EEG-based neurofeedback and “brain coaching” improved cognitive function

Aug 20

This is the last week of our 10-week Concussion Alliance summer internship; thank you to the interns, mentors, and volunteers who have written this newsletter!

Contributors this week:

Editors: Conor Gormally and Malayka Gormally.
Contributors: Will Altaweel, Cassidy Bins, Hannah Kennicott, Caroline Saksena, Srishti (Shelly) Seth, and Trinh Tieu.

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Education

New educational resources for families, teachers, and coaches

The Ontario Neurotrauma Foundation has released three short handoutsgeared toward coaches, teachers, and parents that contain concussion information, including signs and symptoms, recovery, and additional resources. The foundation also published an extended “family version” document with concussion recommendations.

Sports

Statement critiques ethics of rugby trial after results show increased concussion risk

A recent editorial by Adam White et al. critiqued a trial that examined whether lowering the permitted tackle height in rugby would reduce concussion frequency. The editorial, published in the British Journal of Sports Medicine, addresses several ethical issues presented by the trial.

The authors claim that the rugby players could not realistically opt out of the trial without penalty, given that they are employed to play rugby. The original study also found that, relative to the original tackle height, there was a 30% increased risk of concussion with the lowered tackle height. White et al. note that players were unaware of the potential harm. Both of these concerns reflect a lack of informed consent for the study's participants.

The authors recommend that future trials conducted by World Rugby—the governing body for professional rugby—should be reviewed by external institutions before their onset to avoid unethical research practice.

Cannabis

Cannabinoids may be beneficial in treating TBI and multiple sclerosis

To read this synopsis, see our blog post.

Diagnostics

mTBI associated white matter microstructural changes detected with advanced imaging in a longitudinal study

Palacios et al. conducted a longitudinal study, published in Science Advances, on white matter microstructural changes after mTBI. The study used a type of brain imaging with significant potential for diagnosing mTBI. Using “neurite orientation dispersion and density imaging” (NODDI), the authors found significant correlations between patients’ white matter microstructural changes and neuropsychological function.

Two groups of 40 patients with mTBI and two control groups participated in testing at two weeks and six months post-injury. Along with diffusion tensor imaging (DTI) and NODDI, the researchers included a neuropsychological battery and machine learning analysis of cognitive and behavioral recovery.

The researchers created a single global improvement measure (GIM) based on the study participants’ change in self-reported symptoms and their cognitive performance measures. Unsupervised machine learning identified two groups based on GIM - one group whose symptoms did not improve at all over six months and one group whose symptoms significantly improved.

The authors found a significant correlation between NODDI (but not DTI) metrics and their GIM. One primary result of the study was the strengthening of preliminary evidence for the “sensitivity of NODDI as a biomarker for progressive WM degeneration due to mTBI.”

White matter changes from mTBI most affected the posterior regions of the brain. These regions are integral to the neural networks involved in multiple sensory and cognitive domains, including attention and executive function. White matter changes may contribute to cognitive impairments, though further research is needed.

Self-care

Driving after a concussion may have risks even after symptoms abate, according to a preliminary study

A preliminary study presented at the American Academy of Neurology’s Sports Concussion Virtual Conference investigated reaction times in individuals who recently recovered from concussions. A press release by the American Academy of Neurology explains the results, highlighting that although immediate symptoms may not be present, people who recently had a concussion may still have slower reaction times when making split-second decisions, which are essential to driving.

The study looked at 14 individuals with a concussion history and 14 healthy controls, who completed a driving reaction time test simulation and a neurocognitive test. Landon Lempke et al. tested the concussed group within 48 hours of becoming asymptomatic, which occurred an average of 16 days after the injury. In the driving simulation, “when reacting to a change in stoplight color, it took those with concussions 0.24 seconds longer to react, or the equivalent of 15.6 feet in stopping distance, compared to those without concussions. During the driving simulation involving a child running in front of a car, it took those with concussions 0.06 seconds longer to react, or the equivalent of 3.3 feet in stopping distance, compared to those without concussions.”

The authors conclude that the individuals sustaining a concussion may have “lingering deficits” in their complex reaction times, but acknowledge that there is only a moderate correlation between driving and computerized neurocognitive testing reaction times. U.S. News and World Report also reported on the study, noting that “Data and conclusions presented at meetings are usually considered preliminary until peer-reviewed for publication in a medical journal.”

