Qeeg, Brain Rate, Executive Functions and Neurofeedback Training in Patients with Traumatic Brain Injury

Transcription

1 Qeeg, Bran Rate, Executve Functons and Neuroeedback Tranng n Patents wth Traumatc Bran Injury 23 Qeeg, Bran Rate, Executve Functons and Neuroeedback Tranng n Patents wth Traumatc Bran Injury Tatjana Zorcec, Aneta Demerdzeva, Nada Pop-Jordanova Pedatrc clnc, Faculty o medcne, Unversty o Skopje, Republc o Macedona Orgnal paper SUMMARY Traumatc bran njury (TBI) s a serous and growng problem, and long-term consequences become more wdely acknowledged recently. A group o sx patents wth traumatc bran njury have been accepted or neuroeedback tranng. All o them have been njured by ar accdent. Mld motor mparment was apparent n all patents; however, cogntve dcultes were the man problem. Prelmnary qeeg assessment showed generally predomnance o slow bran waves n ronto-paretal regons. Ths ndng ndcated the type o appled tranng protocols. We organzed 20 sessons o neuroeedback, two tmes a week, each 40 mnute duraton. Subjectve assessment concernng mood, qualty o sleep, ever day s actvty and cogntve abltes, as well as the changes o qeeg ndngs promsed good outcome. All patents, except one, contnued normal educaton as well as normal le. It s the rst applcaton o neuroeedback or treatment TBI n our regon. Key words: neuroeedback, traumatc bran njury, qeeg, accdents, cogntve mparment. 1. Introducton Traumatc bran njury (TBI) s a serous and growng problem, and long-term consequences become more wdely acknowledged recently. New studes are contnually beng conducted to try to gan a better understandng o how the bran s mpacted, as well as whch new treatments or therapes are avalable to help. Persons suerng loss o unctons due to head njures were usually examned wth CT and MRI scans, whch n some cases mght not reveal any serous organc leson. In addton, quanttatve EEG wth bran mappng and event related potentals can reveal changes n cortcal actvaton (1, 2). The symptoms whch accompany head njury nclude Physcal - headaches, sleep dsturbance, atgue, nausea or sezures; Emotonal - depresson, anxety or agtaton, anger or explosveness, and mood swngs; Cogntve - attenton problems, memory problems or conuson. Usually, the more severe the trauma, the more severe the cogntve dect s. However, sometmes the apparent severty o the njury, ncludng the length o perod o unconscousness ( any), has lttle nluence to the severty o subsequent symptoms. New symptoms may arse months or even years ater the head njury. In adolescents, there are not bg muscular-skeletal handcap, the man problem arses wth post-traumatc poor school achevement due to cogntve mparment. Most bran njures are drectly related to car accdents, whose number s growng every day. The consequences o TBI depend on the stuaton and person, but the most common eects nvolve psychologcal and cogntve unctonng. Ths means that the person s ablty to reason, solve problems, or concentrate become challenged. Along wth these, other problems develop, ncludng depresson, atgue, rrtaton, and lack o motvaton, whch s understandable. Followng acute TBI rehabltaton, a lmted number o strateges have been used or treatment o cogntve mparments. These methods have ncluded restoratve cogntve rehabltaton procedures that utlze stmulaton and practce as well as medcatons drected at arousal, attenton and/or memory. However, all these methodologes may provde only modest mprovements, so that t s stll common or patents wth TBI to be told that they must smply adjust to the current state o stuaton. In the last ten years the applcaton o boeedback arses as a new method n cogntve rehabltaton o patents wth TBI. Generally, boeedback means learnng process to obtan control over unconscous unctons (skn conducton, temperature, heart rate, breathng, or bran actvty). In act, neuroeedback s central boeedback based on branwave modulaton. The process conssts o placng the electrodes on the scalp whch allows to see n real tme the screen representaton o branwave actvty a ew thousands o a second ater t occurs, and to nluence ths actvty. A computer dsplay may be as smple as two bar graphs, wth one representng necent bran actv-

