surgery to replace a stenotic heart valve?

One’s heart valves are meant to last a lifetime.  The heart valves are paper thin and amazingly flexible and strong. The majority of people are born with the valves they will have at the end of life – 5-6 billion beats later. Arguably the greater risk associated with valve replacement surgery may be linked to the pre-surgical health of the recipient of the valve.  It is common that patients have multiple comorbid medical conditions such a diabetes, poor cardiac health, hypertension, and obesity.  The outcomes become only slightly murky with the host of illnesses I just cite.

My role in the cardiac rehabilitation is to assess cognitive functions when necessary. This includes concentration, attention, S-T memory, problem solving, and higher order thinking skill.  It is not uncommon for patients to have altered mental status following surgery.  Sometimes this is simply the result of pain cocktail and anesthesia but other conditions can contribute to changes in one’s cognition as well.  Sometimes I am asked to provide support and counseling for those few patients who exhibit affective changes or frank signs of depression. On occasion behavior therapy is needed to redirect idiosyncratic motor restlessness or agitation.  In general the goal of cardiac rehabilitation is to enhance functional capacity in the areas of endurance, physical fitness and activities of daily living to regain their independence.  Full recovery requires a change in habits and lifestyle. This takes time.

The rehabilitation process is a continuum of care provided to those recovering from surgery who may be ready for the changes that will take them forward.  This includes physical exercise and the nutritional support needed to enhance patient outcome.

The vast majority of patients who undergo valve replacement surgery sail right through it and never come to hospital acute rehabilitation.  Most are referred to outpatient rehabilitation where they stay at home and attend rehabilitation during the day.  For those who are sent for inpatient rehabilitation they wrestle with fatigue as much as anything.  Many were in poor physical shape prior to surgery because of the insidious impact of declining cardiac health in the months or years prior to the procedure.  Post surgical depression is common in as many at 25-40 % of cases. Psychotherapy and coaching can assist in the management of feelings that are sometimes present during recovery.  I have heard “why am I doing this…” just as much as: “I can do this and have a second chance for health…”.

Risks of valve replacement

  • Infection
  • Blood clots
  • Cardiac arrhythmia – atrial fibrillation
  • Excess bleeding
  • Transient ischemia or stroke
  • Kidney failure
  • Death – 1-2 %
NHS – UK website – taken 3-10-2016

The Cleveland Clinic has a wonderful video that is attached.

Cleveland Clinic Cardiac – Valve Replacement video