Clinician Name: Robert Longo, MRC, LPC, BCN
Clinic Name & Location: Serendipity, Lexington, North Carolina
Professional Status: Masters Rehabilitation Counseling. Licensed Professional Counselor. Board Certified Neurofeedback
- Abstract: This case study reviews Ms. B., a 56 year-old female with a history of multiple head injuries. She is a nurse practitioner who contracts her services to several organizations and companies. She presented for treatment due to symptoms that included, anxiety, insomnia, and cognitive deficits.
The patient has a history of multiple head injuries, sleep problems, high blood pressure, and thyroid problems and reports diagnosis of anxiety, depression, insomnia, seizure disorder, panic attack, migraine, TMJ and memory problems.
She was taking prescriptions of Tegretol, Lithium, and Gabapentin which combined reduces alpha power and decreases alpha peak frequency, increases delta and theta and results in diffuse slowing of the EEG
Physiology problems included, but were not limited to, insomnia, depression, anxiety, headaches, dizziness, shaking & tremors, fainting spells, agitation, visual blurring, and nausea.
- Description of Case Study:
The patient underwent an initial QEEG on November 5, 2014, and a subsequent remapping on March 2, 2015 to ascertain her status/progress after it was learned that she had sustained a head injury from falling on ice sometime around February 17, 2015.
When the patient indicated that she wanted to continue Neurofeedback (despite potential caveats about starting Neurofeedback immediately following a TBI), an additional map was acquired on March 16, 2015 (her ‘new’ training map).
A subsequent head injury occurred via a bicycle accident on April 17, 2015. At that point, the patient completed a formal acknowledgement/consent to continue Neurofeedback treatment in spite of the new head injury, because she felt that the training was beneficial and wanted to continue.
QEEG maps were acquired via a 19 channel simultaneous acquisition process using the Brainmaster Discovery hardware and software. Artifacted data sets (eyes closed condition; eyes open condition) were then uploaded to the NewMind Expert QEEG Interpretive system for statistical analysis and spectral mapping. NewMind assessment questionnaires, such as the Cognitive-Emotional Checklist (CEC), Interpersonal Style Inventory (ISI), and Metabolic (Physiological symptom) Checklist, were also administered and scored as part of the QEEG interpretive report.
Overall, the patient received 36 sessions of neurofeedback over the course of 11 months. Sessions were conducted 1-2 times per week. Each neurofeedback session lasted an average of 30 minutes. The patient progressed well despite incurring 2 additional head injuries after NFB training started.
III. Literature Review:
The Brain Injury Association of America notes that 1-5 million traumatic brain injuries are sustained annually (Morkides, 2009.) Each year, traumatic brain injuries (TBI) contribute to a substantial number of deaths and cases of permanent disability. A TBI is caused by a bump, blow or jolt to the head, or a penetrating head injury, that disrupts the normal function of the brain. The severity of a TBI may range from “mild” (e.g. concussion), to “severe” (e.g. involving midline shift), based upon variables such as duration of loss of consciousness and/or duration of post-traumatic amnesia. Objectively-derived empirical data from various sources (physiological, psychological, occupational, socioeconomic, psychosocial, socio-legal, sports-related, etc.) are critical to understanding the impact of this important public health problem. This information can help inform TBI prevention strategies, identify research and education priorities, and support the need for services among those living with a TBI (http://www.cdc.gov/traumaticbraininjury/pdf/BlueBook_factsheet-a.pdf)
Cognitive functioning is thus often overshadowed by psychiatric problems. The question often posed, with regard to TBI patients, concerns whether persistent dysfunction can be attributed to an underlying acquired neurologic disorder, versus whether problematic sequelae are primarily psychologically-mediated. Recent findings are that many TBI patients (e.g. NFL football players) have treatment-resistant depression. Endocrinological research and clinical practice in the treatment of TBI indicates that ½ or more of patients referred for treatment become clinically depressed within one year post-injury. (Mark Gordon, MD, Personal Communication)
Client Gender: Female
Socioeconomic status: Middle Class
Public or Private School: N/A
Years in School: 16 / college undergraduate degree
Started Dating at Age: N/A
Number of Friends: several
Social Groups: N/A
Frequency of Dating: N/A
Sports Played: cycling, kayaking, hiking
Parental Status: N/A
Amount of Parental Discord: N/A
Sexual or Physical Abuse: N/A
Family Substance Abuse: unknown
History of Head Trauma: Multiple head injuries and TBIs from playing sports and falling.
(2) Presenting Symptoms:
Insomnia: Sleep onset
Attention: Difficulty focusing at work
Memory: Working Memory and Short Term Memory Problems
Worry: Constant- Especially at work.
Suicidal Thoughts: Yes
CPT (add here) N/A
(3) NewMind Assessment Data:
- Cognitive-Emotional Checklist (CEC): Patient acknowledges problems with attention, memory, impulsivity and anxiety, as indicated below.
