Behavioral Medicine Associates, Inc.

Education Pages

Brain Injury

A lot of people get traumatic brain injury, estimates are 600,000 per year in this country. Often this happens from car accidents, including relatively "minor" accidents. The most common result is that you have lower concentration, trouble reading, mental slowness, often sleep disruption. Often vision is "not right," with sudden loss of reading speed, comprehension or comfort; depth perception may be dramatically worsened. Getting poor sleep because of sore muscles from whiplash injuries makes the effects of any mild brain injury much worse. The hard part is that you look normal to friends, family and your doctor. If you keep complaining, people will often think you're depressed or just a complainer. Not so.

We have treated several hundred people over the last 14 years using a variety of cognitive and emotional rehabilitation methods, including neurofeedback, cognitive behavior therapy and binocular vision training.

Assessment: We discuss your history, your level of accomplishment before your injury, any intellectual testing you might have had before the injury. If you haven't had intellectual testing since the injury I may refer to a neuropsychologist for testing, depending on the depth of testing that appears necessary. Keep in mind, however, that without detailed testing before an injury, you can only get limited information from tests.
Neuropsychological testing may be helpful, although it is insensitive to subtle impairment and may show a person as "normal" who in fact had a higher IQ and/or memory capacity before injury. This type of patient may test in the normal range and be told they're fine, but may have in fact suffered major loss. No test can prove you are injured, none can prove you are not injured. Patients often will have had a "normal" MRI scan of their brain and will have been told they are fine. The MRI, however, cannot show microscopic shearing and tearing that is thought to be the major mechanism in mild to moderate brain injury. We also assess attention (auditory and visual), binocular function (to see how well your depth perception is working and to see if your eyes converge properly for reading). We will want intellectual, memory of other objective tests.

When treatment is desired, we will use a quantitative EEG to assess the levels of abnormal electrical activity that is present. The QEEG is very sensitive to signs of mild brain injury (95%) and fairly specific (90%), although we do not attempt to use it as  "proof" of an injury in litigation.

Treatment:  We use neurofeedback to train back normal electrical signalling between affected parts of brain. Frequently there is poor connectivity (low coherence, slowed phase and unsteady synchronization). Neurofeedback improves these signs of connectivity and with them the subjective sense of alertness, attention and normal thinking. Neurofeedback is coupled with cognitive retraining exercises, memory and attention exercises, binocular visual training and cognitive behavior therapy (CBT). CBT includes keeping thoughts, feelings and behaviors going in a constructive direction; developing and accepting accommodations (like having to take one task at a time, having to record appointments, make lists, take longer to speak and express one's ideas). Our orientation is that one must accommodate what one can't change, but one also must activate the brain's circuits and insist on more normal function.

What is it that we are treating?

Traumatic brain injury (TBI) typically occurs when the head is suddenly accelerated and/or decelerated during an accident of some type. There may or may not have unconsciousness, or even a blow to the head. A severe whiplash situation can cause the same kinds of twisting and shearing forces on the brain's axons - the nerve fibers connecting one part of brain to another - as does a blow to the head. It is thought that these forces damage the connections between nerve cells and possibly the conducting fibers themselves, resulting in impairment of function.

Damage to the networks of connections in the brain also occurs with a stroke or surgery. A "stroke" means that either there was a blockage in a blood vessel feeding a particular region of brain, or a blood vessel broke open and bled (aneurism). There will be a local area of damage from the cells not getting enough bloodflow. The piece of brain that is directly damaged by the stroke will be impaired, at least for a while, and won't be able to serve its normal function.  Beyond that there can be effects in regions the local area of damage is supposed to communicate with. Many regions of brain perform regulation of other regions, so if an area is damaged by a stroke or surgery other areas - not necessarily nearby - can lose function because they're not being regulated properly. 

Brain can also be injured if a person is unable to breath for long enough, or if the heart stops for too long. This happens from lack of oxygen and blood sugar getting to the brain cells. This is why it is so important to provide emergency CPR at the scene, immediately. If you do not know how to administer CPR, you should learn. Contact a local hospital, fire department or medical clinic and ask how to get basic first aid training including CPR. Even when the person is revived, the brain may have suffered widespread damage, since all the cells need oxygen and glucose to survive. Some are tougher than others in the face of oxygen deprivation. The cells in the hippocampus, which is vital for memory formation, are unusually sensitive to being deprived of oxygen, so loss of ability to store new memory is very common in "anoxic" (without oxygen) brain injuries.

TBI patients often show emotional instability, which may be from the emotional regulation regions having been injured, or from the incredible frustration of everyday life with a brain injury, or both.  Brain injuries from many causes create impaired concentration and memory and reductions in the ability to "multi-task," that is, to keep on top of several things at once.  Patients with brain injury (particularly from traumatic injury) often show a dramatic drop in their visual processing ability. This is measured by a relative failure of the eyes to converge and/or diverge rapidly and accurately. This results in decreased reading skill and decreased depth perception. Patients often have further accidents, and tell us they feel "clumsy," disoriented in space. In traffic for example, they feel confused about where the other cars are relative to their car. This is obviously dangerous and predisposes to further injuries. The impaired attentiveness coupled with the visual problems and emotional instability probably contributes to the finding that a person with a head injury is six times more likely to have another one. We've had great results correcting this problem with binocular vision training. 

