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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Resilience needed after Concussion

WESTBOROUGH, MA May 2, 2018  At a meeting of the Sports Neuropsychology Society held in early May each year the topic of “resilience” emerged as a term referring to the physical and emotional response to adverse events. According to Sonia Coelho Mosch, Ph.D., “your body and mind can choose how to respond to the event with ‘I’m really screwed’ or you can change what you say to yourself with the expectation that you are going to overcome it” on Forbes.com.  Patients who obsess over every symptom may be those who go on to experience post-concussion syndrome.
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” according to the American Psychological Association.
Dr. Mosch believes people who take responsibility for their injury and focus on intermediate goals for restoring themselves often recover quickly “as long as they do not focus on small symptoms and pathologize every internal feeling state.  She works with NHL pro hockey players as well as clinic patients who are referred for any number of possible injuries causing concussion e.g. car accident.  Positive outcomes are linked to handling the stressful event with positivity and the expectation for a positive outcome. The pro athletes more often than not express a strong willingness to do “whatever is necessary” to get back to work and take responsibility for their recovery. “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” according to APA site.
At Whittier Rehabilitation Hospital we are often working with people who have been symptomatic for months or even years.  They come to Whittier not expecting to get better and believing they are truly sick and no one understands what they are going through. When told they must alter their expectations and begin to work towards better management of stress, physical mobility and light exercise, and nutritional health and well-being they sometimes become disenchanted and move on.
In the first meeting, I have had a patient tell me that he believed that he was dying and had started telling his friends as much.  These cases are very difficult to treat and require both physical and emotional support for successful outcome. 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.  A re-exertion plan along with physical therapy, aquatics, and mindfulness are components of a complete plan of action for recovery from concussion.

Wagner, R Neuropsychologist shares pro hockey players’ secrets to resilience. Forbes.com taken April 30, 2018
APA. Road to resilience. http://www.apa.org/helpcenter/road-resilience.aspx Taken 4-30-18.

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

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

Brain, Concussion and Stress: Health effects and post-concussion syndrome

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Amygdala highlighted is over active when stress exists and raises the body’s threat level as shown in this BBC graphic
WESTBOROUGH, MA January 15, 2107 The human cost of stress has been well-studied and the effects of stress are a well-known cause of cardiovascular illness including heart attack and stoke.  It is now known that the brain plays a big role in all of this. The human stress response elevates heart functioning – especially blood pressure and normal heart rhythms in unhealthy ways.  Stress activates the amygdala in the brain by tricking it – as if some great threat exists.  People believe that the body’s autonomic nervous system can be thrown off after a concussion slowly becoming irregular resulting from an abnormal stress response. There is a deactivation of inhibitory neurons in the brain resulting in greater sympathetic activity. This involves progressive relaxation and guided imagery that can slowly lower the tension felt in the body.
Symptoms of concussion are known to elevate the sympathetic nervous system over time. Known as the fight-flight mechanism, stress activates the mechanism in the brain that prepares us each for battle.  This level of tension can only last for so long without needing a break. That is where the parasympathetic system comes in putting the brakes on the body allowing it to rest. The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.
Study: Overactive system of emotional drive
Many believe that an overactive system in the brain results in the elevation of the autonomic nervous system. A Harvard study followed 300 patients for several years and found that those with an overactive amygdala were more likely to have cardiovascular disease and be at greater risk for stroke and heart attack. The amygdala is a tiny organ responsible for the emotions such as fear or pleasure.  It also plays a role in the systemic inflammatory response that may prolong the symptoms associated with concussion. “Heart experts said at-risk patients should be helped to manage stress” according to a BBC publication taken from Lancet.
The protocol I use involves paced breathing and heart rate entrainment as a way of putting the brakes on stress. But it takes time and American’s want instant fixes. Mindfulness requires self-monitoring and personal reflection.  If more people understood the health cost of stress and were able to identify high stress lifestyles then they might make behavioral changes that can lower the risk for cardiovascular disease later on.

The protocol quickly assists in helping patients find a balance or resonance between sympathetic and parasympathetic systems in the 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.

In several blog posts I have illustrated the potential negative health effects of high stress and physical functioning for which I am providing biofeedback at Whittier Rehabilitation Hospital in Massachusetts. This process helps put the brakes on the stress response and quiet the body.  The effects of concussion slowly elevate autonomic response adding to tension and physical malfunctioning. The biofeedback protocol helps lower the human cost of stress and the body’s inflammatory response and may lower feelings of tension and anxiety.  In doing so a rise in physical and emotional well-being may be expected.