- Interpersonal Style Inventory (ISI): The patient scored above the norm on scales assessing Depression (score = 27) and Anxiety (score = 22). The ISI inventory data are consistent with the patient’s self-report in interview of feeling depressed (with suicidal thoughts); anxious (with panic attacks); stressed at work with difficulty completing work tasks; and experiencing ongoing difficulties focusing and sustaining attention, with a tendency to behave impulsively.
- Metabolic Checklist:
This patient obtained a total score of 195 on the Metabolic Checklist. Her most elevated scores were on item clusters associated with dysfunction in the following bodily systems: Kidney (27); Thyroid (e.g. Hypothyroidism; 26); Adrenals (25); Thyroid (e.g. Hyperthyroidism 24); Blood Sugar (22); Cardiovascular (18); Pituitary (20); and Blood Sugar (18). It was recommended that she share this information with her Primary Care Physician.
The Metabolic Checklist data raise the possibility of that a metabolic/medical load on the bodily system could potentially attenuate the rate (speed) of effectiveness of Neurofeedback training. This metabolic load may correlate with hypothesized neuroinflammatory and endocrinological changes in the brain in response to repetitive insults to the brain; processes which initially are intended to be protective, but which over time have a degrading effect upon the brain’s structural and functional integrity.
(4) Neurofeedback Training Sessions:
- Patient began NFB on November 7, 2014. A two-channel Bipolar Montage was used: New Mind Protocol #3 (2-12d, 15-20u on the Left and 2-12down, 13-15u on the Right) at Active sites C3 & C4, in the Eyes Closed condition. Reference sites used were A1 and A2, and Ground was placed at Cz.
- On January 30, 2015, an alternate two-channel Bipolar Montage was used: New Mind Protocol #17 (2-7d, 15-20u on the left and 2-7d, 9-11u on the right) at Active sites P3 & P4 in the Eyes Closed condition, for 4 sessions. . Reference sites used were A1 & A2, and Ground was placed at Cz.
- On February 17, 2015, Ms. B. slipped on the ice and sustained another head injury. A second QEEG was performed on March 2, 2015 to assess impact of injury.
- On March 16, 2015, 4 weeks post injury, a third QEEG map was done, as the patient requested to continue NFB.
- On March 27, 2015 (over one month after falling on the ice and sustaining a TBI), as a condition of continuing Neurofeedback, she read and signed the following acknowledgement of new TBI and consent to continue treatment, indicating that she did not want to stop her neurofeedback training due to the benefits she was receiving from the intervention”
I, _________, acknowledge that approximately 6 weeks ago, I slipped on the ice and sustained a new head injury. My subsequent QEEG brain maps reveal that my EEG has changed; and those indicated changes are likely from that injury; and are signs consistent with a new brain injury. I understand that neurofeedback is not conventionally recommended until at least three months following a head injury, to allow sufficient time for the brain’s intrinsic healing processes to occur (e.g. the brain’s neuro-plastic compensatory processes involving reorganization).
I consent to continuation of Neurofeedback training with the understanding that participating in Neurofeedback sooner than the customary 3 month wait period might potentially result in negative symptoms or side effects. In the event that I (or my family) begin to notice any unusual or lasting negative effects during my neurofeedback training over the next few months, I agree to inform Robert Longo immediately.
- On March 27, 2015, she began a “Squash” Protocol for 15 sessions, in the Eyes Closed condition: A single-channel Monopolar Montage (2-30d) at Active site Cz , with Ground at A1 and Reference at A2.
- On July 3, 2015, she began a different two-channel Bipolar Montage: NewMind Protocol #10 (2-12d, 15-20u on the Left and 13-15u, 16-30d on the Right) at Active sites Fp1 and Fp2 in the Eyes Open condition for 2 sessions. Reference sites used were A1 & A2, and Ground was placed at Cz. Each session was approximately 30 minutes in length.
- On July 17, 2015, she began another two-channel Bipolar Montage: NewMind Protocol #4 (2-7d, 15-20u on the Left and 2-7d, 13-15u, on the Right) at Active sites F3 & F4 in the Eyes Open condition for 4 sessions. . Reference sites used were A1 and A2, and Ground was placed at Cz.
- Pre-Post Trend Screens:
NewMind Protocol #3: 11 Sessions
Pre-Protocol Trend Screen
Post-Protocol Trend Screen
NewMind Protocol #17: 4 Sessions
Pre-Protocol Trend Screen
Post-Protocol Trend Screen
“Squash” Protocol: 15 Sessions
Pre-Protocol Trend Screen
Post-Protocol Trend Screen
NewMind Protocol #17: 2 Sessions
Pre-Protocol Trend Screen
Post-Protocol Trend Screen
- Pre-Post QEEG Map Comparisons:
After 15 sessions, a remap revealed a 28% overall change in the Eyes Closed condition with 45% reorganization and 55% normalization. The Eyes Open condition revealed a 24% overall change with 45% reorganization and 55% normalization.
