WESTBOROUGH, MA It is time once again to select the “Clock of the Year”. Voting will go on for the next week. There are 10 clocks featured this year each one drawn by a patient undergoing rehabilitation at Whittier Rehabilitation Hospital in Westborough, MA. The diagnoses of each patient may or may not be presented with the clock as it scrolls through. Any clock with a measuring tape would be presented in millimeters-centimeters not inches. The clocks shown in millimeters are tiny – micrographic in quality. The first clock in the slideshow is drawn by a 93-year old – each one would then become a successive number through # 10.
I have published many blogs about the use of the clock drawing in clinical practice. Clock drawing was first introduced to me in my practice as a pre-doctoral student in psychology at the V.A. Medical Center in Boston by Dr. Edith Kaplan. She taught us that
something as simple as a clock drawing can become a daunting task when faced with cognitive changes from brain injury, stroke, or dementia. I carry on this tradition in honor of Dr. Kaplan and the role she played in my formative work as a neuropsychologist. Today, every discipline it seems uses a clock to assess problem solving, organization, and following directions in patients with suspected decline in their thinking skill. Dr Kaplan died in September, 2009 and is missed even now.
WESTBOROUGH, MA November 8, 2017 There are several types of biofeedback that are useful when recovering from a concussion. The first may help with the stress response that sometimes goes into overdrive after TBI or concussion. This involves becoming familiar with the fight-flight mechanism and its useful purpose as an early warning system. Throughout time the autonomic nervous system (ANS) allowed animals and man to be ready whenever threats to personal safety were present. When we are able to out fox the threat then our sympathetic cascade may slowly return to normal as the parasympathetic breaking mechanism exerts its balancing influence.
There is no way to avoid a stressful life it seems. Some people are better than others at reducing the impact of stress. Excercise, healthy eating, regular sleep, and mindfulness reduce the impact of the stress and tension we all experience in our lives. Michael Sefton 2017
The automatic process of sympathetic arousal ramps us up as if to say “bring it on” – activating us to fight or fly the coop. The problem all too often is an insidious elevation of normal baseline physiological values that create a sympathetic-parasympathetic mismatch. This results from over active adrenergic fibers largely activated by hormones such a cortisol looking the system. Over time this leads to heart disease, hypertension, and a host of inflammatory diseases and may prolong those needessly.
The primary goal of all modalities of biofeedback including psychophysiologic and neurofeedback is to restore the body to its “normal” state. The process promotes mindfulness and paced breathing to gradually lower respiratory drive, reduce heart rate and blood pressure, and enhance other abnormal physiological readings of skin conductance, finger temperature, and electromyography. It takes practice and understanding of its value. Not everyone has elevations in each these bodily measures. The specifics of abnormal findings are discussed as part of the treatment plan with the doctor or clinician.
There is a well established link between heart rate and the pace of breathing. 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. When this system is damaged due to traumatic brain injury 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.
“Autonomic dysfunction must be carefully managed in patients recovering from TBI. This is not conceptually novel although its application to health conditions continues to broaden. Biofeedback may be a useful modality for migraine headaches, anxiety, pain management, concussion, and stress. I have used a combination of physiologic and neurofeedback for patients with failure to thrive, depression, post-concussion syndrome, and severe traumatic brain injury” 2014). In 2006 I was invited to London, UK to present the findings of a case study with a high school boy who had sustained a severe TBI and was in a minimally conscious state. The results were remarkable and not entirely the result of the neurofeedback protocol I used with him. Our team did a good job keeping him moving and gradually he became more functional and regained his independence. It was a fun trip I was able to take with colleague Paul Liquori, MD, medical director at Whittier Rehabilitation Hospital in Bradford.
Relaxation and mindfulness have existed for over 60 years bringing together conscious conscious effort to control bodily system that were once thought to be automatic. Sefton, 2016
Sefton, M (2014) Blog post: https://concussionassessment.wordpress.com/consultation/topics-in-neuropsychology/tbi/autonomic-dysfunction/ Taken 11-13-17.
Sefton, M (2016) Blog post: https://concussionassessment.wordpress.com/2016/04/01/biofeedback-for-post-concussion-syndrome/ Taken 11-13-17
WESTBOROUGH, MA September 25, 2017 This clock is unique simply on the basis of it’s size. The scale below the 3 clocks is used for measuring wounds. It was given to me by the certified wound care specialist here at Whittier. The top clock was the “finished” product. One can see all the numbers were written and there was a series of hands drawn that appear as scribble moving from left to right. The numbers fall outside of the circle – drawn by the patient. You can appreciate what effort went into the clock as small as it was – only 8 millimeters across. Micrographia is a term given to drawings that are tiny – a syndrome often assigned to dysfunction in the frontal lobe of the brain. Just to be sure, I consulted with Lezak – 3rd Edition. Micrographic written output is seen in patients with Parkinson’s Disease. In another blog published in 2016, I shared a similar clock and describe this interesting syndrome.
