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EEG: Traumatic Brain Injuries Case Study
EEG Biofeedback Training for Minor Traumatic Brain Injury
The long-term consequences of Minor Traumatic Brain Injury (MTBI) have recently become more widely acknowledged. Persons suffering loss of function due to minor head injuries were usually given CAT scans and MRI scans, which might not reveal any organic injury. As a result, victims were often not taken seriously, and accused of fabricating their symptoms and malingering. More recently, tests of brain function have demonstrated a basis for the symptoms which are described. Such tests include PET scans, topographic brain mapping of EEG activity, and evoked response measurements. These functional tests reveal changes in cortical activation, anomalous EEG activity traceable to head injury, and slowed response.
The symptoms which accompany minor head injury include principally loss of energy; headaches and chronic pain; dizziness and vertigo; memory impairment; difficulty concentrating; anxiety, depression, and mood swings; sleep disturbances; irritability; visual perception problems and dyslexia; and even apparent personality changes. Seizures may also be observed, or seizure-like activity such as auras. If persons exhibited certain weaknesses before the accident, such as attention deficit disorder, migraine headaches, or sleep difficulties, then such symptoms might be considerably exacerbated by the head injury. The apparent severity of the injury, including the length of period of unconsciousness (if any), has little to do with the severity of subsequent symptoms. New symptoms may arise months or even years after the head injury.
We know of no published literature on the use of EEG biofeedback for head injury. We are aware only of clinical work in this field in a number of settings. Over the past six years, we have obtained considerable clinical evidence for the effectiveness of EEG biofeedback training as an adjunct modality for remediating the symptoms of minor closed head injury. By September of 1992, we had accumulated a clinical history of EEG training for 88 cases of (mostly minor) traumatic brain injury. The training appears to be effective even years post-injury, when spontaneous remediation is no longer expected. The training can impact favorably on all of the symptoms listed above.
By means of EEG training, we have been able to restore to productive life a number of individuals who had been totally disabled for a number of years due to head injury. The training is not always that effective. However, essentially everyone who undertakes the training for head injury derives significant benefit. The training needs to be undertaken for a minimum of ten training sessions in order to be able to make a meaningful assessment of whether the training is worthwhile. Completion of training may take anywhere from 25 to more than 100 sessions. Of course, anyone continuing for 100 sessions would only be motivated to do so if there were continuing benefit. The gains made in the training appear to hold for the long term. That is, once the brain is taught again how to regulate itself, it does not relinquish that capability.
When clients are seen within the first six months after head injury, there is a concern about new symptoms continuing to emerge post-injury. Clients must be aware that this may happen despite the biofeedback training, since the latter takes effect gradually. If this understanding exists, and the client is willing to proceed, there may be additional benefit if the training is undertaken soon after injury.
23 year old male Brain Injury Patient
From an interview with a rehabilitation case manager (RN), February 1998.
The case manager is working with a 23-year old brain injury patient. After the injury, the patient had been in a coma for 2 weeks. He subsequently was treated at Emory Medical Center in Atlanta. He later moved to Gainesville, GA and worked with a neuropsychologist there, Dr. Stephen Farr, who started the patient on Neurofeedback about a year ago.
Since starting Neurofeedback, the case manager feels her patient has made significant strides in functional levels - well beyond the progress he was making before. She said the progress with the outpatient Neurofeedback treatment has been "almost phenomenal."
The patient's doctor at Emory was surprised, when he came back for an evaluation, how well the patient was able to say why he was there and what he was going to be doing. Previously, the patient had been unable to express this information. Subsequent follow-up Neuropsych tests at Emory confirmed definite improvements since starting Neurofeedback. Dr. Farr gave a pre and post TOVA test which showed the treatment shifted his score from borderline to average performance, with clear steady improvement recorded through the course of his treatment.
The patient has been able to return to reading, with much greater concentration and focus. Before, he could not do that. He had received cognitive training at Emory on basic skills such as balancing the checkbook, but was not making much progress. These skills have progressed much further since starting the Neurofeedback.
This patient was not a good math student in high school prior to the accident, and since the accident, testing both at Sylvan Learning Center and elsewhere had confirmed that he was very weak in math - a 6th grade arithmetic level. However, after the Neurofeedback training, the patient was able to pass the College Proficiency Exam used to get into vocational training school without any remediation - the very first time. This was an extremely surprising result, according to the case manager.
Ataxia, 11 year old Male
The following is the case of an 11 year old boy who came to me because of significant neurological impairment following a tumor removal, complications, and resultant Ataxia.
