MAKING A CASE FOR NEUROFEEDBACK

by Victoria Ibric, MD

FOR  TRAUMATIC BRAIN INJURY  AND IT’S USE

IN OTHER APPLICATIONS

            NEUROFEEDBACK using EEG (Electroencephalography) can show us areas of the brain which don't function well due to stress, brain damage, epilepsy, stroke, ADD or ADHD, poor performance, memory loss etc. Biofeedback simply means feedback of information to you from an instrument which is monitoring a physiological process you are learning to control. EEG Biofeedback (Neurofeedback) is a specific learning technique that enables a person to control and modify his or her brainwaves and directly  affect behavior, academic performance, as well as physical and emotional awareness.  Neurofeedback is a non-invasive technique. The brainwave activity is monitored by a computer from sensors placed on the scalp. Changes in the brainwaves reflect changes in the state of arousal, from sleep to alert wakefulness. The computer rewards the trainee for producing the desired frequency, which characterizes a focused attention. The training is accomplished by operant conditioning. The feedback from the instruments may be visual, auditory or tactile. The trainee uses the information from the body to initiate and maintain desired mental/physiological changes. The effects of the treatment are permanent and long lasting. The applications of the neurofeedback are numerous, encompassing diagnostics related to stress induced disorders, such as hypertension, tension headaches, insomnia, or diabetes, as well as cognitive disorders, such as attention deficit disorder, memory impairments, and psychological disturbances (depression, anxiety, or eating disorders), etc. 

By using this knowledge, therapists are able to help us retrain the areas of the brain which do not function well. Significant benefits are shown by almost everyone who goes through the training, whether it be for brain injury, sleep apnea, bedwetting, attention deficit disorder, dyslexia, memory impairment, visual perception, seizures, migraine headaches, chronic pain, depression, dizziness and vertigo. It is also possible to help normal patients achieve optimum performance levels in sports, sales, tests, and other areas of life where doing your best has become a challenge.

In 1963, Barry Sterman first documented epilepsy while working with the EEG fingerprint of the brain and it’s designated functions. He then used Neurofeedback in the treatment of epilepsy based on its operant conditioning effect.  Neurofeedback therapists have since treated thousands of patients with good results in epilepsy (Sterman, Finley, Lubar), ADD (Alhambra, Barabasz, Dobbins, Fehmi, Lubar) and Parkinson’s (Pozzi, Santos). TBI work was a natural extension from the epilepsy work and Margaret Ayers who worked with Sterman has presented a great number of TBI cases including some comatose, since 1978, treated by her with Neurofeedback training with success (Ayers, 1987,1991,1997). The number of publications increases every year with the addition of increasingly centers offering Neurofeedback and reporting their positive results. (See the numerous references at the end of the chapter).

In this chapter I hope to give you a better understanding of the neurophysiological basis regarding the use of Neurofeedback training in the case of traumatic brain injury and the great usefulness of it for other applications such as depression, anxiety, conduct disorders, chronic fatigue, and peak performance. This field warrants more than just the technicians use of any given protocol.  Accurate diagnosis is of primary concern as there are limited or unclear objective findings in many studies of closed head injuries or neurological illnesses.

TRAUMATIC BRAIN INJURY AND STROKE

Theoretical Aspects

·         Definition- Brain insults, either traumatic, infectious, or vascular are followed by a variety of functional cognitive and affective impairments. From the electroencephalographic standpoint, there are distinctive changes in the neurophysiological profile. Damage to white matter is followed by increased delta activity. Damage to the gray matter is followed by increased beta and alpha activity.

·         Time Consideration, The Important issue is to consider the length of the loss of consciousness and the length since the injury occurred. To account for the level of dysfunction and for establishing the length of Neurofeedback program and training.

·         Intake and Assessments are used at the intake as well as measures of progress. Medical reports, medical testing and other treatments or medications are taken into account. 

