Neurofeedback Shows Promise in Treating Traumatic Brain Injury

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Injured brain

Traumatic brain injury (TBI) results when an external force produces intracranial injury through acceleration or direct impact. Mild TBI symptoms that NF may treat include deficits in memory, attention, and decision-making. Traumatic brain injury (TBI; mTBI representing mild TBI) is an issue that has attracted increasing attention in recent years. The 2015 film Concussion exposed the denial and active suppression of chronic traumatic encephalopathy (CTE) findings reported by Nigerian-born pathologist Bennet Omalu. Concussion focused on American football and the repetitive concussions experienced by many players that Dr. Omalu identified as leading to CTE. Other researchers and clinicians have focused on TBI related to military service, particularly combat, including exposure to blast injury. Peskind and colleagues (2013) reported that approximately 28,000 military service members each year experience TBI, many considered mild but often repetitive. David Brody, MD, defined mTBI as follows: "Traumatic brain injury is damage to the brain's structure and function caused by an acute external physical force. What is considered 'mild' has varied quite a bit, but a widely used definition of mTBI is loss of consciousness for up to 30 minutes, a change in mental status for up to 24 hours, or posttraumatic amnesia for up to 24 hours. If any of these problems lasts longer than the specified time, or if intracranial pathology appears on structural imaging of the brain, then the injury is considered moderate or severe. Acute symptoms may appear immediately or a few minutes after the injury." Concussion is another term often used to define the consequences of such an injury and is also considered a mTBI. More than 90% of individuals with more than 5 mTBI episodes had a neurologic deficit, while less than 20% of those with a single episode had such a deficit. Helmet-installed technology shows that a single player can experience 900 head impacts in high school football (Broglio, 2011) and nearly 1500 impacts in college football (Crisco, 2010).

With the increasing awareness of and attention to mTBI and its consequences, it has become important to identify the brain effects of such events and develop methods to remediate such damage. Most mild injuries do not produce identifiable findings in standard imaging studies such as CT or MRI, and diffusion tensor imaging (DTI) has also proved inconclusive (Rosenfeld, 2013). Most mTBIs are diagnosed using careful clinical assessment of the injured person and witnesses as soon as possible to the time of injury. Neuropsychological tests, questionnaires, and symptom tracking methods may be helpful 2-3 months after injury if symptoms do not spontaneously resolve. Quantitative EEG (qEEG) assessment is a promising approach for identifying TBI changes in the brain. The qEEG can detect changes in brain function and brain communication. The qEEG allows clinicians to determine the consequences of mTBI and track changes due to spontaneous healing and treatment.

The images (courtesy Mary Tracy, PhD, Northern California Neurotherapy) below show LORETA imaging analysis of an individual struck in the face by a man using a closed fist. The first image is derived from an EEG recording done 4 days post-assault. The red areas represent activity at 2 Hz, in the delta frequency range that exceeds 2 standard deviations (SD) greater than expected according to a reference database of typical age-matched subjects. The images show what is likely a contra coup injury in the right posterior temporal/parietal/occipital cortices resulting from the impact of the brain on the inside of the skull due to the punch from a right-handed individual striking the center-left front of the face and forehead.

LORETA of TBI 4 days post-assault

The second image shows a qEEG recording of the same individual 2 months post-injury using the same frequency and SD scale, confirming the resolution of the initial findings. There were no interventions beyond rest and a leave of absence from work (Mary Tracy, personal communication).

qEEG of TBI patient 2 months post-injury

The images below (Koberda, 2015) are from an individual with multiple concussions with an additional diagnosis of ADD and behavioral problems. The first image's top row shows topographic statistical maps where the green color shows typical values within 1 SD, the yellow color within 2 SD, and the red color between 2.5 - 3 SD, indicating excess delta, theta, and alpha activity.

qEEG of patient with multiple concussions, ADHD, and behavioral problems

The second image shows the same client after 10 sessions of neurofeedback training where much of the atypical activity has resolved.

qEEG after 10 neurofeedback sessions

Foster, Foster, and Gross (in press) assigned a level-3 rating of probably efficacious to neurofeedback for TBI.

Evidence-Based Practice in Biofeedback and Neurofeedback cover

Conclusion Quantitative EEG can be helpful in identifying the physiological changes in brain function resulting from even a single mTBI as well as from multiple mTBI events. It can also be used to show the resolution of such changes. The qEEG is especially helpful following mTBI and more severe forms of traumatic brain injury in guiding neurofeedback to train the brain to correct atypical and dysregulated patterns, ideally to recover functions impaired by such injuries. References

Broglio, S. P., Eckner. J. T., Martini, D., Sosnoff, J. J., Kutcher, J. S., & Randolph, C. (2011). Cumulative head impact burden in high school football. J Neurotrauma, 28(10), 2069–2078.

Crisco, J. J., Fiore, R., Beckwith. J. G., Chu, J. J., Brolinson, P. G., Duma, S., McAllister, T. W., Duhaime, A.-C., & Greenwald, R. M. (2010). Frequency and location of head impact

exposures in individual collegiate football players. J Athl Train, 45(6), 549–559. Foster, S. R., Foster, D. S., & Gross, M. N. (in press). Traumatic brain injury. In I. Z. Khazan, F. Shaffer, D. Moss, R. Lyle, & S. Rosenthal (Eds.). Evidence-based practice in biofeedback and neurofeedback (4th ed.). Association for Applied Psychophysiology and Biofeedback.

Koberda, J. L. (2015). LORETA z-score neurofeedback-effectiveness in rehabilitation of

patients suffering from traumatic brain injury. J Neurol Neurobiol 1(4). 7150.113

Peskind, E. R., Brody, D., Cernak, I., McKee, A., & Ruff, R. L. (2013). Military- and sports-related mild traumatic brain injury: Clinical presentation, management, and long-term consequences. J Clin Psychiatry, 74(2), 180-188.

Rosenfeld, J. V., McFarlane, A. C., Bragge, P., Armonda, R. A., Grimes, J. B., & Ling, G. S. (2013). Blast-related traumatic brain injury. The Lancet Neurology, 12(9), 882–893.

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