New Biofeedback protocol: Expanded Service for Brain Injury and Trauma

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Biograph instrument showing paced breathing protocol by Thought Technologies

WESTBOROUGH, MA April 1, 2016  The Neuropsychology Service at WRH has added both physiologic and EEG biofeedback to the service for those afflicted with concussion, TBI, and trauma. The protocol involves heart rate variability and controlled or paced breathing as a means of gaining enhanced resonance in the autonomic nervous system.  Autonomic storming is a common reaction to traumatic brain injury and can be debilitating over and above the structural changes that impact condition and behavior. It is not new and has utility in treating anxiety and other stress-related conditions.  The protocol is designed to activate the body’s parasympathetic function as a “quieting mechanism” – to put the brakes on for relief and a variety of physical symptoms including pain, irritability, and depression.  The “protocol quickly assists in helping patients find a balance or resonance between sympathetic and parasympathetic systems in their 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.  Patients are urged to have at least 10 sessions of HRV biofeedback and may practice at home between sessions.  Diet and exercise are important parts of recovery from TBI, concussion, and other pain-related syndromes. Dr. Sefton is certified in biofeedback including neurofeedback and is a Certified Brain Injury Specialist.  Contact Dr. Sefton for more information of this protocol or an appointment 508-871-2077.

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What to expect with first concussion?

WESTBOROUGH, MA March 21, 2016 Here is a blog that I first published in September 2013 when I first started to write this blog.  I occasionally am asked to “put up” a blog post that was previously published.  I resist this out of fear of growing irrelevant.  In any case, this blog cites some of the concerns people have when a child is diagnosed with concussion for the first time.  What can you expect?  I think it is a reasonable post that I will update with the current standard of care. Here are some of my early thoughts and those that are new.

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Student athletes experience fatigue and decreased mental endurance

“I remember when my son was playing ice hockey.  He was 12 or 13 years old.  He was hit at center ice near the bench.  The opposing playing went low hitting Casey – toppling him head over heels.  He managed to get right up but had rubber legs and skated away from the bench not toward the bench and the safety of his coaches.”  Michael Sefton, Ph.D.

WHAT TO EXPECT ?

The first concussion results in a wide range of responses from players, parents, and coaches.  Some result in an ambulance ride to the local trauma center.  Whenever an athlete is suspected to have sustained a head or neck injury his spinal cord needs to be held at midline so that he may be immobilized.  This results in the placement of a cervical collar and usually being strapped to a long board and can be a scary process for a young athlete.  Yet most concussions do not require advanced life support for their management. While working in the ambulance I have taken care of many players with concussion – all of whom did just fine.

Shortly after injury and usually prior to EMS arrival someone may assess the injured athlete at rink side or in the locker room.  It is commonplace to use an assessment tool like the SCAT to measure the athlete’s orientation, awareness, concentration, and short-term memory.  A concussion does not require that an athlete be knocked unconscious to signal an event has occurred – most concussions do not result in unconsciousness.  Remember this if you ever have a son or daughter with a concussion.

What is most common is post-injury confusion, irregular balance, inattention, and decreased short-term memory.  Some athletes become emotional and cry.  This usually results from confusion and not understanding what has happened.  This may be limited if a parent or coach is with the player in the ambulance or hospital.

Once the ambulance hands of your son or daughter to the emergency department nurses he or she is likely going to have an x-ray of the head and neck and probably a C-T scan of the brain to rule out fracture and intracranial injury.  Sometimes lab studies are undertaken.  These tests are frequently negative in spite of active concussion.  Some parents leave with the false sense that nothing has happened to their child.  Why?

The answer to concussion lies in the metabolic cascade – a shift in neural transmission and the onset of reduced efficiency between centers of the brain.  Structurally the brain is uninjured but its intracellular transport system may be temporarily corrupt. This hallmark injury is difficult to document in the ED but clinically results in cognitive slowing and some physical signs like sensitivity to sound and light, headache, fatigue, irritability, and often poor balance and memory.  The symptoms frequently can be measured for 7-10 days before they are fully healed.  Athletes should not return to play before they are fully healed and cleared by a physician.