Neurophysiological symptoms are a consequence of axonal shearing which is followed by functional disconnect or in gray matter by neuronal loss or neuronal network disruption.

Localization of deficits and the description of injury are important issues to consider also for the Neurofeedback training protocols.

General and specific symptoms will be encountered.

·         General symptoms are fatigue, mood swings and depression, irritability, poor concentration and memory, pain, dizziness, poor sleep, poor vision or changes in appetite.

·         Specific symptoms are due to bruising of the cortex – often prefrontal or temporal.  Specific symptoms are either cognitive and/or motor deficits, and/or personality changes, and/or seizure disorder due to irritable foci.

·         Specific cognitive deficits- based on localization can be memory, aphasia, apraxia, anomia, etc.

·         Motor  symptoms based on localization  can be:

                                                            Intentional movements – frontal cortex

                                                            Smoothing of movements – subcortical

                                                            Paresis and paralysis – contra lateral to symptoms –

Considering the humunculus distribution over the sensory motor area

                                                            Spasticity, tremor

                                                            Initiation of movement, cerebral palsy

·         Seizure disorders- issues to consider:

Seizure focus due to injury or developmental

Type of seizure disorder:            -     focal seizures

-          generalized seizure

-          partial and generalized

-          absence (Petit Mal) seizures- generalized

-          temporal lobe (Limbic or  complex partial)  seizures

      – may generalize

Training will address:

1.       Recruitment and stabilization

2.       Backward barrage in selective attention circuits – generalized seizure

3.       Threshold and arousal level

4.       Training site of seizure focus, contra lateral or central

5.       Other behavioral interventions, education, taking control, sleep diet

6.       Anticonvulsant action and medications  changes with training

                                                                   Training will be designed for: 

1.       stabilization and motor and behavior control - SMR (12-15 Hz)

2.       increased control, better attention, less depression – generalized seizures - Beta

3.   increased focused attention, less depression –  Alpha or     Delta Inhibit

·         Assessments       

·         EEG (Electroencephalography) over the sensory motor area

·         QEEG (Quantitative EEG)

·         EMG (electromyography) to determine spasticity or  flaccidity, or dysponetic use of muscles

·         TOVA (Test of Variables of Attention) from Universal Attention Disorders Inc.

·         MAS (Memory Assessment  Scale) (PAR)

·         Neuropsychological testing (PAR)

·         CARB (Computerized Assessment of Response Bias) from Cognisyst., Inc

·         WMT (Word Memory Test)

·         Instruments: EEG NF: Neurocybernetics, ROSHI/Brain Linkâ(AVS)(EMS)

                                         EMG and PPP: Biocomp Research Instrument

                                         QEEG: Lexicor Medical Technology Inc.

·         Training

·         Beta training for control and activation

·         Central training for general effects – C3, Cz, or Fz

·         Site of injury or contralateral

·         Looking at symptoms pre and post injury

·         SMR for stabilization

·         Alpha/theta inhibit when necessary and even Delta Inhibit, when in excess due to injury of the white matter

·         Special considerations for:

                                                            Stroke and hypertension

                                                            Brain surgery, tumors

·         When to train, onset and resolution of symptoms

*Movement disorder – tremor, spasticity, cerebral palsy, Parkinson’s disease – may require contra lateral central area or frontal area training. More experience is necessary to define protocols. However, we obtained positive results with training SMR (12-15Hz) over the central contra lateral area corresponding to the affected limb (less spasticity, better movement, gait control and tremor reduced to none, e.g. in case of using the electromagnetic stimulation (EMS) coupled with neurofeedback)

Practical Aspects

I would like to offer the case histories as a learning tool for what may work in a particular instance. However, you must realize that the protocols for each patient must be tailored to their particular case.  There may also be times you use several protocols in one session. For the following case histories, the following was done:

A standard evaluation procedure is done pre/post training of 20 consecutive sessions, as well as after 1 - 2 post interruption of the training.  The evaluation normally consists of [1]a Psychophysiological Profile (PPP); [2] (EMG) over the affected muscle groups; [3] Electroencephalography (EEG) over the sensory motor area of the brain, [4]Quantitative EEG (QEEG), [5] Cognitive functioning tests which include: [5.1] TOVA (Test of Variables of Attention), [5.2] MAS (Memory Assessment Scale), [5.3]Affect evaluation: [5.4] Beck inventory scale, [5.5]SCL-90R, [5.6]CARB (Computerized Assessment of Response Bias), [5.7] WMT (Word Memory Test) and [5.7] Stress Test. Neurofeedback training is designed for each individual according to the central and peripheral expression of the brain impairment, and varied numbers of 45 minutes sessions were done.

Four of my brain injured patients, who had been referred to me for Neurofeedback training are presented here. 

·         The first  case  is an 11 year old male student who had a traumatic head injury at the age of 18 months, and who developed a multitude of symptoms: cognitive, emotional and physical.  He was diagnosed with ADD/Dyslexia. This patient could not read at the age of 11, had a special education aide with him for 5 hours a day to decode everything in the  classroom  and had a GPA (grade point average) of 1.35 in school. After 80 sessions of Neurofeedback, this patient was reading at a third grade level with continuous improvement shown in all areas and a GPA of 3.51.

·         The second case is a 78 old female retired writer, with multiple head injuries, who developed “Alzheimer” symptomatology: memory loss, confusion, depression, speech impairment. With ongoing treatments (280+) this patient has resumed an active lifestyle, and in 1999 was able to take multiple trips to London, Paris, Ireland, and Mexico City, and a cruise to Australia, and spent 6 weeks traveling around the United States. Recently she returned from another trip to England, France, Italy and Greece.

·         The third case is a 29 year old male student who had a traumatic brain injury post auto accident, followed by 3 months of coma, and who developed left side hemiplegia, speech impairment and partial complex seizure disorder. After one year of training this patient returned to school, his walking improved and continues to improve by gaining more feelings and strength in the affected leg. His left hand is not spastic anymore, and he is working towards improving motion control of his affected hand. His seizures have been reduced in frequency, intensity, and the length of recovery from them has shortened considerably. He is no longer depressed. Actually, he is very optimistic about a return to a normal life.

·         The fourth case is a 20 year old male student, who had a right parietal traumatic brain injury after a motorcycle accident, with left side hemiplegia *This case is presented below in more detail.

            The effectiveness and the long lasting effects of the Neurofeedback training in traumatic brain injuries are based on the neuromodulation process obtained by modifying the electrical activity of the brain accordingly, which leads to a correction of functions  through operant conditioning.

Case # 4: D.R. Age 20

Post a Traumatic Brain Injury (2/92) that affected the right parietal region under the motor strip, and experienced an extended loss of consciousness, the symptoms at his initial visit were as follows: Hemiplegia L-side, depression, fatigue, irritability, cognitive deficits, amnesia for the event, easily distracted, apathy, anxiety, short term memory problems, slow processing. Prior to the accident, he had been good in Math, but post accident he observed great difficulties in Math comprehension.

            This patient had a history of risk-taking behavior: such as his collar bone being broken twice in childhood; a first head injury in1988, while playing ice hockey which broke his jaw, and a second head injury 2/1992, from a motorcycle accident.

EEG Training began 8 months after accident. T.O.V.A.  No. 1,  at intake could not be done.

            Session 3: Dad reports that D.’s word retrieval was improved

            Session 8: More articulate; smiling a lot; D. termed:

                        “EEG/BFT is the miracle cure I’ve been looking for!”

            Session 11: Feeling less fatigued, and less confused

            Session 12: Improved concentration

            Session 13: D. came without the cane; not sleepy as in the prior sessions

            Session 15: after this session the first T.O.V.A. done

                                    (All the Std Scores below 40).

                                    Session 16: D. can concentrate for longer periods of time; his overall thinking process improved (“Even better than before the accident”, D.’s remark)

D.R. left for college and returned after 6 months.

