Neurofeedback Shows Promise in Treating Traumatic Brain Injury

Traumatic brain injury (TBI) results when an external force produces intracranial injury through acceleration or direct impact. NF treats mild TBI (mTBI) symptoms, including memory, attention, and decision-making deficits.

TBI can result from so-called “open” injuries when something penetrates the skull, such as a bullet, and “closed” injuries occurring during acceleration-deceleration injuries. Examples include a motor vehicle collision or when the head and a hard object come into forceful contact, such as during a fall. TBI can also result in diffuse and/or localized damage. Localized damage is very unlikely following mTBI.

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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 last 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. Measurable cognitive deficits following mTBI are rare after several months and are probably attributable to non-cerebral causes (Belanger et al., 2018). 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 per season 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; 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. Susceptibility-weighted imaging (SWI), a form of MRI, provided additional sensitivity beyond DTI in the neuroimaging of mTBI (e.g., Beauchamp et al., 2013). 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. Unlike structural imaging, the qEEG can detect brain function and communication changes. This distinction is important because persisting cognitive symptoms and fatigue may be related to reduced neural communication efficiency resulting from TBI (Levine et al., 2008). The qEEG allows clinicians to determine the consequences of mTBI and track changes due to spontaneous healing and treatment. qEEG measures that are associated with traumatic brain injury often are metrics related to neural communication, such as coherence and phase (Thatcher et al., 1989). However, localized changes shown by qEEG can be seen with more severe TBI. Although brain damage from moderate-severe closed TBI usually involves the frontotemporal regions, localized, as contrasted with diffuse damage, can be quite heterogeneous.

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.

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).

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. 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.

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