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.

Complex Issues of the Brain Usually Have Complex Solutions. The Fallacy of using medication for the treatment of ADD/ADHD.

The brain is an extremely complex organ that functions in ways that we are just beginning to understand. Issues of focus and attention are the result of many potential causes that include:

Adverse effects from medication use

Allergic rhinitis


Food sensitivities




Lead toxicity


Sensory impairment, like vision or hearing

Brain injury

Developmental delays

Learning disability

Intellectual disability

Seizure disorder

Sleep disorders

Speech or language problems


Conduct disorder


Obsessive-compulsive disorder

Oppositional defiant disorder

Posttraumatic stress disorder

Substance abuse

Child neglect

Physical or sexual abuse

Parenting issues


Improper learning environment

Parental psychopathology or substance abuse

Social skills deficits

Sociocultural factors

So why are people with attention issues quickly labeled as ADD or ADHD and placed on medication in the USA? This is certainly not the case in most of the rest of the world. Many advanced countries report low or virtually no incidence of ADD/ADHD.

I would argue along with many other clinicians in the US that attention problems are being pathologized with little examination of potential underlying causes. Then those with attention problems are placed on medicine with the mistaken notion that doing something so simple is the solution for a condition that is usually the consequence of many influences on the brain.

 Evidence is mounting for ADD/ADHD drugs having positive effects only for a few weeks. These same short-term improvements of improved focus, memory, and energy levels are felt in almost anyone who takes medication, both “normal” and ADD/ADHD-diagnosed subjects.   As data from long-term studies is analyzed, no differences in behavior can be discerned in continuously medicated children versus non-medicated children at both 3 and 8 years. Medicated children have no advantage in academic performance, flexibility in thought for complex tasks, peer relationships, antisocial behavior, substance abuse, or arrests. In fact, medicated kids have a higher drop out rate from high school and worse relationships with their parents versus non-medicated kids. Medicated boys trend towards worse academic performance. Medicated girls tend to have more emotional problems.

 Problems with medication for ADD/ADHD are well known, and include:

 Decreased appetite

Sleep problems








Growth retardation

Cardiac arrhythmias, hypertension and other cardiovascular issues

Rebound symptoms as medications wear off

Withdrawal symptoms when attempts are made to discontinue medication

 So how have an estimated 15% or 6.5 million American children ended up diagnosed as being ADD/ADHD, and an estimated 3.5 million of them placed on medication? First of all our care system routes children with attention problems into the medical system where attention issues are generally perceived as a biological disorder of biological causes as opposed to a medical condition, psychosocial condition, a condition of differently paced brain maturation, or a mix of these. Our current medical models reward “efficiency”. This means a short, screening visit possibly followed by family and school questionnaires to confirm an attention problem. Then a prescription is written. A follow-up appointment in a few weeks might confirm that the medicated patient is quieter and more focused. However, almost anyone placed on ADD/ADHD medication will also be more focused in the short run, too. Thus begins years of medication, and neglect of identifying and remediating the underlying causes of the attention problem.

 Placing kids on drugs give a sense of “doing something” about the issue of attention. Medical providers, families, and schools are looking for a simple fix for a complex brain issue. The mistaken impression that popping a pill is going to solve the issues of someone with attention problems is passing the buck on meaningful treatment. This causes a great disservice to those with attention problems, their families, and society at large since many do not go on to get the attention in school, psychosocial treatment, and other treatments like EEG neurofeedback that have been proven to treat attention disorders as well as behavioral issues on a long term basis.

 I try to look at each person who comes into my practice with attention problems as their own unique case. It is important to tease out the important contributions to an inability to focus well and consistently. Then I try to help that person and their support system to prioritize and deal with the factors that seem to be driving the problems that they present with.

 EEG neurofeedback is an important component of this treatment. However, most patients benefit from a thorough re-evaluation of their psychosocial milieu. Circumstances that promote inattention need to be recognized. Just like neurofeedback does not change brain function and architecture overnight, psychosocial interventions take time and practice. Neurofeedback and behavioral therapies are time-consuming, but long-term outcomes justify the additional effort. Those who prescribe and use medications for ADD/ADHD are using a Band-Aid approach that can cause more harm than good.