My first personal experience turned out well thankfully.  Casey underwent the million dollar work-up at the hospital and each test was normal.  We were given written instruction for what to watch in the unlikely event he was bleeding into his brain, somnolence, seizure, vomiting followed by unresponsiveness.  None of this occurred.  Our son was held off the ice for 2 weeks before he returned to practice.  He had about 3 days where he was not himself – a normally talkative, curious boy.  During his recovery he rested and was not permitted to use the many video game systems we own.  He needed to rest.  Slowly as we could see he was more himself he was given back a wide range of activities like attending the full school day.

Parents can expect a comprehensive evaluation when student athletes are injured from concussion.  Post-injury neurocognitive testing is sometimes recommended.  My son took 2 post-injury ImPACT tests until he reached his baseline.  By then he was feeling fine and beginning step one of the return-to -play protocol.  Some athletes require a few physical therapy sessions for balance, vestibular functions and proprioception.  These can be arranged by the pediatrician or brain injury specialist.  Consultation with school nurses and teachers should be considered given the reduction in cognitive functions like: attention.  Some athletes return to school for half days during the acute recovery from concussion.  I have written education plans for recovering students to have reduced homework load, delay all tests until recovery, early release, and well-timed rest breaks.  A small subset of injured players require more prolonged care and go on to develop post-concussion syndrome.  This results when symptoms persist beyond the normal trajectory of recovery.  In most cases, when an athlete has symptoms lasting over 6 months one can begin to think about post-concussion syndrome.  With effectice management and planning most athletes heal and recover from concussion without complication.  They should not be rushed and post-injury return-to-play plans should be addressed.  No player should go from zero play to tournament play without first undergoing a step-by-step protocol to make certain symptoms do not recur with exertion.

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.

Prolonged symptoms signal delayed healing

Lacrosse players are at high risk for concussion
Lacrosse players are at high risk for concussion

WESTBOROUGH, MA  May 4, 2014 Concussion management requires a sensitive and honest discussion between the patient and the concussion specialist.  The reason for this is most apparent when the athlete, or anyone recovering from a brain injury, fails to return to his or her baseline within 7-10 days.  There are a host of factors that contribute to this some of which have to do with the degree of physical and cognitive activity immediately after injury.  It is now well understood that post injury rest is a key component to the recovery from concussion.  Extra sleep is sometimes just what may be needed until the brain has returned to normal.  Arguably this is sometimes not possible – especially when an athlete has to attend school.  Prolonged symptoms like headaches, irritability, and fatigue may signal that the brain has not returned to its normal equillibrium after injury.

Post-concussion syndrome

When symptoms persist beyond what may be expected I often take a careful history about what rest and what activity are truly going on?  This is often quite surprising. As many as 3-10 percent of concussions are outliers and have persisting symptoms greater that 21 days. I encourage complete rest immediately after injury. That includes physical and cognitive rest.  Rest from physical activity is largely intuitive – no running, no practice, no lifting weights and so forth.  It also means – no internet, no instagram, no social media, no TV, no fun!  At least for the first few days.  When this fails it may be a signal that the brain has not return to its baseline.  Concussion may be thought of as an energy crisis in the brain. In order for the healing to take place the brain needs rest.  The failure to allow full recovery to take place prior to exerting the athlete places him or her at risk for additional injury from second impact.

History of prior concussions

Another important clue to a prolonged symptom profile may be the prior history of concussion.  Second and subsequent concussions sometimes demonstrate an alternate recovery curve and take longer to heal.  These factors will also determine the course of recovery as well as the return to play protocol and the return to learn accommodations that may be necessary to support a student athlete.  Just as athletes should not return to play before they are ready an athlete suffering with symptoms of concussion should modify the school day so as to allow for time needed for recovery.  There should be an understanding that no student may be expected to take tests – even state mandated achievement tests until they are fully recovered from their injuries.  Some students require a formal 504 support plan for the duration of their symptoms. This is a plan that mandates a host of school-based accommodations to support prolonged symptoms.  Some students experience physical signs like lingering fatigue, poorly deployed attention, headaches, sensitivity to sound or light, and decreased balance.  Other students exhibit changes in behavior and mood as a prominent sign of the concussion.  Some students have the combination of physical and emotional symptoms that are worsened by forced overwork and failure to rest.

