Certified Brain Injury Specialist

FOR IMMEDIATE RELEASE – RESCHEDULED
WESTBOROUGH, MA March 29, 2018  Whittier Rehabilitation Hospital is proud to announce that they will be offering a Certified Brain Injury Specialist (CBIS) class at its hospital in Westborough, MA.  This is a new class and is the first in classroom CBIS program to be offered in over 2 years here in the Boston area.  The class is occasionally offered in web-based format.  The upcoming class is being planned and will be re-scheduled for October 2018.  The class will be taught by Michael Sefton, Ph.D., who is a
downloadCertified Brain Injury Specialist -Trainer and Director of Neuropsychology and Psychological Services at the Rehabilitation Hospital.  This is a new course that provides extensive education in all areas of traumatic and acquired brain injury.  The certification comes through the Academy of Brain Injury Specialists and must be renewed annually.  Students must pass an online test at the end of the course. Students who receive their certification will receive 1 year of the Journal of Traumatic Brain Injury as part of the certification cost for the first year.
The cost of the course is approximately $525.00 which includes the examination fee and catered lunch both days. The textbook The Essential Brain Injury Guide – 5th Edition  was published in 2016 by the Brain Injury Association of America.  It is extensive in its revision over the 4th Edition text.  It can be purchased on-line or at the class for a discounted price.
download Class prerequisites include 500 hours of direct service to patients suffering from the effects of traumatic or acquired brain injury and completed their post baccalaureate training.  Others are permitted to take the class and obtain a Provisional certification that may be transferred to full certification once they have completed prerequisite educational requirements.
Contact ACBIS faculty Michael Sefton at 508-870-2222 x 2153 or msefton@whittierhealth.com about becoming a member of the class.  Interested students may also contact Beth Pusey at the Brain Injury Association of Massachusetts at 508-475-0032 for more. Class size will be limited. Additional details about the Academy of Brain Injury Specialists is at https://www.biausa.org/professionals/acbis
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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

Mitigating the impact

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“Players are rarely hit by a direct linear force.  They are struck from the side or oblique angle and the force causes the head to suddenly turn or twist a millisecond prior to the whiplash impact we see on television.”  Sefton, 2018

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

Neurological trauma and enduring change in survivors

Westborough, MA December 18, 2017 The British Medical Journal Lancet recently published a series of articles describing the long-term effects of brain trauma. The series is worth a serious read for those who are in the position to take care of trauma patients.

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There has been little change in our approach to handling the individual grind of caring for the TBI patient I must sadly admit.  Young and old it takes both patience and dedication to achieve the best outcomes with those we bring into our treatment continuum. “Survivors experience a substantial burden of physical, psychiatric, emotional, and cognitive disabilities, which disrupt the lives of individuals and their families, and pose huge costs to society” according the Lancet, 2017.  Many readers have read my post Updates in these pages where I have detailed well-known athletes like Formula 1 car driver Michael Schumacher and Mike Towell, the Irish boxer both of whom were seriously injured from TBI.  Towell died from injuries linked to second impact syndrome following a match in 2016.
Schumacher remains in a minimally conscious state in Switzerland.  He is conscious but does not speak or move about.  He requires 24 hour medical care and is living is a special suite adapted in his home that allows him to continue to receive the best care possible while being in his familiar setting surrounded by family and friends.  The cost of his care exceeds $ 100,000 per month.
Some reports suggest Mr. Trowell had sustained a brain injury in the early rounds of the fight.  “Essentially, “second impact syndrome” or SIS results from the brain’s inability to autoregulate cerebral perfusion pressure and swelling as a result of repeated cerebral trauma.” Sefton, 2016 on second impact syndrome and Mike Trowell
Autonomic regulation is the role of the brain stem that maintains the diurnal pattern of arousal for wakeful activity and sleep hygiene.  The brain stem regulates heart rate and respiratory drive as well.  These functions are vital to survival and comprise the autonomic nervous system.  The ANS functions as the brain and body’s alarm system signaling the need for fight-flight activation according to a Autonomic Storming post by Michael Sefton, Ph.D.
Lancet identifies the complexity of TBI and its multifactorial underpinning.  A growing number of patients are elderly that contribute to “heterogeneity of outcomes and consider ways forward for targeted management of severe TBI in the intensive care unit” as mentioned in the 2017 Lancet summary.  Improved management of TBI in the trauma centers and ICUs bring forth better rehabilitation candidates and better outcomes including return to home and eventually return to preinjury employment for many.  Surgical intervention crafted to decrease secondary injury to brain have been enhanced by improved diagnostic accumen, imaging and novel techniques such as radical craniectomy and cranioplasty for management of intracranial pressure and its associated edema.
The series also explains PSH or “autonomic storming” something that I have described in several posts and can be quite serious both in the trauma canter and later in the rehabilitation hospital   “Geert Meyfroidt and colleagues provide an overview of paroxysmal sympathetic hyperactivity, a consequence of acute brain injury, and discuss the promise of improved characterization and implications for management”. Damage to the system that regulates sympathetic and parasympathetic functioins due to traumatic brain injury can be unsettling for familiy members and clinicians alike. The recovering subject can have wild swings of autonomic arousal such as elevated heart rate – patients sometimes chug along at 140-160 while autonomic storming.  Paroxysmal changes in blood pressure may pose significant risk, respiratory rate may become tachypnic, patients frequent are febrile and may become excessively sweaty  as a consequence of autonomic dysfunction.  Patients in our rehabilitation frequently undergo repeated blood cultures and lab studies looking for a source of infection.  Many are returned to the trauma centers for additional brain imaging studies and cardiac monitoring that takes hours and is often unneccessary.  These procedures delay recovery and add confusion to the patient and his family.
The regulation of the secondary injuries such as paroxysmal sympathetic hyperactivity is essential for patient well-being and outcome measures including returning home and re-entering the work force. The Lancet series is a well written update on current brain injury treatment and management of this serious public health threat.