There may be major depression and anxiety associated with these symptoms. In fact, these symptoms are often misunderstood by family and health care providers as "nothing but" depression, or worse still, malingering. However, the symptoms do not yield to standard medical treatment (cognitive therapy plus medication). That may be due to the injury of brain systems that support normal mood, or to irritation in other systems that support irritable moods, or to the failure of the medical and psychological treatment to provide adequate explanation of what's going on, adequate rehabilitation and hope. Cognitive behavior therapy helps people keep their thoughts useful and helpful to their recovery.

Finally,  patients with brain injury from accidents usually have severe "trigger points" in the neck and back muscles, which cause chronic headaches. These headaches are not often cleared up by relaxation, chiropractic or passive physical therapy. Triggered muscle causes "myofascial pain" and the pain and dysfunction is often "referred" to other areas of the body. This is well described in the Trigger Point Manuals by Drs. Travell and Simon. The necessary treatment is compression and stretching of the affected tissue several times daily. This must be coupled with very deep autonomic relaxation. This is easy to learn and we teach most of our patients to self administer this treatment. 

The brain can repair itself

In the past we thought brain damage was permanent. We now know that there is birth of new cells going on in adult brains. In fact a stroke actually has been shown recently to be a stimulus for a higher rate of cell birth in animals. These new cells grow into the regions of damage and can help restore function. What's important is that the person get good nutrition, minimize stress (more about that later) and place a persistent demand on the brain to perform the impaired function(s). To understand the treatment we do and its efficacy, you must understand that the connections between our brain cells are extensively influenced by learning. In other words, we learn to construct the visual world as infants; we learn emotional control, strategies of attention, strategies of learning and memory itself. It is well established that these learnings cause the growth of new neuronal connections. We believe our treatments may, by rewarding new learning, promote the growth of new, "replacement" connections.

Education regarding what has happened, how the brain functions, the effects of various types of injury begins our treatment. Relaxation training is a basic part, since excessive arousal from frustration, anger at the injury, etc. will make things worse.

We also assess the binocular vision and correct poor binocular control. We have consistent success with restoring normal binocular control using guided practice with binocular stimuli which is done along with the neurotherapy (described below) to correct the abnormal brain function.

More about the QEEG technology we use:

The American Psychiatric Association textbook "Neuropsychiatry of Traumatic Brain Injury" states: "qEEG is not currently a standard part of the neuropsychiatric evaluation of postacute and chronic neurobehavioral and neurocognitive syndromes in patients with brain injury. However, when carefully applied and thoughtfully interpreted in relation to the results of the other currently available structural and functional imaging studies and neuropsychological test results, it may yield additional information that can be beneficial in diagnosis and management" (p. 122). This instrument allows us to measure the electrical functioning of the brain at rest and during mental tasks, like reading, listening, math, etc. We can also compare the patient's record against non-injured normal qEEGs to determine what areas of the brain have been most affected. We can see regions that are not activating consistently and are therefore not functioning well. We can also see measures (termed "coherence") that reflect the quality of communication between regions. This information is helpful in determining the directon of rehabilitation efforts, the types of tasks one should be practicing most and the training approaches we will use during neurofeedback.

The sister technology to qEEG analysis is called EEG biofeedback, neurofeedback or neurotherapy. The qEEG provides the "targeting" information. That is, it tells us where and under what conditions (reading, listening, math, etc.) the problem is worst. This analysis allows accurate electrode placement for feedback and suggests the tasks that should be used during therapy. Neurotherapy is EEG feedback-assisted cognitive behavior modification. It couples EEG feedback with the full range of traditional cognitive behavior therapy methods, including imaginal rehearsal, correction of maladaptive thought patterns, and rehearsal of new skills. We commonly utilize intensely activating, challenging tasks (such as computerized stereo vision training, memory and reaction time challenges) during the sessions to enhance brain activation and teach what it feels like to be focused and functional again. The EEG feedback signals the patient when their brain is in fact in a more activated state, indexed by decreased delta and theta brain wave amplitudes, and increased beta and/or alpha amplitudes.

Neurotherapy is no panacea. Like any therapy, it works best with the smartest, least brain damaged patients. Patients with profound memory loss which prevents the acquisition of new learning at all are not likely to be helped. On the other hand, patients with emotional dyscontrol, impaired memory and concentration, and a good pre-morbid level of functioning are responding very, very well to the treatment. Most interestingly, good results are being achieved in patients who are 2, 3 or even 5 years post injury; these are times at which improvement cannot be attributed to "spontaneous recovery." We have documented improvements on standardized memory tests of several standard deviations, showed essential normalization of memory. Our patients report reading returns to normal and they find the visual world no longer confusing. Patients, family and physicians have documented improved alertness and reduction or elimination of emotional instability and depressed mood. We have had patients tell us they feel "back to normal" in as few as 20 sessions. We have seen objective improvement in visual processing, memory, attentiveness and emotional stability even years after injury. We suspect this treatment works best with the smartest people who have the least damage. We encourage patients and their families to understand that this is a new approach, with little formal outcome research to prove it works. There is no guaruntee it will help any particular individual. The treatment is non-invasive, doesn't appear to have any negative side-effects, doesn't involve drugs, and over 95% of the people we've treated rate themselves 50% improved or more. With this improvement rate is so high, particularly with patients who could not possibly be undergoing any "spontaneous recovery" years after their injury, we believe we have clear evidence this treatment helps.

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