Therapies

Comprehensive concussion recovery program with EEG-based neurofeedback and “brain coaching” improved neurocognition index

A retrospective analysis of the NeuroGrowth Concussion Recovery Program found that the 12-week rehabilitation program led to significant improvements in complex attention, cognitive flexibility, and executive functioning for mTBI patients experiencing post-concussion syndrome (PCS). Majid Fotuhi et al. published their study on their rehabilitation work at the NeuroGrow Brain Fitness Center in the Journal of Rehabilitation. The study involved 46 patients in a combination of electroencephalogram-based neurofeedback (EEG-NFB) and Brain Coaching twice a week for 12 weeks.

EEG-NFB seeks to restore brain oscillations using operant conditioning biofeedback to reward a patient for modifying their brain activity toward an age-matched normative pattern. Each patient worked with their “brain coach” in one-on-one meetings, where their coach served as both a brain training coach and a life coach. Supervised by neurologists, the overall role of the brain coach was to support patients with positive feedback and encouragement, guide them targeted brain training games, and encourage adherence to healthy lifestyle choices such as improved diet, exercise, sleep, and meditation. Brain coaches also assisted patients with incorporating necessary lifestyle changes into their lives to improve fitness, lower anxiety, and maintain a positive attitude towards their recovery.

After 12 weeks, the average change in score on the “CNS Vital Signs” Neurocognition Index significantly improved by 10.56 points. At least 64% of the patient subset who initially scored in the “abnormal” Neurocognition score range experienced reliable and clinically significant improvement in the three CNS Vital Signs domains considered to be most sensitive to mTBI: complex attention, cognitive flexibility, and executive functioning.

This comprehensive and individualized program with a brain coach and EEG-NFB work offers a promising model to help patients integrate lifestyle changes, stay motivated through their recovery, and avoid falling through gaps in the healthcare system. The findings of this analysis suggest that rehabilitation counselors can consider offering a combination of neurofeedback and brain coaching for patients with PCS. More research is needed to verify and expand upon this analysis, as mTBI rehabilitation requires such a multifaceted and personalized approach for each patient.

Veterans and Service Members

Veterans with mTBI and history of adolescent binge drinking at higher risk for PTSD

In a recent study published by Alcohol and Alcoholism, Catherine Fortier et al. found that “veterans with a history of early adolescent binge drinking and military mTBI are at greater risk for incidence and severity of PTSD.” These results indicate that “mTBI exacerbates the risk” of PTSD in veterans with a history of binge drinking. Understanding this relationship may aid the Veterans Administration in anticipating and addressing veterans’ needs and prompt earlier intervention.

Mental Health

Reductions in self-reported cognitive mTBI symptoms related to improvement in physical and emotional symptoms

A recent study in Norway by Jonas Stenberg et al. investigated mTBI patients’ cognitive concerns compared to their cognitive test performances between two weeks and three months after their injuries. The participants, 135 concussion patients aged 16 to 59, were mostly men who went to urgent care after they experienced an mTBI.

The researchers predicted that patients’ self-reported cognitive symptoms would match their test results. However, in a press release published in Medical Xpress, Stenberg elaborated that “If someone reports significant memory problems, we expect them to also have poor results on the memory tests. But that wasn’t the case.”

Reductions in self-reported cognitive symptoms were unrelated to the patients’ cognitive test performance but correlated positively with improvements in their emotional and physical symptoms. Thus, reducing emotional symptoms could, in turn, improve cognitive abilities like memory.

“This finding may be a clue that treating one type of symptom, such as the emotional, can also improve cognitive symptoms,” said Stenberg. The study was published in Neuropsychology.

Statistics

Dementia prevention, intervention, and care report adds three new risk factors, including TBI

A report authored by Gill Livingston et al. integrates three new risk factors for dementia (excessive alcohol consumption, air pollution, and TBI) into an “updated 12 risk factor life-course model of dementia prevention.” The report, published in The Lancet, asserts that modifying these 12 risk factors could prevent or delay as much as 40% of worldwide dementia incidence.