Session 17: “School was super!” A’s and B’s only. Now he remarks that he enjoys reading and is very talkative.

            Session 21: D. started to make plans for his future.

            Session 22: D. showed a lot of compassion for another patient.

                        Session 24: D. plans to improve strength in his left hand so he can play a stringed instrument. He thinks it would be wonderful if he could  feed  his words directly into the computer.

Session 26: D. brought his new banjo and played notes with his right affected hand

                        Session 30: Father recognizes improvement in D.’s ability to remember and to follow through schedule. Mom says that D. is more realistic and he has started to make plans for the future.

After 30 sessions the Second T.O.V.A.  Test shows great improvement: Std. Scores; Inattention = 109; Response Time = 77, and Variability = 61

                        Session 36: Very talkative; unrealistic plans about sustaining a guitar performance. He has started guitar lessons and is very optimistic.

            Session 37: New hair cut; nicely groomed

                        Session 39: Cleaner and better day by day. Gait modified; less thrashing with his left leg.

                        Session 42: D. Less controlled for about three weeks during which he also did not attempt EEG sessions.

            Session 44: Continues to take guitar lessons.

                        Session 46: D. is very much involved in the Landmark project, in helping other people. He brought his banjo and played a few tunes, using his left hand. Gait improved.

            Note: After 7 years, I spoke to D.R. on the telephone in February 2000: he is now working full-time, riding a bike, and is very happy with his life and is very thankful for Neurofeedback training..

OTHER APPLICATIONS

Neurofeedback training may be useful on Depression & Anxiety Disorders. C3 Beta can be used on depression, lack of well-being, social anxiety, PMS symptoms, chronic pain, perfectionist attitude, insomnia (TOVA may be slow and careful).  Cz SMR can work for anxiety, panic attacks, physical agitation, intolerance of stimulants, or obsessive-compulsive disorder (TOVA may be normal).  C4 Beta usually works well for deep physiological “Chemical” depression, shyness, or moods unrelated to life events (TOVA in this case may be fast and impulsive).  C4 SMR can be used for *Bipolar disorder but this usually requires some combination of C4 SMR - for mania and irritable depression, and C3 Beta for depression and requires a careful balance of protocols within each session. C4 SMR can also be used for aggressiveness, controlling attitudes, poor body awareness, autism or someone who may over or  under report pain (again TOVA may be fast and impulsive). Most recently many other therapists reported positive results in  treating depression and other affective disorders by training frontal alpha asymmetry (Rosenfeld). In our practice we also obtained good and long lasting effects in correcting affective disorders by training alpha down (AO[I], alpha only inhibit) or by enhancing Beta 16-17Hz over the frontal area Fp1/Fp2 or F3/F4,  using light stimulation in parallel with the Neurofeedback (Ibric).

For the eating disorder profiles: C3 Beta as well as Alpha/ Theta protocols are useful in patients who have binge eating with regret and depression  (also in Anorexia/Bulimia if depressed, PTSD- early abuse or emotionally fragile, or feels bad about self - including poor body image).  C4 SMR must be used in compulsive overeating or overeating because of a poor sense of appetite.

Addictions may be addressed by using SMR/Beta followed by Alpha-Theta Protocols.

*C3 Beta will work usually for Depression, Nicotine cravings and sugar cravings (Ibric, appendix C). 

Cz SMR is used in anxiety panic attacks and insomnia (overarousal). C4 SMR  is useful in treating cocaine cravings, compulsive overeating, thrill seeking or criminal behavior (Bermea, Ibric, Raine) (see also Appendix A).

You will need to start with SMR training for physiological stabilization (10-20 sessions) to decrease cravings and improve control of arousal, attention and mood. Teach conscious relaxation skills and develop imagery at the same time. Then Alpha/Theta training can be used for psychological integration and resolution. End the sessions with SMR/Beta as needed to maintain control of attention and arousal.