The Concussion Assessment and Management Program is now at Whittier Rehabilitation Hospital in Westborough.  It isn’t easy getting student athletes to rest.  They want to be active and to be with friends and teammates.  Unfortunately, unless they can permit themselves to fully shut down they may expect to have symptoms longer than most.  This protocol often requires coaches and parents to closely monitor their activity and set firm limits on physical and cognitive activity during recovery from concussion. There are health risks when athletes try to “work through” an injury. It is now well known that repeated concussions lead to long term brain injury with potentially fatal outcome. Concussion is thought of as an invisible injury because a player show’s no outward sign of debility but a price is paid when the first step to recovery is not heeded. Rest. Complete rest and no exertion until the athlete is symptom free.  Whittier can offer assessment and rehabilitation of athlete’s dealing with concussion.

Snowboarding and terrain parks – Boarders must know the ground rules

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Dr. Mike Sefton speaks to athletes at Boston Bruin’s camp
WESTBOROUGH, MA – The greater Boston area has its first white Christmas in a few years.  This makes it easy to seek out local mountain skiing and riding – especially during the school break.  Riders are especially eager to check out all the changes made to the local terrain park in terms of added features, jumps, and rails.  The trouble with this is that in the early season the depth and texture of the snow may not yield midseason quality nor readiness to safely attack the hill.  Injury is all too often the result of the build up of excitement, excessive speed and lack of familiarity with terrain during early season practice runs.  I have already seen an uptick in the number of concussion cases in my practice most of which will recover and heal normally. How  are concussions impacted by the history of prior concussions?
DOES THE NUMBER OF CONCUSSIONS IMPACT RECOVERY ?
Yes.  In August 2013, I published a blog that described the current return to play protocols.  It is now understood that an accumulation of concussions can lead to a serious degenerative disorder called chronic traumatic encephalopathy or CTE.  The risk of this may be diminished by allowing the brain to fully recover before returning to the field of play.  This means no formal exertion and very limited cognitive exertion too.  The NFL and NHL have both paid out large sums of money to settle the lawsuits of athlete’s suffering from a host of symptoms thought to linked to repeated concussions during play.  The end product of CTE is death. The Boston University School of Medicine in collaboration with the Sports Legacy Institute is conducting extensive research on the donated brains of professional athletes.  One stunning discovery was the presence of CTE in the brain of an 18-year-old boy who died from an unrelated cause.
When can an athlete start return to play?  The answer to this question depends upon the duration and intensity of symptoms. The consensus is that an athlete should be symptom free before returning to any form of exertion.  It has been shown that the subtle cognitive effects of concussion can last 7-10 days or longer.  Certainly a person with a high number of prior concussions will have a recovery that can differ from the first injury athlete.  An athlete with 3 or more prior concussions may be symptomatic for weeks – a condition known as postconcussion syndriome.  Athlete’s do not need to be rendered unconscious by their injuries we now realize. This was once thought to be an essential element of concussion and it has been dispelled now as new protocols and greater understanding of brain injury are emerging.
ROTATION AND SHEER
In fact, a concussion can occur from any force or trauma being applied to the brain.  This creates secondary force or energy within the skull that puts strain on tissue and white matter fibers – interconnections between important regions of the brain.  Changes in cognitive functioning occur when these myelinated fibers are stretched such as when an athlete is concussed. The snowboarder who rides a rail only to catch the tip of his board can be thrown forward with enough force to begin the physiological cascade of strain and sheer that results in transient cellular numbing.  If these fibers are stretched to the point of breaking, then the cell bodies to which they transmit their vital neurochemical messages will die leaving a penumbra of necrotic tissue often seen in more serious traumatic brain injury.  Chronic traumatic encephalopathy results in a growing number of these necrotic or dead areas in the brain coupled with the presence of destructive proteins found in the brain’s of patients suffering with Alzheimer’s Disease.
Athlete’s need to know the terrain at which they intend to ride.  Trail maps prevent skiers from becoming lost so to will terrain maps reveal each feature a boarder must navigate as they ride.  Safety and common sense dictate a slow start to each new season along with care to fully prepare for hazards and new features.  Resort operators can be expected to post terrain changes and ground rules for skiers and boarders as they change from year to year.  Elite athletes push themselves in order to reacher higher heights and set new records.  When they become injured great care should be taken to educate them about the long terms risk of repeated concussions, postconcussion syndrome, and CTE.
Sefton, M (2013) Return to play. http://www.concussionassessment.wordpress.com.  https://concussionassessment.wordpress.com/return-to-play/