- Eyes-Closed Map Comparison: 11/5/2014 versus 3/2/2015
- Eyes-Open Map Comparison: 11/5/2014 versus 3/2/2015
- Eyes-Closed Map Comparison: 3/2/2015 versus 3/16/2015
After her head injury, remapping between 2nd and 3rd remap EC revealed 21% overall change with 50% reorganization and 50% normalization EO revealed 30% overall change with 53% reorganization and 44% normalization.
- Eyes-Open Map Comparison: 3/2/2015 versus 3/16/2015
- Results: Weekly Symptom Tracker
Patient tracked progress for 11 symptoms. The trend suggests a reduction in severity in all symptoms. The most pressing symptoms (identified by the patient) below reflect the reductions in sleep disturbance, depression, anxiety, panic attacks, and suicidal thoughts.
Neurofeedback began on November 7, 2014 and was terminated on September 11, 2015 (after roughly 10 consecutive months). A total of 36 sessions using five different protocols involving single-channel Monopolar and two-channel Bipolar protocols were used during the course of her neurofeedback training. The patient’s overall progress ranged from good to excellent, and her self-report indicated that all symptoms had improved. The patient was encouraged to practice diaphragmatic breathing multiple times per day.
The patient was asked to track her progress weekly for the following symptoms: Dysregulated sleep cycle, difficulty organizing personal time or space, reading difficulty, auditory hypersensitivity, trouble doing anything because felt bad, anxiety, depression, mood swings, panic attacks, suicidal thoughts, and poor balance. The patient reported overall symptom reduction and improved higher quality of life.
Changes in reorganization and normalization occurred with each QEEG remapping. Unfortunately, it is not possible to ascertain what proportion of change in the map(s) (corresponding to neuro-physiological changes in the brain) was potentially attributable to neurofeedback intervention (e.g. between the November 5, 2014 and March 2, 2015 map). The QEEG map comparison data are included primarily to demonstrate how the brain reorganizes itself: whether with positive intervention, such as neurofeedback, as well as in response to new insults to the brain (such as repeat TBIs).
In this respect, it is noteworthy that the patient sustained a TBI (slipping on ice and falling, hitting her head) in mid-February, which is a confounding factor (potentially likely to undo some of the beneficial effects of the neurofeedback). The patient also began to make other important lifestyle changes, which likely contributed to changes in the maps. Other uncontrolled factors (e.g. work and family stress, sleep patterns, even light cycle changes such as reduced daylight hours in midst of winter, etc.) may potentially contribute to changes in QEEG maps. This is why subsidiary measures, such as the weekly symptom tracker are so vital in ascertaining positive change (based upon self-report) in neurofeedback training.
Editor’s Note: This case study provides an important training lesson for practitioners, particularly new neurofeedback clinicians. On March 2nd, 2015, as soon as it was learned that the patient had sustained a new TBI (from slipping on ice and falling, hitting her head in mid-February), the neurofeedback sessions were put on hold, and a remap was done at that very session (which would have been about 2 weeks, post-injury). The patient was wanting to continue the neurofeedback right away, but the author wisely waited until one month had transpired since the accident, and did a second remap. Waiting a month allowed some brain organization/ reconsolidation to occur as part of neuroplastic compensatory processes. Waiting 3 months could have too long a period of dysfunction for this distressed client to endure before resuming.
In a very pragmatic fashion, the practitioner educated the patient about the rationale for customarily waiting 3 months before re-engaging in neurofeedback, and potential risks of resuming training sooner. She was agreeable to taking this risk, because she had found the neurofeedback to be so helpful. The author had the patient sign an acknowledgement statement (that she had sustained a new TBI, and an understanding of how the new TBI may have interfered with previous progress, and how opting to continue neurofeedback might interfere with the brain’s neuroplastic recovery processes). He obtained her consent to continue neurofeedback, and used the 1 month post-injury map as the new starting place to determine the most effective protocol. Initially, he opted to do a “squash protocol” at Cz via Monopolar Montage, presumably because of across-the-board excessively high amplitudes of most or all of the frequency bands. Once the amplitudes began to reduce, he then shifted to a different two-channel Bipolar Montage with more specific targeting of problematic amplitudes in select frequency bands. Again, the use of a weekly symptom tracking system proved invaluable, as it demonstrated that despite new TBIs (which could confound the interpretation of pre-post maps), the overall trajectory of neurofeedback intervention was to reduce symptoms across the board appreciably from baseline, and allow for a very positive outcome for this complex patient. By the end of 10 months of treatment, her depression and anxiety had significantly improved, her TBI symptoms had improved, and she was very pleased with the improvement in her functioning and quality of life. This case example represents flexible, informed neurofeedback at work.
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