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.