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

TBI, concussion and headaches in females

headache-2-mbhi5p4ess5v9x1kbfpafgnr6lyhkdbydmq67h3pno.jpgWESTBOROUGH, MA March 15, 2018 Serious and chronic headaches are a frequent complaint of those recovering from mild traumatic brain injury.  “Headache is one of the most common symptoms after traumatic brain injury (often called “post-traumatic headache”). Over 30% of people report having headaches which continue long after injury.” (TBI and Headaches, 2010) They can be quite debilitating. The NCAA Headache Task force listed headaches as among the most debilitating symptoms in the aftermath of concussion.  Young women tend to have a higher incidence of post-concussive headaches than males.  There is treatment for post-concussive head pain.
Migraine headaches are three times more common in females than males.  Rates of emergency room visits related to traumatic brain injury (including concussions) among women almost doubled from 2001 to 2010, according to the Centers for Disease Control and Prevention (CDC). In my own practice here in Massachusetts I have seen more recurring headaches in females than in males. In addition, female athletes generally have a longer recovery course than some of the males I follow.  I will say that males are prone to abuse alcohol when recovering from concussion that may also be a confounding variable in the trajectory toward their normal baseline.
Individuals previously treated for headaches are at greater risk of both developing post-concussive headaches and for having chronic headaches following recovery from concussion.  These injuries can be caused by not only sports but also falls, car crashes, blunt trauma (getting hit on the head by an object), and assaults as noted in a 2016 Health.com report on women and concussion. I have worked with several high school athletes who had pre-injury headaches and received treatment for chronic headaches who went on to have an increased frequency of headaches after concussion. I worked with a tenured college professor who developed headaches from being hit with a basketball at her daughter’s middle school practice. This was shortly after being diagnosed with concussion from a prior head trauma.
American Olympian Lindsey Vonn suffered with the effects of concussion for months following a skiing accident in 2015  including chronic headaches.  The BBC recently featured 22-year old skier Rowan Cheshire who sustained a concussion 4 years ago that kept her from competing in the 2014 Olympic Games.  Cheshire had won the World Cup event one month prior to the Olympics in Sochi and suffered a severe concussion in a fall off the halfpipe. It was the first of two subsequent concussions over the next 3 years that caused severe side effects including migraine headaches and panic anxiety.  Cheshire worked closely with a sports psychologist during her recovery.
One reason for the difference between men and women in concussions is that women tend to have smaller neck and shoulder muscles allowing for greater whiplash from force striking the upper body.  Episodic headaches are usually set off by a single stressful situation or a build-up of stress. These are tension-related headaches which may be unrelated to concussion but whose frequency and intensity change following concussion or when under stressful life conditions. Nevertheless, unchecked stress and tension may contribute to an increased proclivity for head and neck pain and both respond very well to biofeedback and alternative interventions such as acupuncture and progressive relaxation. Daily strain can lead to chronic headaches. Coupled with concussion, stress can become inflammatory in terms of the frequency and intensity of headaches.
“Post traumatic headaches are seriously debilitating in terms of lost school and work days.  They are often a late symptom in the recovery from brain injury and concussion” Michael Sefton, 2018

Symptom presentation
In early childhood there is similarity between boys and girls in symptoms profile. This changes as children enter their growth spurt. “Puberty, which marks a significant developmental fork in the road for males and females, also marks a divergence for concussions. With its onset, females increasingly experience higher incidence of concussions, different and more severe symptoms, and are often slower to recover from the injury.” Treatments for post-concussion range from complete rest to gradual re-exertion, to physical therapy and more. There is a growing trend to slowly increase physical activity once symptoms resolve and I have seen a return of symptoms in cases where physical activity is premature and in cases of second or subsequent concussion.
One clear intervention for post-concussion headaches involves a paced-breathing protocol and neurofeedback that I have been using.  I teach and practice stress management using biofeedback instruments that have demonstrated reducing duration of headaches, reducing stress, and lowering sympathetic abnormalities including heart rate.  The goal of treatment is to reduce the body’s reactivity and normalize the autonomic system. “Fortunately, even if post-concussion headaches don’t get better in the first few weeks after concussion, most are better within 3 months and almost all are better within a year after injury” according to Heidi Blume, M.D., at the American Migraine Foundation.

Sefton, M. (2018) Abnormal Stress response from mTBI often sometimes leads to headaches. Response comment in Emergency Medicine Journal, Volume 34, Issue 12, February 23, 2018
Levine, H. (2016) The Truth about concussions and women. http://www.health.com/headaches-and-migraines/women-concussions
Roehr, B. (2016). Concussions Affect Women More Adversely Than Men: Differences between how females and males experience concussions suggest the need for gender-specific prevention and treatment strategies. Scientific American posted March, 2016. https://www.scientificamerican.com/article/concussions-affect-women-more-adversely-than-men/ Taken February 28, 2018.
Lahz S, Bryant RA (1996). Incidence of chronic pain following
traumatic brain injury. Arch Phys Med Rehabil, 77(9),
889-891.
Blume, H. (2016). Headaches after Concussion. American Migraine Foundation.  https://americanmigrainefoundation.org/understanding-migraine/headaches-after-concussion/ Taken February 28, 2018

Clock of the week: February 16, 2018

WESTBOROUGH, MA February 16, 2018 Here is the clock of the week for mid February, 2018.  It is quite unusual as you can see. The clock of the week is sent to me by a speech language pathologist here at Whittier
Name in clock
Rehabilitation Hospital in Westborough, MA.  It was drawn by a 76-year old H.S. graduate with one year of college.  As you can see this patient was provided with standardized directions that I have described in many other posts.  “Draw the face of a clock with all the numbers – set the hands for 11:10.”  It is amazing how the brain operates – or in some cases fails to appreciate the task demands and process the 3 steps of the task as it is given. What is also missing in this creation is an awareness of the errors made relative the task demands.
In this case the speech language pathologist drew the circle because she was using the SLUMS Examination – a V.A. Healthcare screening tool. The SLUMS gives the patient a circle but in general the directions prefer the patient to draw the circle him/herself.
Whatever clock
  The name has been altered for privacy.  What do you make of this clock? Whatever, it’s about
12 before 10? No?