Regarding TBI’s addition as a risk factor, the authors point to five studies of various cohorts that have associated TBI with an increased risk for dementia among older adults (>50 years), veterans, and athletes. While some of the studies referenced in the report differentiate between mild, moderate/severe, and repetitive TBI, the authors did not account for these differences in severity when performing their meta-analysis. Pooling data from eight “original population-based cohort studies,” Livingston et al. calculated that the risk ratio (relative risk of dementia) for “all-cause dementia from all severities of TBI” was 1.84 times higher than the general population. This analysis is limited, as the eight studies varied in estimates, populations, and severity of TBI reported.

Youth

Pre-existing anxiety disorders increase the risk of more symptomatic and prolonged recovery following a concussion

A study conducted by Alexia Martin et al. found that children and adolescents with pre-existing anxiety disorders experienced more symptoms and took longer to recover following a concussion. The study, published in the Journal of Neurology, Neurosurgery, & Psychiatry, examined data from 637 patients (ages 5-17) of a Minnesota concussion clinic, 155 of whom reported pre-existing anxiety disorders.

After controlling for sex and age, patients with pre-existing anxiety disorders had, on average, 2.64 more concussion symptoms and scored 7.45 points higher (out of a maximum of 60) on the (vision-related) Convergence Insufficiency Symptom Survey (CISS). They also took longer to reach symptom resolution, return to academics, and return to physical activity.

In practice, these results indicate that healthcare providers should account for a patient’s history of anxiety when making recovery predictions, which may help them better anticipate patients’ needs. More accurate recovery predictions may minimize the emotional stress experienced by patients and their families following a concussion.

Women's Health

Raising awareness of traumatic brain injuries among domestic violence survivors

An estimated 75-90% of individuals experiencing intimate partner violence (IPV) sustain brain injuries. In her article in The American Prospect, Shera Avi-Yonah writes that many women who experience IPV do not have the resources to get assistance. Additionally, there is little funding for research in women’s experience of brain injuries in IPV, and the available research is “too limited to tell whether they might cause the long-term effects commonly associated with sports-related injuries.”

Avi-Yonah stresses that, especially during the COVID-19 pandemic, the number of domestic violence cases has increased. More research is needed to develop our understanding of the symptoms affecting those who have experienced IPV-related brain injuries. Dr. Eve Valera “recently received the first-ever federal grant to scan the brains of women who have experienced IPV.” Additionally, proposed Initiatives, such as The HEROES Act, “would allocate $50 million for Family Violence Prevention and Services, $2 million of which would go to the National Domestic Violence Hotline.” See our page on Partner-Inflicted Brain Injuries for more information.

Culture

What they didn't tell novelist Chimamanda Ngozi Adichie after her concussion

Prizewinning novelist Chimamanda Ngozi Adichie wrote a “H ealth Perspective” piece, published in the Washington Post, talking about her concussion experience. Adichie writes about her brief time in the hospital with apathetic nurses and struggling at home with persistent symptoms she doesn’t understand. Here at Concussion Alliance, her piece is striking for reasons she didn’t intend.

Adichie wonders if the apathetic nurses were burnt out by Covid-19. We wonder if it was due to racism - a 2019 study found racial differences in emergency room visits for children and adolescents with sports-related head injuries.

Adichie was sent home with a “generic discharge paper,” feeling “unsatisfied” and wanting an explanation of “what to expect in the coming days.” A 2020 study found that at an academic level 1 trauma center, only 15% of those diagnosed with a concussion received mTBI specific discharge information. Adichie was not given an mTBI specific handout, which explains symptoms and red flags that would require follow-up. Such a handout which would have helped her evaluate her symptoms and reduced her anxiety.

Adichie does not mention getting a follow-up exam, despite describing disabling, persistent symptoms. A 2018 study found that only 44% of concussion patients diagnosed in the ER “saw a physician or other medical provider within three months,” according to a UCSF press release. Apparently, Adichie wasn’t advised to do a follow-up visit. The current consensus recommends that adults whose symptoms last longer than two weeks should seek care at a multidisciplinary clinic, such as a rehabilitation outpatient department or a high-quality concussion clinic.

Adichie experiences disruptions in her menstrual cycle and asks, “Do women suffer differently? Does a concussion affect the menstrual cycle, or has my stress brought it on? A 2017 study found “increased odds of multiple, abnormal menstrual patterns following concussion,” as described by the lead author in a MedicineNet article. And yes, women do suffer differently. There is a growing body of evidence suggesting that women are at higher risk for concussions and experience a greater number and longer duration of concussion symptomscompared to men.