In PMS and Menopausal profiles, C3 Beta is helpful for PMS symptoms of depression, irritability, mood swings, poor concentration, fatigue, insomnia, food cravings, Migraine, pain and bloating while Cz or Fz Beta can be used  as needed for attention and memory or when C3 Beta causes agitation or headache.  C4 Beta can be used as needed for period irregularity (timing and flow) , for persistent depression after C3 Beta. Cz SMR  or C4 SMR is helpful for hot flashes and *C4 SMR as needed for bipolar, irritability or irritable depression. *Start with C3 Beta for PMS and try combining with C4 SMR in most cases. P3 Alpha-Theta can be used for PTSD - associated with severe PMS. Continue Beta training as needed.

In our practice we also reported that elderly population can benefit from Neurofeedback training. Memory improvements and emotional balancing as well as sleep regulation were observed (Ibric, see appendix B).

In conclusion, neurofeedback can be used for a variety of neurological based disorders, using a system of protocols  designed for each individual patient following a detailed evaluation and careful monitoring of the therapy as it progresses.

Appendix A

Damaging Effects of Drugs and/or Alcohol Exposure Intrautero on Brain Activity and Behavior may be reversed by EEG Biofeedback Training (BFT). The importance of EEG-BFT in reducing the incidence of violence in such cases will be discussed. Victoria L. Ibric, M.D., Ph.D., George M. Robson, Ph.D., and Sue Othmer. Biofeedback Institute of Los Angeles- EEG Spectrum, Inc. Los Angeles, CA.

            The exposure of the offspring to drugs or alcohol during pregnancy has a negative impact on brain development. Many such children are diagnosed as having Attention Deficit/ Hyperactivity Disorder (ADD/ ADHD) with conduct disorder, which may include antisocial/aggressive behavior, bipolar personality, Obsessive Compulsive Disorders, social anxiety, depression, and a tendency towards drug or alcohol abuse later on in life. We will discuss the effect of the EEG-BFT on three children (5-18 years of age) who have been exposed intrautero to alcohol and drugs and diagnosed as having ADD/ ADHD, and conduct disorder. The children’s diagnoses were based on the evaluation of personal/family history, Test of Variables of Attention (TOVA), DSM-IIIR behavioral rating scale, EEG, cognitive functioning, and academic achievement tests. At intake, the two younger subjects showed a high amplitude/rhythmic theta, while the older subject had an overall low EEG profile. CZ and C4 SMR training were employed in all three cases. The EEG-BF training was followed by a significant decrease of theta amplitudes, and stabilization of the other brainwaves, and TOVA normalization, and there were correlated with improvements in the academic/behavioral areas. Our findings suggest that the damaging effect of intrautero exposure to drugs/alcohol may be reversed by EEG-BFT. The consequential reduction in violence in children and adolescents may be a very important application that needs consideration.

            Key words: ADD/ADHD, EEG-Biofeedback Training, Drug Abuse, Antisocial Behavior.

Appendix B

THE USEFULNESS OF NEUROFEEDBACK TRAINING IN ELDERLY POPULATION WITH EMPHASIS ON MEMORY RECOVERY

and EMOTIONAL BALANCING

Victoria L. Ibric, MD, PhD, Therapy and Prevention Center- Medical Associates

Pasadena, CA, USA

Abstract

Memory loss is a common problem with our elderly population and of great interest to the aging baby boomers. The purpose of  this presentation is to outline and discuss the importance of the neuromodulatory mechanism through Neurofeedback (NF) in the improvement of memory and attention focusing.

