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Head Injury |
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Definition Mild traumatic brain injury (mTBI) is characterized by a period of unconsciousness for
less than 20 minutes, or a score of 13 or above on the Glasgow Coma Scale
without unconsciousness. The injury should also show no evidence of
deterioration or post traumatic amnesia within 48 hours after the
occurrence. Symptoms and Causes The symptoms of mTBI are
generally categorized into three groups; physical/somatic problems, cognitive
dysfunctions, and emotional/personality symptoms. The physical/somatic problems may include
seizures, headaches, fatigue, sleep disturbance, dizziness, light/noise
sensitivity, nausea, blurred vision, vomiting, loss of sexual drive and
tinnitus. The cognitive dysfunctions may involve
impaired short-term memory, impaired concentration and attention, slower
information processing, disorganization, lexical deficits, forgetfulness and
distractibility. The emotional/personality symptoms may
include irritability, anxiety, mood swings, depression, impatience, lower
frustration tolerance, and explosive temper. The mTBI symptoms,
listed above, are primarily caused by mechanical forces and the effects they
produce. Mechanical forces typically include rapid acceleration/
deceleration forces that can affect cortical regions and rotational forces
that can twist the brainstem. In addition to damaging the area directly
involved in the impact, mTBI may also produce a
coup-contra-coup effect or a shearing effect. The coup-contra-coup
effect involves brain injury at the site of impact, as well as the site 180º
opposite this site. The shearing effect, also known as diffuse axonal
injury, involves the unraveling of myelin in the brain. By unraveling
the myelin sheaths around the axons, mTBI slows
down the speed of electrical communication between cortical regions. Brain injury may cause generalized attenuated
cerebral activity, specific areas of slow-wave activity, or disconnection
syndromes. Usually, with closed head injury, contusion (bruising)
occurs in the absence of skull penetration. The brain bruises as it
strikes against the skull in rapid acceleration-acceleration or
coup-counter-coup injuries. These result in laceration, intracranial
injury to the brain, hemorrhage, and/or axonal injury. Individuals with
mTBI often show various deficits known as post
concussive symptoms, consisting of slowed information processing, memory
deficits, and/or some degree of language impairment as well as executive and
frontal lobe dysfunction. Diagnostic Tools The most common tools used to
diagnose mTBI include past medical history, CAT
scan, MRI, standard EEG and neurological exams. The main problem with
these tools is their ineffectiveness when it comes to detecting subtle
impairments. This diagnostic battery has been known to produce normal
test results, despite patient complaints of significant neurocognitive
dysfunctions. Another type of imaging that
has become popular in the diagnosis of mTBI is the
Quantitative Electroencephalograph (QEEG). The QEEG reads a patient's
real-time electro-cortical activity and compares it to a normative database
to detect any dysfunctions. By comparing the acquired data to a
normative database, the QEEG is able to detect minute changes in brain
activity that other methods might not be able to detect. The QEEG also
enables the discrimination between mechanical injury and diffuse axonal
injury. Treatment The traditional treatment
regimen for mTBI focuses on medical management,
psychotherapy, coping skills, vocational rehabilitation, counseling and
cognitive rehabilitation. This combination of treatments usually
involves a wide array of specialists; ranging from physicians and
physical therapists to psychologists and social workers. Despite the
fact that these interventions are clearly beneficial to severely injured
individuals, the research has shown mixed results for the mildly injured
population. This treatment strategy may also be very expensive, since brain
injured patients receive an average of 250 hours of treatment. Neurofeedback A relatively new and promising treatment for mTBI is EEG neurofeedback training. Guided by QEEG testing, neurofeedback trains an individual to normalize and stabilize brain function. By providing the client with real time EEG feedback, the clinician trains the client to increase the production of desired brainwaves in specific cortical regions (regions that might be injured by brain trauma). In addition to helping mTBI patients' regain their cognitive abilities, neurofeedback also dramatically cuts the costs of the traditional treatment procedures by successfully treating patients in an average of 40 sessions. EEG neurofeedback treatment stems from the revolutionary biofeedback work of Dr. Barry Sterman. Sterman found that by training epileptics to increase SMR (12-15 Hz) brainwaves, he could significantly reduce the amount of their seizures. Subsequent biofeedback experimentation by Sterman and Lubar revealed increased attentiveness and concentration among their test subjects. From its meager beginnings, neurofeedback has grown into a treatment option that continues to broaden its range of applications. In 1941, Williams and
Denny-Brown documented abnormal EEG activity subsequent to penetrating
traumatic brain injury, mild traumatic brain injury (mTBI),
or closed head injury. In the 1980's, clinicians began applying
neurofeedback training to the treatment of mTBI.
Bruner (1989) reported that his subjects regained their cognitive functioning
after training high alpha and SMR (10-14 Hz). Some researchers, such as
Tansey, have successfully trained mTBI patients with SMR (12-15 Hz). Ayers has reported significant results by inhibiting theta
(4-7 Hz) and rewarding Beta (15-18 Hz). Regardless of the differences
in protocol, these researchers have reported significant returns to
pre-morbid functioning as a result of neurofeedback training. In order to obtain the best
results from neurofeedback, clinicians must perform a comprehensive
evaluation. This evaluation should examine medical history, mental
status, neurophysiological screening, information from related professionals
(i.e. physicians, neurologists, teachers, etc.), and Quantitative
Electroencephalographic data (QEEG). Together, this information will
provide the clinician with a road map for developing the best possible
treatment. References 1. Hoffman, D. A.,
Stockdale, S., Hicks, L., Schwaninger, J.
(1995). Diagnosis and Treatment of Head Injury. Journal of
Neurotherapy, Vol. 1 (#1), pp. 14-21. |
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