2 24 Qeeg, Bran Rate, Executve Functons and Neuroeedback Tranng n Patents wth Traumatc Bran Injury ty, and another the ecent one. When the patent concentrates on the dsplay and through ths concentraton decreases slow (e. g., theta or alpha) actvty and slghtly ncreases the ecent actvty (e. g. SMR or beta), both vsual and audtory eedback are receved. Change occurs through a process o operant condtonng, gradually recondtonng and retranng how the bran s unctonng. Our team uses neuroeedback treatment or many stress-related dsorders (3, 4, 5. 6) as well as or ADD/ADHD chldren (7, 8). In addton, usng neuroeedback we have obtaned very postve results or better school achevement n healthy students (9), as well as or musc and sport perormance (10). In those studes we have used neuroeedback equpment made by Thought Technology, Canada. It allowed more nterestng manner o tranng conssted o vdeo games related to the bran electrcal unctonng. The game s gong the clent produces needed bran waves and stops n opposte cases. The neuroeedback (EEG boeedback) represents a relatvely new approach n the treatment o TBI patents. In a ew publshed studes, neuroeedback was appled or tranng sesson n central head ponts (manly n Cz) and rewardng hgh alpha bran actvty, showed mprovement o the cogntve unctonng (11, 12, 13). Thornton and Carmody ound 186% mprovement n memory scores n TBI patents treated wth neuroeedback [14]. When these authors compared neurocogntve rehabltaton strateges, medcaton treatment, and neuroeedback treatment n an eect sze analyss, neuroeedback appeared more ecacous than other treatment strateges. Ayers have even brought many patents out o coma usng neuroeedback (15). 2. Am o the study The am o ths study was: a) to analyze qeeg ndngs o njured patents and to compare the results wth data base; b) to mprove neuroeedback tranng wth parallel applcaton o perpheral boeedback; c) to ntroduce the calculaton o bran rate parameter as an ndcator o general mental arousal n TBI patents and d) to assess the executve unctons beore and ater applcaton o boeedback. 3. Subjects and methodology Sx patents o derent age and gender wth TBI have been accepted or neuroeedback tranng. Intervews, data rom the medcal hstory as well as CT and MRI scans have been elaborated. Intellgence was assessed wth Koch s cube test. The patents were recorded wth qeeg (MITSAR, Russa) n eyes open (EO) and eyes closed (EC) condtons or 5 mnute duraton, as well as durng vsual (VCPT) and audtory cogntve perormance tasks (ACPT). The data was compared wth data-base obtaned rom Human Bran Insttute, St Petersburg, It s mportant to stress that regardless o the ste o njury, real-tme dgtal EEG assessment always nvolves recordng sensormotor cortex (stes T4, C4, T3, C3 and Cz). Sensormotor cortex controls all sensory and motor unctons and medates behavor based on ncomng sensory nput and past experence. In general, hgher ampltudes o slow waves n some regon ndcate the ste o mpact, whle beta ampltude can be ncreased n an eort to compensate. So, the goal o neuroeedback s manly to reduce the theta actvty. Beta ampltude automatcally ncreases, and there t s no need or specal tranng o beta actvty. Indvdual protocols or neuroeedback tranng are adapted concernng qeeg ndngs. Generally, all patents were traned or SMR rhythm (hgh alpha) or 20 sessons. The poston o the actve electrodes or tranng was n Fz and Cz. The goal was to nhbt theta (4-7 Hz), rewarded sensory motor rhythm (hgh alpha Hz), and nhbt muscle actvty/tenson. In addton to neuroeedback, some modaltes or perpheral boeedback (namely, skn conductance or pulse balance) have been used or obtanng control o the autonomous nervous system. As shown n our prevous publcatons, the bran rate (EEG spectrum weghted requency) can be consdered as an ntegral state attrbute correlated to bran electrc, mental and metabolc actvty. In partcular, t can serve as a prelmnary dagnostc ndcator o general mental actvaton (.e. conscousness level), n addton to heart rate, blood pressure or temperature as standard ndcators o general bodly actvaton (16). It was shown that bran rate can be used to