Deep Brain Stimulation

Scientific American has posted a guest blog on their MIND feature from psychiatrist Don Malone of the Cleveland Clinic. He has been involved with research on Deep Brain Stimulation (DBS) for a number of brain conditions including obsessive-compulsive disorder and depression. Here is his article:

My first reaction to this article was, “Why have the patients he describes received trials of medication, counseling, electro-convulsive therapy (ECT), and other treatment modalities, but not EEG neurotherapy before undergoing as drastic and invasive a procedure as DBS.” DBS involves introducing a foreign object, a wire, into the brain. It needs to be connected with the electronic stimulator. This has the potential to be a major cause of complications just as any time the integrity of the body is breached. On top of all this, it seems to work well in only about 50% of those who undergo the procedure and it is very expensive to set up and maintain.

EEG neurofeedback significantly helps around 80% of those who undergo neurotherapy for depression and OCD. It is non-invasive and usually costs considerably less than 1/10th of initial DBS. Few patients need follow up neurofeedback sessions to maintain their functional gains. Wouldn’t this be a much more productive way to spend our healthcare dollars? Those who seem to be good candidates for DBS after a fair trial of EEG neurofeedback could then be referred on for the procedure.

Secondly, I agree with the main premise of his blog. While a few people seem to grab better brain function and soar with it, others need to be coached and counseled into using their brains in ways that they have never know or realized possible. This is a learning process and like any learning process takes time, effort and persistence. Brain health needs to be supported by excellent health habits such as diet, exercise, sleep, appropriate brain challenges, good mental health support, and minimizing stress. Quick and easy fixes are rare.

The Evolution of Memory

Today’s Washington Post had an interesting interview of Michael Kahana of the University of Pennsylvania. He is working with the US military to develop an implantable device that will help those with memory disorders. However, his bottom line is that those of us with more-or-less normal brains need to go through the tedious task of practice to learn any skill in which we wish to be proficient. The practice is skill specific. So practicing mental exercises on the computer seems to improve one’s skills in those mental exercises. I know that my skills in crosswords and sudoku have improved remarkable in the years that I have enjoyed doing them, but it does not seem to help my ability to remember people’s names.

He implies that the converse, not practicing skills may promote losing the ability to do those skills, is also true. There is a discussion on relying on electronic devices as our memories. I believe in a compromise. Continue to keep up a regular intellectual tasks through a variety of exposures. However, since knowledge increases in such a spectacular way, knowing how to look something up on your electronic device is a wonderful way to further explore new intellectual and cognitive challenges.

Neurofeedback seems to be a good way to put the brain through a series of challenges to remediate or improve memory abilities. It’s utility in helping recovery from traumatic brain injury is well documented. Evidence that it can help stabilize deterioration in dementia has also been described. However, I agree with Professor Kahana that specific practice in the tasks that we wish our brain to perform must be part of any memory improvement scheme. After all, how many people do you know who learned how to speak Chinese by learning to ride a bicycle?

Neurofeedback for Traumatic Brain Injury

There are approximately 1.7 million traumatic brain injuries (TBI) in the US annually. Automobile accidents and falls account for the majority of these injuries. Recently, awareness of TBI is rising because of the need for rehabilitation of some 200,000 Americans who suffered head injuries in recent military conflicts and the publicity surrounding both acute and chronic head injuries in the National Football League.

Catastrophic head injuries are easily identified, but closed head injuries are often quite subtle. Part of the problem with diagnosing brain injury is the limitation of our imaging techniques. Conventional studies such as CT scanning and MRI may not be sensitive to the microscopic level of disruption of brain anatomy. Functional imaging techniques, such as fMRI, SPECT scanning, and PET scanning, are also limited since we are able to see only static “snapshots” of brain function, and scan readings are open to interpretation.

Even when structural disruptions of the brain are demonstrated, functional symptoms often do not closely correspond with known neuroanatomy. In fact, many symptoms of TBI, such as headache, dizziness, fatigue, cognitive deficits, anxiety, depression, irritability, mood swings, memory impairment, sleep disturbances, attention issues, and personality changes, are considered generalized and cannot be localized to a specific area of the brain.

In particular, headaches occur in about 70% of TBI and are still present in 40% of patients after 12 months. Interestingly, headaches are not correlated with the severity of the injury, but do correlate with past headache history and happen more often in female patients.

Because it is difficult to image changes in the brain due to TBI and symptoms may be non-specific, we need to think of many TBI injuries as disruptions on the level of neurons and neuronal circuitry. This certainly seems to be the case with the types of injuries, Post Concussion Syndrome and Chronic Toxic Encephalopathy, which have been described in NFL players. This is the area where neurofeedback can play an important role.

In animal models of brain injury, the initial healing response seems to be geared towards preservation of neurons and their axonal branches (neuron connectors). Unregulated regrowth of neurons may not restore previous connections within important functional networks. In addition, generalized metabolic activation may make it difficult for neurons to function correctly in distinguishing useful neuronal activity from background “noise”. So the patient experiences undesirable, non-specific symptoms. Unless the TBI patient can rewire their brain in beneficial ways, the ease and usefulness cognitive abilities will remain compromised.

This leads to the concept of “recovery burden”. TBI causes brain stress. It is well demonstrated that people under stress make inferior decisions that result in lessened cognitive performance. Repeating these behaviors tends to strengthen them. Thus dysfunctional patterns are reinforced. This is why rest is prescribed initially for TBI. Rest and sleep allow for brain repair without external distraction and demands.

Neurofeedback and other behavioral techniques have been demonstrated to decrease brain stress and restore functional connectivity in the brain. Othmer method neurofeedback enables brain calming by guiding the brain to lower activation states. Then once the brain is ready for gentle challenges, neurofeedback guides restoration of functional networks as an experienced clinician utilizes her skills in functional neuroanatomy to encourage coordination of brain function.

Studies using neurofeedback to enable functional recovery from TBI have been very encouraging.

Study 1: 16 patients, who were all at least 2 years post TBI, were given symptom questionnaires. All patients had been determined to be medically disabled and were no longer receiving active treatment. After regular neurofeedback treatments, all patients had at least 50% reduction in their TBI symptoms with an average of 85% reduction in symptoms. All 14 of the 16 patients who held jobs prior to their TBI were able to return to those jobs.

Study 2: 26 patients who were 3-70 months post TBI completed a course of neurofeedback. 25 of 26 patients showed an improvement of at least 50% (average improvement was 72%) on pre- to post-treatment symptom checklist.

In my practice, I have been impressed with how the combination of neurofeedback and rest has helped patients with mild-moderate TBI get back to their normal lives. The functional rehabilitation approach engendered by neurofeedback is a potentially power tool in recovery from TBI for many patients.