Clock of the Week: 1-25-18

Whatever clock
Unusual clock seen store window in Rockland, ME  January, 2018
Westborough, MA February 1, 2018 The video below is the clock of the week for this week in January, 2018. It is an interesting construction by a 81-year old male who is undergoing treatment for respiratory failure and myelodysplastic disease – a blood disorder in errant white blood cell production. He has had difficulty with all of his activities of daily living including dressing, bathing, personal hygiene and toileting.  He is recovering slowly and receiving daily therapy for these physical and occupational deficits.
“Renowned neuropsychologist Dr. Edith Kaplan too had a love affair with clocks (and owls as I recall) and taught us the unique importance of this seemingly simple neuropsychological instrument.” Sefton, 2015
 Clock video
The “clock drawing” task is described throughout the pages of this blog and is widely used by psychologists as a screening for cognitive dysfunction.  I like it because it is not threatening and is not a great challenge to the patient.  That said, I have had many people say ” I am not an artist” when asked to draw the face of a clock.  Interestingly, I suspect those who deny being artistically gifted (drawing a clock) may have some degree of preserved insight into their declining cognitive ability.
Clock of the Week: 1-25-18
https://www.youtube.com/watch?v=5FetKtiEzJE
The video is produced by the Neuropsychology Service at Whittier Rehabilitation Hospital. HIPPA protected.

 


Sefton, M. (2015) All this from a clock? Blog post: https://concussionassessment.wordpress.com/2015/04/29/all-this-from-a-clock-a-cognitive-test-for-the-ages/ . Taken January 26, 2018

CTE found in teenage brains by B.U. team

WESTBROUGH, MA January 18, 2018 The scientists studying the damaged brains of older athletes have had the opportunity to study brain damage in athletes who died from other causes.  In 4 such cases, there was evidence of chronic traumatic encephalopathy (CTE) that was not commensurate with the degree of brain trauma that was observed during their athletic careers according to Felice Freyer of the Boston Globe. This recent study was published in the journal Brain illustrates that the onset of CTE may be closer to onset of brain injury than first thought not much later in life.
“The report, published Thursday in the journal Brain, also provides what Goldstein called “the best evidence to date” supporting the theory that CTE is caused not just by concussions, but rather by any blow to the head, including mild impacts. Instead of diagnosing and responding to concussions, he said, coaches would do better to protect children from all hits to the head.” Felice Freyer – Boston Globe 1-8-18
The possibility of younger athletes developing CTE and the symptoms associated with this progressive disease is quite worrisome especially to parents.  It was always thought that CTE would develop later in life if at all. With the prospects of the disease having a much earlier onset the cost of CTE over a lifetime is incalculable in terms of medical costs and neuropsychological sequelae that may evolve in time. The true impact of this and the consequence for repeated, subclinical blows to the head is only now becoming clear.
Like dementia of the Alzheimer’s type the build up of tau protein underlies the changes associated with CTE. “Chronic traumatic encephalopathy is a condition bringing forth progressive tauopathy that occurs as a consequence of repetitive mild traumatic brain injury. We analysed post-mortem brains obtained from a cohort of 85 subjects with histories of repetitive mild traumatic brain injury and found evidence of chronic traumatic encephalopathy in 68 subjects: all males, ranging in age from 17 to 98 years (mean 59.5 years), including 64 athletes, 21 military veterans (86% of whom were also athletes) and one individual who engaged in self-injurious head banging behavior” according to the journal Brain. McKee, A. et. al. 2017

McKee, A. et. al. (2017) The spectrum of disease in chronic traumatic encephalopathy. Brain, Volume 136, Issue 1, 1 January 2013, Pages 43–64, https://doi.org/10.1093/brain/aws307

Neurofeedback: Entrainment options for recovery from concussion

WESTBOROUGH, MA February 28, 2018 There is a growing consensus among providers that a multidisciplinary approach to concussion management is necessary.  Along with heart rate variability neurofeedback helps to reset the sympathetic-parasympathetic mismatch using proven entrainment techniques such as increasing amplitude of sensory motor rhythm (SMR) that has been shown to quiet the body.  I use both neurofeedback and traditional physiologic biofeedback modalities with all kinds of physical conditions from chronic pain to traumatic brain injury with good results. The sensor is placed at the central z-spot or Cz on the 10-20 EEG placement map. A combination of paced breathing, relaxation, and EEG SMR entrainment help bring the body into a more restful coherence and decrease the body’s physical reactivity that causes tension and a host of lingering physical issues.  The emotional and financial cost of these issues is enormous over time. We use the ProComp + and Thought Technology software in our work.

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A Brief Review and Clinical Application of Heart Rate Variability Biofeedback in Sports, Exercise, and Rehabilitation Medicine. Gabriell E. Prinsloo, H.G. Laurie Rauch & Wayne E. Derman  The Physician and Sportsmedicine Vol. 42 , Iss. 2, 2014