dscrmnate between the groups o under-arousal and overarousal dsorders, to assess the qualty o sleep, as well as to ndcate the IQ changes caused by some envronmental toxns (17). Bran rate s also sutable to reveal the patterns o senstvty/rgdty o EEG spectrum, ncludng requency bands related to permeablty o correspondng neuronal crcuts, based on whch the ndvdually adapted neuroeedback protocols can be elaborated (18). Bran rate s calculated by ollowng ormula: P V V b, wth V V where the ndex denotes the requency band (or delta = 1, or theta = 2, etc.) and V s the correspondng mean ampltude o the electrc potental. Followng the standard ve-band classcaton, one has = 2, 6, 10, 14 and 18, respectvely. In ths context, bran rate can serve as an ndcator o total bran actvty n TBI patents. Executve unctons (EF) are set o cogntve processes whch uncton s the optmzaton o the complex stuaton ecency, requrng a large number o cogntve unctons. Man characterstcs o executve unctons are plannng, lookng Orgnal paper

3 Qeeg, Bran Rate, Executve Functons and Neuroeedback Tranng n Patents wth Traumatc Bran Injury 25 or alternatve solutons, strateges or executng plans and nhbtons o the unsutable answers. Localzaton o EF s n the prerontal cortex, whch reaches ts maturty n the adulthood. Evaluaton o executve unctons was perormed wth psychometrc nstruments Wsconsn Card Sortng (WCST) and Stroop Color Word (19, 20). I K M V B G Mean Age Duraton o the bran njury (years) Length o coma(days) Estmated pre-morbd IQ Post-morbd IQ Table 1. Some speccs o TBI patents 4. Results 4.1. Psychophysologcal data Table 1 shows some general characterstcs o our TBI patents. It s clear that the patents der n age, duraton o coma as well as years snce bran njury. Concernng cogntve unctons, all o them (except the patent K) manested problems wth concentraton, memory and attenton, as well as decreased IQ. MRI generally showed small degree o lesons n the ronto-paretal zones, except n patent K. whch MRI showed mnmal nterne hydrocephalus wthout any cortcal mparment. On Fgure 1 a row EC recordng or one patent (I) s presented. The more typcal are slow bran waves n central and paretal parts o the bran. On Fgure 2. EEG spectra and Fgure 1. Row EC recordng o the TBI patent I. bran mappng or the same patent s presented Bran rate In addton to qeeg analyss we calculated bran rate or each pont o the scalp. As we expected, bran rate n all patents showed underarousal t s compared wth normal or anxous patents (Table 2). In patents wth anxety we showed n prevous studes the exstence o so called nner arousal where bran rate s hgher n EC condton (21, 22, 23, 24). Also, t s clear the derence between eyes open (EO) and eyes closed (EC) condton as well as durng vsual or audtve tasks. The ANOVA test or calculated bran rate n all scalp ponts (10/20 nternatonal system) showed sgncant derences or both EO and EC condtons (Table 3). It means that bran rate s derent n specc cortex area correspondng to the level o arousal. For practcal reason, the more mportant s mean bran rate showng general mental arousal. In patents wth TBI mean bran rate corresponds to under arousal state. Bran rate EC Bran rate EO Normal adults 8,56 10,54 Adults wth ADD Anxous patents 10, 85 9,73 TBI 4,81 6,87 Table 2. Bran rate n derent groups o clents ANOVA eyes open F=9.43 p= eyes closed F=14.5 P= Fgure. Spectra wth bran map showng sgncant slowng n centroparetal regon Table 3. Analyss o varance or bran rate values

4 26 Qeeg, Bran Rate, Executve Functons and Neuroeedback Tranng n Patents wth Traumatc Bran Injury In Fgure 3 the derence between bran rate durng EC, EO and cogntve perormance tasks s presented. It s clear that bran rate, measurng general mental arousal, s hgher durng cogntve perormance tasks and slower n EC condton. On Fgure 4 bran rate n eyes open and eyes closed condtons or all patents s shown. The derence between the two condtons s mnmal n paretal ant occptal regons. In Table 4 mean values or bran rate or all patents n EO and EC condtons are dsplayed. It s clear that n EO condtons bran rate s much hgher due to the sensory nluences. In patents wth anxety we showed n prevous