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

_93357606_c0036850-amygdala_in_the_brain_artwork-spl
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

images
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.

IMG_5093
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.