 Lancet Neuology (2017) Jun;16(6):452-464. doi: 10.1016/S1474-4422(17)30118-7. Traumatic Brain Injury. Taken 12-18-2017.

The state of knowledge and policy on concussion in Rugby Football Union

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Westborough, MA  August 15, 2017 Just as American’s have begun to understand the true impact of concussion and the risk associated with repeat concussion and other blows to the head, the Rugby Football Union has started to take a serious look at the problem with respect to the long-term consequence of brain injury.  According to the New York Times in April 2014 “a tidal wave of earnings” may confound the rightful medical response to concussion injuries and dominate the return to play decisions on behalf of athletes who are found to have concussion. The remove-from-competition protocol has not taken hold in European rugby where players are routinely returned to play after a 5 minute time out during which they are examined by team medical personnel. Most are back on the pitch within 5 minutes. I have seen college Rugby games where this precise “recovery” was the norm.  The NCAA has protocols for managing concussion but in some club sports these protocols are not followed.
In 2011, Ben Robinson, a 14-year old boy in Northern Ireland, died from second impact syndrome resulting from playing through a concussion. He returned to the game three times after first being injured in a high school rugby match.  Ultimately he died after collapsing on the rugby pitch. Second impact syndrome results from a repeat brain injury resulting in a metabolic “energy crisis” that interferes with brain function including maintaining homeostasis on a cellular level. I  have documented it in several published Word Press Human Behavior posts.
More recently Irish Boxer Mike Towell died from second impact syndrome hours after his fight much the same way as 14-year old Ben Robinson.  He was seriously injured early in the bout and knocked down.  His toughness and tenacity along with unacceptable referee decision making allowed him to return to the fight. “The assumption that rugby had a better handle on concussions than football, however, might have been flawed from the get-go. The most recent injury audit performed by England’s Rugby Football Union (RFU) established that concussions in elite-level professional games were occurring at a rate of 13.4 per 1,000 player hours.” Bandidi, 2016
The NCAA protocol is cited here.  “Medical personnel with training in the diagnosis, treatment and initial management of acute concussion must be “available” at all NCAA varsity practices in the following contact/collision sports: basketball; equestrian; field hockey; football; ice hockey; lacrosse; pole vault; rugby; skiing; soccer; wrestling.” Female athletes are particularly vulnerable to concussion and tend to have longer recover times. Concussion is sometimes considered an invisible injury largely due to the absence of frank signs of injury on the outside of the head.
According to the BBC, Towell was knocked to the mat in the first round of a 10 round bout.  He was given a standing 8 count and continued the fight.  Some said he dominated the next two rounds when finally in the fifth round he was again knocked down and the fight was ended.  Michael Sefton blog 2016

Burns, J. NY Times, In Europe, Echoes of America as Concussions Spur Debate, April 5, 2014. https://www.nytimes.com/2014/04/06/sports/in-europe-echoes-of-america-as-concussions-spur-debate.html?_r=0  Taken June 13, 2017
Sefton, M. (2016) Second Impact Syndrome. https://concussionassessment.wordpress.com/2016/10/03/second-impact-syndrome-rare-but-often-fatal/ Taken August 7, 2017
Bandidi, P. (2016) Rugby, like NFL, doesnt have the conussion-issue figured out.  http://www.espn.com/espn/story/_/id/16029747/rugby-nfl-concussion-issue-figured-out Taken August 7, 2017
NCAA Concussion Concussion Safety Protocol. Guidelines https://www.ncaa.org/sites/default/files/2017SSI_ConcussionSafetyProtocolChecklist_20170322.pdf Taken August 8, 2017

The results of postmortem examination of over 100 brains of NFL athletes are in

WESTBOROUGH,MA July 25, 2017 The laboratory at the Boston University School of Medicine has recently completed its initial examination of over 100 brains donated by the family members of those athletes who have died because of marked behavior and personality changes attributed to playing football.  The results confirm the presence of destructive proteins that have come to be known as chronic traumatic encephalopathy.  This was first reported over 10 years ago and was featured in the movie Concussion released in 2015 starring Will Smith as Bennet Omalu, M.D. who first reported on the syndrome.