studes the exstence o so called nner arousal where bran rate s hgher n EC condton Boeedback treatment The neuroeedback protocol we appled was SMR tranng n Cz and Fz or all patents two tmes a Fp1 F7 Fz F8 C3 C4 T5 Pz T6 Fgure 3. Bran rate n derent condtons obtaned durng qeeg assessment (patent M) Fp1 Fp2 F7 F3 Fz F4 F8 T3 C3 Cz C4 T4 T5 P3 Pz P4 T6 O1 O2 Fgure 4. Bran rate n EO and EC condtons week, 40 mnute duraton. Because general anxety was present n all patents, we ncluded also EDR boeedback as well as pulse related perpheral boeedback to obtan relaxed state. So, our protocol conssted rstly the applcaton o perpheral boeedback or mnute duraton and ater obtanng EC mean mn. max EO mean mn. Max Fp1 4,121 5,435 6,66 FP1 6,76 5,435 7,176 Fp2 4,11 6,449 6,164 FP2 6,53 5,4 10,46 F7 2,18 5,257 4,355 F7 6,60 5 7,704 F3 4,051 5,404 6,075 F3 7,58 5,404 7,696 Fz 4,176 5,462 6,264 FZ 6,34 4,927 5,877 F4 4,229 6,195 6,342 F4 6,40 6,195 5,927 F8 3,683 5,145 5,758 F8 7,70 5,145 6,405 T3 3,933 3,694 6,26 T3 5,79 3,694 12,064 C3 4,072 4,861 6,26 C3 7,57 4,861 6,877 Cz 3,759 5,212 5,65 CZ 6,65 5,212 8,1 C4 4,57 6,423 7,27 C4 7,99 6,423 8,1 T4 4,468 8,32 7,27 T4 8,42 8,32 8,1 T5 2,513 4,232 4,99 T5 6,02 4,232 7,157 P3 6,9 4,309 10,4 P3 6 4,309 6,975 Pz 6,9 5,744 10,3 PZ 6,31 5,744 7,249 P4 6,9 4,628 10,4 P4 6,66 4,699 7,249 T6 6,9 6,673 10,3 T6 7,04 6,673 7,249 O1 6,96 5,249 10,3 O1 7,05 5,249 6,278 O2 7,037 6,519 10,4 O2 7,23 6,519 6,206 Table 4. Mean values or bran rate n EO and EC condtons or all patents stable autonomous nervous actvty, the neuroeedback EO tranng was the EC ollowng step. ACPT On Table 5 sgncant changes o VCPT low and hgh bran waves n central bran parts or the whole group are dsplayed. Along wth the changes n EEG spectra, the mprovements o general mood, qualty ec eo o sleep, and cogntve abltes are obtaned. Four o our patents were consderably mproved and contnued wth studes, and only the patent (I) has not sgncant mprovement o cogntve abltes. O Executve unctons In addton, we have perormed the assessment o executve unctons beore and ater boeedback treatment wth WCST and Stroop. The obtaned results showed that our subjects are presentng smaller number o perseveratve errors ater the boeedback applcaton (Table 6 and 7). The Student t-test was used to establsh there locaton delta theta alpha beta Fz 0.056* 0.001* Cz * * Table 5. Statstcally sgncant change (p-values) n absolute power ollowng neuroeedback * sgncant change s statstcal between the tests scores beore and ater the treatment. 5. Dscusson The applcaton o neuroeedback methodology n the rehabltaton o TBI patents s rapdly growng. It s probably the results o very moderate eectveness o other therapeutc procedures. For ndvdual protocol adjustment the qeeg recordng s necessary. The results we obtaned n qeeg recordng correspond to the ndng o Ayers [1,13, 18], Thatcher[15] and Thornton [17]. The man nd- Orgnal paper

5 Qeeg, Bran Rate, Executve Functons and Neuroeedback Tranng n Patents wth Traumatc Bran Injury 27 Stroop categores beore boeedback ng s slowng o the bran electrcal actvty n rontal regon o the bran whch s mportant or executve unctons. A number o publshed studes have explored much more the eectveness o cogntve rehabltaton as treatment or varous squeal ollowng TBI. Most studes n the EEG boeedback eld have aled to compare ths relatvely new technque to well establshed technques beng employed wthn the TBI populaton. Despte usng a small sample sze, the present study s amed to evaluate EEG boeedback wthn the TBI populaton as an addtonal treatment used ater all other therapes appled to the njured patents. In addton to EEG boeedback, we ntroduced perpheral boeedback n order to obtan the balance o Sympathetc/Parasympathetc nervous system. Our orgnal approach n ths study s the calculaton o bran rate as a measure o general mental arousal. Havng n mnd that TBI generally nduce slow cortcal actvaton, especally n the rontal regons, the calculaton o bran rate helps n the plannng o tranng protocol. The present study mplemented a treatment program talored to the ndvdual, whch was consstent wth treatments beng proved by clncans n real