Elderly patients, between 65 and 78 years of age, were treated by the means of  NF,  using protocols designed according to the predominant symptoms that needed correction. We will also look at the antecedents of the aging process in the population approaching this primary group of interest. For each patient, the NF sessions, 30 minutes in length, were recorded  for  further analyses. At this time, we would like to mention some important observations drown from the NF training over the frontal areas: 

1) the patients seem to be able to stay awake most of the time while on the training, and at the end  they feel energized;

2) the high energy level, reported at the end of each session, was constantly kept for a week, at least;

3) the peak performance is accomplished in record time (patients reported feeling more centered, and detached and also that they feel that the time appeared to expand, being able to perform tasks in less time);

4) the emotions, depression or anxiety, may be better controlled by working over the frontal areas;

5) patients with high blood pressure, when treated over the frontal area for beta enhancement, did not exhibit an increase of the blood pressure readings, as observed when treated with beta enhancement over the sensory-motor area;

6) memory  improvements (short  term as well as long  term) and focused attention have been documented by TOVA, MAS, and small memory exercises  repeated weekly;

7) enhanced quality of life was noticed by all the treated patients in specified ways (personal  daily pain and distress diary,  repeated Beck Inventory, and personal rating criteria) and by family members,  care professionals, and patient’s physicians.

                        Various protocols illustrating these will be presented. All these observed changes may be explained by improving the inter-hemispheric communication, which involved training  the frontal  lobes to achieve a greater  neuronal  efficiency. These protocols were particularly useful in the treatment of  the elderly or in those with significant impaired cognitive and memory functions.

            Keywords: Inter Hemispheric, Memory, Emotions, Sleep, Blood Pressure, Neurofeedback

Appendix C

NEUROFEEDBACK IN MAJOR DEPRESSION ASSOCIATED TO ADDICTIONS-

 A CASE STUDY

by Victoria L. Ibric, MD, PhD

ABSTRACT

Depression has been treated for some time with Neurofeedback (NF) and different authors presented different modalities in terms of the electrodes localization, or enhanced or inhibited frequencies (see Othmers, Peniston, Rosenfeld,). The case I am presenting, is a 43 years old Caucasian female with familiar major depression and addictions. The causality of her major depression may also be routed in her early childhood experiences (she lost her father, when she was 12), or may be an expression of a complex PTSD developed later in life (when, her already detached and chronically depressed mother has been diagnosed with Alzheimer).  She started to use drugs and alcohol as self medication. Her depression has been treated medically and with psychotherapy, since childhood, to no avail. From the EEG stand point, she did not exhibit the characteristic signature of depression (lower brain waves amplitude of all the frequencies or only low beta amplitude), rather that she  had a  low  level of arousal, characterized by high amplitude of alpha and theta, great variability of all the BW frequencies, and narcoleptic behavior. She’s been committing a silent suicide, becoming bulimic, obese,  isolated. She called the last 3 years of her life “ THE DEAD YEARS”. When she started the NF she had, as she stated, “nothing else to do and nothing to loose”. Only in one month of beta training she completely wined herself off the medication (Lithium, Prozac and Synthroid) and also she did quit smoking, without even wishing to quit. Her emotional make up, from depressed switched to more anxious and angry. Adjustment, from C3-beta to C4 SMR has been needed. However, all along each session has been a battle for the patient to stay awake. Persistency was the key, for 40 sessions done as 2-3 sessions per week; thereafter, up to the session 60^th, the NF has been done only once a week, and the gains where kept. Meanwhile, she started to exercise and lost 15 lbs. in 2 months. The alpha inhibit in the left frontal area (Rosenfeld protocol) hasn’t been successful, and the alpha-theta protocol (Peninston), threw her back in depression. All these sessions had been done on the Neurocybernetics. Post 60 sessions we started a new protocol on ROSHI. The Beta-17 enhanced over the frontal area and light complex stimulation, lead to a better interhemispheric energy increased and stayed high for a full week. She started to write her life story. The progression was remarkable, and at a rhythm of one session per week, a steady level of well being was observed. (Important Note: during the ROSHI training patient never fell asleep). No more drugs or alcohol, no more smoking, no more Depression. She started to live again!!!

Keywords: Neurofeedback, Major Depression, Addictions, PTSD, Neurocybernetics/ ROSHI protocols.

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