BBC report http://www.bbc.com/news/health-38584975, taken January 14, 2017
WebMD post,  http://www.webmd.com/brain/news/20170111/stress-ball-in-your-brain-may-be-key-to-heart-risks#2, taken January 14, 2017
Sefton, M. (2016) Coincident stress may contribute to post concussion symptoms, blog post, https://concussionassessment.wordpress.com/2016/09/26/coincident-stress-may-contribute-to-pcs/, taken January 14, 2017

Heart rate variability: Biofeedback options for Post-concussion Syndrome

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PHOTO: WebMD

WESTBOROUGH, MA August 3, 2015  Post-concussion Syndrome (PCS) effects about 5-10 percent of those who experience a concussion or mild traumatic brain injury. By definition it is diagnosed when patients fail to recover from their concussion in the expected 2-3 weeks or sometimes longer.  This happens for a variety of reasons that are not always readily apparent.  Sometimes the expectation of a quick recovery is thwarted by the return to full activity too soon, according to Michael Sefton, Ph.D Director of Neuropsychology at Whittier Rehabilitation Hospital in Westborough, MA.  For example, when returning to work after 2-3 days of rest one should not expect the brain to be fully healed.  As a result, a return-to-work plan is essential.  Post concussion syndrome is not common but as many as 10-14 percent of cases exceed the usual 7-10 day recovery period.

There are biofeedback protocols for post-concussion syndrome (PCS) that have been shown to improved the autonomic nervous system mismatch that often accompanies PCS.  Here at Whittier Rehabilitation Hospital I have been using HRV entrainment to activate, or entrain the parasympathetic “braking” system that may directly lower the arousal associated with concussion including muscle tension, anxiety, elevated pulse, and suboptimal breathing.  The method uses paced breathing for greater autonomic resonance and has been shown effective with pain management, poorly deployed attention, ADHD, and peak performance training.

Heart rate variability is a measure of cardiovascular health (Conder and Conder, 2014).  A link has been demonstrated between traumatic brain injury, even concussion, and multiple organs including the heart (Cernak and Noble-Haeusslein, 2009). The effects of brain trauma impact structures deep within the brain including the brain stem.  These cerebral regions impact cardiac function and can lead to cardiac illness.

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Biofeedback console shown depicts HRV screen using paced breathing for greater autonomic resonance

People believe that the body’s autonomic nervous system can be thrown off after a concussion slowly becoming irregular resulting from an abnormal stress response. There is a deactivation of inhibitory neurons in the brain resulting in greater sympathetic activity. Thayer and Lane (2009) propose a right prefrontal cortex as having a direct role in cardiac modulation. This results in decreased heart rate variability and often increased heart rate and a host of other physiologic signs that prolong the recovery from concussion. Williams et al. (2013) proposed a white matter hypothesis highlighting the connection between white matter pathways in the brain and interaction between the amygdala and the sympathetic nervous system.  Autonomic dysfunction is a well established underpinning of elevated stress.  Hypertension is a leading cause of death around the world and may be attributed to the body’s abnormal response to external factors like stress.

“Traumatic brain injuries  or TBI can occur at any time while working, playing, driving, or riding a bike!  TBI is described as a public health problem that results from a sudden force being applied to the head and brain that results from high-speed acceleration-deceleration force coupled with secondary injuries from axonal shearing, cerebral edema, hypoxia, bleeding within the cranium, and autonomic dysfunction” (Sefton, 2014).  In cases of brain injury one might see autonomic storming as just described that results from trauma to regions of the brain that control primitive bodily functions like respiration, heart rate, and emotional regulation.

“The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.” (Sefton, 2014)  The human stress response drives a growing imbalance of the autonomic nervous system.  Namely, the sympathetic nervous system, responsible for our innate fight-flight response is gradually accelerated adding to an influx of stress hormones like cortisol that can cause inflammation in the body.  Cortisol can also have negative impact on sleep, memory, and acts as an appetite stimulant (APA).  Scientists and physicians agree that chronic inflammation within the body can lead to failure in the affected systems like the heart.

Conder R. and Conder, A. (2014) Heart rate variability interventions for concussion and rehabilitation. Frontiers in Psychology, Review Article, August 2014, Volume 5.

American Psychological Association: cortisol. (n.d.). The American Heritage® Science Dictionary. Retrieved August 04, 2015, from Dictionary.com website: http://dictionary.reference.com/browse/cortisol

Sefton, M. (2014). Autonomic dysfunction: “Storming back from brain injury” Blog post. Retrieved August 6, 2015.

Thayer J. and Lane R. (2009). Claude Bernard and the heart-brain connection: further elaboration of a model of neurovisceral integration. Neuroscience Biobehavioral Review, 33, 81-88.