By Catherine Rule
SUBJECT INFORMATION
Name: R
Age: 11
Gender: Male
HISTORY
R was operated on for a Medulloblastoma (tumor) on June of 1998. The surgical report indicates that there must have been a high degree of vascularization of this tumor, as it did bleed extensively during the operation. Following the operation and recovery from anesthesia, he is noted to have been obeying commands and being able to move all four extremities, and pupils were equal and reaction to light. He was transported to intensive care to further stabilize his condition.
The next day it was observed that he had developed Hydrocephalous and that there was also bleeding in the general area of the operation (Occipital area). As a result, he was operated on a second time to remove the blood clot and to maintain homeostasis.
Subsequent problems in maintaining pressure was corrected by placement of a VP shunt a month after the original surgery. Since the time of the second operation it was noted that there was severe neurological impairment, including a note from Neurology indicating that he was, at that time, in a "locked-in" syndrome. He is reported to have significant ataxia.
He was in ICU for three months, and was in the hospital from June until November of 1988. R's mother reports that following the second surgery he was in a "semi coma" for 5 weeks. His eyes were open but he was unable to communicate. After 5 weeks he was able to nod, but his responses were very inconsistent.
R has had a series of chemo, physical, occupational and speech therapies. He presently is only receiving physical therapy, 2 X's out-patient, and 2X's weekly in the school that he attends.
When I first met R, he had great difficulty walking without lumbering from side to side. He need assistance walking from my wait area to the treatment room (about 12 feet). His entire left side was noticeably weaker than the right. His right eye was much more exposed than his left, as he was unable to close his left eye. It appeared that he was having difficulty focusing when looking at me. His eyes seemed unable to coordinate very well. I had difficulty understanding his speech as he slurred his words considerably. His processing time seemed a little slow as he was unable to respond to questions without some delay in his responses. He was quite fatigued by the end of the session.
R's parents report that previously to the surgeries he was a normal, active and highly intelligent 10 year old. He engaged in many physical activities and enjoyed sports tremendously.
TESTING: TOVA
He was given the visual version of the TOVA. He told me that he had no difficulty in seeing the objects on the screen.
INITIAL TOVA: All four quarters were invalid due to excessive anticipatory responses
2ND TOVA: there were no invalid quarters
COGNOMETER
Comparison of test 1 to test 2. Test 2 was administered after 15 NF treatments.
Immediate and Delayed Memory: Both within 1 SD (standard deviation) below the norm.
Attention: First test more than 2 SD below the norm, second test slightly less than than 1 SD below the norm.
Speed: First test more than 2 SD below the norm, second test slightly less than than 2 SD below the norm.
Motor Reflexes: First test more than 2 SD below the norm, second test slightly less than 1 SD below the norm.
Perceptual Threshold: First test more than 2 SD below the norm, second test slightly more than 1 SD below the norm
OBSERVATIONS/CHANGES
Most of the observations came from R's physical therapists as well as observations from myself and others working in my office.
After 1st session: physical therapist reports R is more focused. Parents report that he was not tired following session.
After 2nd session, Dad reports he was much more talkative on the return home. R seemed more able to focus during session, he noticed the change in color on the monitor when switching from left to right side.
After 3rd session: Mom reports that R's physical therapist said he had an excellent session. Ryan was able to walk 12 feet to seat in office without assistance. R appears more focused during training.
After 5 sessions: R reports that work at school seems easier to him, he is noticing that walking seems easier. No report from physical therapist today.
After 7 sessions: Physical therapist reports than R's stamina and distance has improved significantly while walking. They have stopped counting steps as he is able to walk well over 1,000 without assistance.
After 9 sessions: Mom says that R has always been a good speller, she was reviewing his spelling words with him and thought they were very difficult for his age. R got the highest grade on the test, others mostly failed.
After 12 sessions: Physical therapist reports that R's balance is improving greatly. He is able to walk within a 12" space without losing his balance. He is able to stand within a 4" area, one foot in front of the other keeping his balance. Both Ryan and Dad report he is doing very well in school.
After 14 sessions: Physical therapist reports that R is able to step up on a platform without falling off. Never been able to do this before. Physical therapist very excited about changes/improvements in the past month.
After 15 sessions: Insurance is very impressed with reports from this office and physical therapy. Will renew additional sessions.
R is able to walk significantly better as reported by parents, physical therapists and our own observations. He is engaging with us considerably more, even joking with us. His eyes appear to coordinate better when looking at something. His energy level has increased. He is having an easier time at school. There seems to be a softening in his face. His balance is improving significantly.
When I showed Mom the results from his second round of tests (Dec. 24th), she told me that this was the best Christmas present that she had received.
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