Westborough, MA June 6, 2017 The clock of the week is depicted below. It was submitted this week by the Speech Language Pathology service at Whittier Rehabilitation Hospital. I sometimes find it humorous that when I ask a patient to draw a clock they will have already drawn a clock for the speech pathologist. The drawing is used in all aspects of cognitive assessment by pracititioners of all types from neuropsychology to internal medicine to emergency medicine. I typically begin an assessment with the clock drawing because it is nonthreatening and offers a great deal of interesting information about the cognitive capacity of the patient. It was drawn by a 93-year old male with congestive heart
Right handed 93-y/o male with probable dementia
failure and Paget’s disease. It is a disease affecting bone that interferes with the body’s normal recycling process, in which new bone tissue gradually replaces old bone tissue. Over time, the disease can cause affected bones to become fragile and misshapen (Mayo Clinic, 2017). In my experience there is no cognitive deficits associated with Paget’s. This clock is suggestive of what seemed to be a great start – in terms of the initial placement of the numbers although as you can see the numbers 1-6 were drawn on both sides of the circle. This is an unusual finding suggesting decreased problem solving and self-monitoring on behalf of the patient. The SLP drew the circle for the patient. I would suggest that the patient should be allowed to create his or her own circle as this can provide interesting data as well. I once had a patient draw and elaborate grandfather clock fit for a castle. The clock face became secondary and insignificant – for him. The clock is a regular feature here at Concussion Assessment and Management.
Anyone can submit a clock for consideration of the clock of the week. Upload to my email address: email@example.com – No identifying HIPPA protected information please but a brief overview is always helpful.
Westborough, MA May 25, 2017 Cognitive changes are common in patients with dementia. They become increasingly problematic with the disease progression. Some people suffering with dementia have difficulty with even the most basic activity of daily living like dressing themself. Things taken for granted like following directions become a chore as the progression of dementia effects individuals who suffer with the disease. This places a great burden on caregivers who must take over those important functions of daily life.
The clock drawing has been a feature on my blog for several years. It is fun to see people work through the task. Most people complete the task effortlessly. Some are a bit defensive because it seems like such a benign request – “draw a clock…” and I often get “I am not an artist…” in anticipation of failure. I have published over a dozen posts about the clock drawing as a measure of cognitive functioning. Patient with dementia often experience a slow cognitive decline whereby even tasks like constructing a clock become a challenge.
The clocks drawn in this post reflect the effort of a person of 89-years of age who tried very hard to get it right. She had enough preservation of her self- monitoring
3 Clocks drawn in succession by 89-year old female with hypoxia and underlying dementia of Alzheimer’s type – note size in centimeters
that she could tell something was wrong. As you can see the left most circle was the first attempt. It was too small according to the patient and she wanted to try again. The middle clock was her next attempt and shows her disorganization and minimal change in the size of the drawing – approximately 3 centimeters in size. In the center of the drawing there are 2 hands that roughly represent the time 11:10. She told me she needed more space to place the hands so that they could be clearly read and offered to try a third time. On the right is her final attempt. There are two hands (to the right of the number 9 and a second pointing to the number 2). As you can see the circle is only 2 cm in size and was a modest improvement over the first two attempts.
She had fun drawing the clock and did not feel as though she had failed the task. I was encouraging and praised her for staying with the task. At some point she had lost her capacity to plan and execute her visual motor function of crafting the circle. Each attempt was made with the goal of drawing a larger circle. This fine woman was still capable of doing many of her activities of daily living and enjoying her friends and family. She was not at all upset that I had been asked to help with her care.
Dementia requires family support and can be costly to those in need of care. The risk of caregiver fatigue exists in all families. As much as possible, I enourage people to allow the patient to work toward completing their own self-care unless there are risks such as falling due to poor balance. This requires herculean patience and sensitivity because there is often a degree of “awareness” of the cognitive changes experienced by the patient himself. Preserved dignity and sense of independence go a long way toward quality of life in the latter stages of dementia. Most spouses will do whatever it takes to support a loved one with whom they have shared 50 or more years of marriage and experience the decline in functioning as both a personal failure and a heart breaking loss.
WESTBOROUGH, MA September 28, 2016 There will be a free seminar offered at Whittier Rehabilitation Hospital in Westborough on Wednesday September 28, 2016 on Sports-related Concussion along with updated information about post concussion syndrome and its treatment. The program is presented by Michael Sefton, Ph.D., director of neuropsychology and psychological services at Whittier Rehabilitation Hospital and certified brain injury specialist. The program begins at 5:30 with a dinner being served. Call WRH at 508-870-2222 to reserve your spot.
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.