le. ater boeedback errors (St) II 52 average 55 average 0,25 errors III 50 average 53 average 0,17 errors III/II 49 low average 53 average 0,79 St III-St II 50 average 53 average 0,92 Table 6. T-value and statstcally sgncant change or Stroop beore and ater boeedback applcaton WCST categores beore boeedback ater boeedback N categores 50 average 52 average 0,77 N perseveratons 2 42 low average 50 average 0,00000* N errors 45 low average 51 average 0,14 cards total 47 low average 52 average 0,32 M categores 47 low average 51 average 0,42 Table 7. T-value and statstcally sgncant change or WCST beore and ater boeedback applcaton * sgncant change 6. Concluson Overall, the ndngs provde prelmnary support or the ecacy o EEG boeedback n the rehabltaton o a broad range o squeal ollowng TBI such as cogntve abltes, executve unctons, and emotonal stablty. Future research assessng the ecacy o EEG boeedback n the TBI populaton s needed, n partcular to drectly compare ths treatment to a wdely and commonly used treatment (e.g. cogntve rehabltaton) but usng a larger sample sze. Reerences 1. Ayers ME. Assessng and treatng open head trauma, coma, and stroke usng real-tme dgtal EEG neuroeedback. Edtors: Evans JR. and Abarbanel A. Introducton to quanttatve EEG and neuroeedback. New York: Academc Press, Kropotov J, Quanttatve EEG, eventrelated potentals and neurotherapy. Elsever, Amsterdam, Pop-Jordanova N. Electrodermal based boeedback n pedatrc patents, Paedatra Croatca. 1999; 3: Pop-Jordanova N. Boeedback mtgaton or eatng dsorders n preadolescents. Internatonal Pedatrcs. 2000; 1: Pop-Jordanova N, Zorcec T, Demerdzeva A. Electrodermal boeedback n treatng psychogenc nonepleptc sezures. Prloz. 2005; 26(2): Pop-Jordanova N. Boeedback modaltes n chldren and adolescents. n New Research on Boeedback. Nova Bomedcal Books, New York, Pop-Jordanova N. Boeedback n the assessment and treatment o somatoorm dsorders and ADHD n chldren. Internatonal Journal o Medcne and Medcal Scence. 2009; 1(2): p p 8. Pop-Jordanova N. Gucev Z. Gamebased perpheral boeedback or stress assessment n chldren. Pedatr Int [Epub ahead o prnt] PMID: Pop-Jordanova N, Markovska-Smoska S, Zorcec T. Neuroeedback treatment o chldren wth attenton dect hyperactvty dsorder. Prloz. 2005; 26 (1): Pop-Jordanova N. EEG spectra n pedatrc research and practce. Prloz. 2008; 29(1): Pop-Jordanova N, Cakalaroska I. Comparson o boeedback modaltes or better achevement n hgh school students. Maced J Med Sc. 2008; 1(2): Markovska-Smoska S, Pop-Jordanova N, Georgev D. Smultaneous EEG and EMG boeedback or peak perormance n muscans. Prloz. 2008; 29 (1): Ayers ME. Electroencephalographc neuroeedback and closed head njury o 250 ndvduals. In: Natonal head Injury Syllabus. Washngton, DC, Byers AP. Neuroeedback therapy or a mld head njury. Journal o Neurotherapy. 1995; 1(1): Thatcher RW. EEG operant condtonng (boeedback) and traumatc bran njury. Cln Electroencephalogr. 2000; 1: Rma EL, Albert NS, Henry S. EEG- NeuroBoFeedback treatment o patents wth bran njury. Journal o Neurotherapy. 2002; 1: Thornton KE, Carmody DP. Ecacy o traumatc bran njury rehabltaton: Interventons o QEEG-guded boeedback, computers, strateges, and medcatons. Appled Psychophysology & Boeedback, 2008; 33: Ayers ME. A controlled study o EEG neuroeedback tranng & clncal psychotherapy or rght hemsphere closed head njury. Boeedback and Sel Regulaton. 1993; 18(3): Stroop JR. Studes o ntererence n seral verbal reactons. Journal o Expermental Psychology. 1935; 18: Berg EA. A smple objectve technque or measurng lexblty n thnkng, J Gen Psychol. 1948; 39: Pop-Jordanova N, Pop-Jordanov J. Spectrum-weghted EEG requency ( bran-rate ) as a quanttatve ndcator o mental arousal. Prloz, 2005; 26 (2): Pop-Jordanov J, Pop-Jordanova N. Quantum Interpretaton o Mental Arousal Spectra. Prloz, 2005; XXV, 1-2: Pop-Jordanova N. EEG spectra n pedatrc research and practce. Prloz. 2008; 1: Pop-Jordanov J, Pop-Jordanova N. Neurophyscal substrates o arousal and attenton. Cogn Process. 2009; 10 Suppl 1: S71-9. Epub 2008 Oct 31.PMID: Correspondng author: Tatjana Zorcec, MD. Pedatrc clnc. Unversty o Skopje, Republc o Macedona.