By Richard Nahas, MD CCFP DAAPM ABIHM

Reprinted from the OBIA Review, June 2016 Volume 23, Issue 2

brainThere has been a huge increase in awareness of post-concussion syndrome (PCS) in recent years.  Those of us who work with people with PCS, as healthcare providers, researchers, lawyers or advocates, are encouraged by this.  There have been more media stories, more prevention efforts, more research dollars, more conferences and workshops and more startups focused on PCS and traumatic brain injury (TBI) than ever before.  But we all agree that better diagnosis and treatment are urgently needed, and the number of people who need them is growing every day.

The quantitative electroencephalogram (qEEG) has been for decades, but it just now being recognized as a powerful tool with the potential to help these folks – and it is available today.   Our patients have found this test to be incredibly important.  For many of them, it has been the first clear and objective evidence that their symptoms are not just ‘in their heads’.  As I have reviewed the report with them, showing them the specific areas that are affected, I have seen tears well up in their eyes.  In many cases, the most affected area corresponds exactly to the place where they were hit – or the place where they feel most of the symptoms in their head.

This simple test, which is safe, noninvasive, painless and relatively easy to do, offers a unique view of a person’s function that is based on the electrical activity of the brain.  Psychologists, physicians and researchers use qEEG assessment to find and measure specific areas of the brain that produce abnormal patterns of electricity.   In addition to PCS, this test can help diagnose and treat epilepsy and ADHD, and newer studies suggest it may be useful in depression, anxiety, PTSD and other disorders.

The concept is simple.  Electrodes are placed on the skin of the head, and they measure electricity.  That electricity comes from neurons firing in the brain, and it can tell us a lot about what the brain is doing.  Neurologists use a regular EEG test to look for seizures, which they identify as spikes by visually scanning the EEG tracing.  The qEEG, in contrast, is analyzed by a computer.  It performs millions of calculations per second to compare each electrode to every other electrode – and to a huge database from the general population.  This allows it to identify specific areas that are producing abnormal electricity.

A qEEG assessment report can provide strong support for clinical symptoms of post-concussion syndrome.  While it has been used as evidence in several US cases, its legal status in Canada remains inconclusive.  In 2011, the Supreme Court of British Columbia deemed qEEG evidence presented in Bialkowski vs. Banfield to be inadmissable.  This was based on the judge’s belief that the medical expert in the case was not sufficiently trained in the field.  To my knowledge, it has not been used since.

We use the qEEG report to support our clinical diagnosis of PCS, which is especially important in the many create a personalized plan for neurofeedback treatment.  This is another great tool with the potential to change many lives.  Neurofeedback, also called EEG biofeedback, allows us to focus on the specific area affected and the specific type of electricity that is most abnormal.  If the right frontal lobe is overactive in the delta range (0-4 Hertz), we can train it down.  If the left middle parietal lobe is underachieve in the alpha range (8-12 Hz), we train it up.

Neurofeedback helps people learn to feel their way back to normal brain function.  It is like meditating with a mirror.  By connecting the brain to a computer that shows you what your brain is doing in real time, you can learn to adjust it at will.  This occurs gradually, usually over a series of treatments that are done 2-3 times per week.  We combine neurofeedback with vision therapy, acupuncture, mindfulness training and other modalities that promote brain recovery.

Research on neurofeedback is still in the early stages.  A systematic review by May et al was published in 2013 in the Annals of Clinical Psychiatry. They identified 22 published reports of its use in TBI, all of which were positive, but none were placebo-controlled randomized controlled trials.  These are sure to come, as interest in the field is growing by leaps and bounds.  This is another case of researchers struggling to keep up with patients, who are seeking out neurofeedback to help them improve their brains and their lives.

There are also a number of emerging companies that are using qEEG technology to develop self-help tools and therapy systems for use with smartphones and other mobile devices.  Another has paired this technology with glasses that become tinted when the wearer’s brain needs a nudge towards optimal focus. These tools may one day revolutionize brain recovery, but for now the EEG data they collect is still too noisy to provide reliable feedback.  As sensor technology improves and smartphones become more powerful, this may change.

One of our research interests is to figure out whether qEEG data can be used to identify the people who will not recover from their concussion.  While PCS is very unlikely to improve symptoms persist beyond one more, it cannot be officially diagnosed until three months after an injury.  This precious window would ideally be the time to start aggressive treatment to prevent complications.  We have identified a few specific abnormalities in a group of patients with longstanding PCS symptoms, and we are preparing to look for these same changes a few weeks post-injury.

While qEEG and neurofeedback are not available on every corner, there are a few specialized centres that offer this treatment now.  As research continues to emerge, their popularity is likely to grow.  While this test is not insured by the Ontario Health Insurance Plan (OHIP), we are beginning to see them accepted by auto insurers, both for established cases of PCS and for patients whose symptoms suggest this condition.  I look forward to a day when every concussion will lead to a qEEG.  Until then, our patients will rely on their advocates – people like us – to help them access innovations with the potential to improve their lives.

Dr. Nahas is the Director of The Seekers Centre in Ottawa and Assistant Professor in the Department of Family Medicine at the University of Ottawa. He treats chronic pain and post-concussion syndrome using mindfulness, education and self-care alongside medical therapies.  He is evaluating a treatment system called the Seekers Method using outcomes data in clinical practice.   

 

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