9th Annual NKY TBI Conference 3/27/2015
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QEEG andNeurofeedback
www.LITTLEPSYCH.comBRIDGES, 03-27-15
Introduction – Kirk D. Little, Psy.D.
President Little Psychological Services, PLLC
President-Elect International Society for
Neuroeedback and Research (ISNR)
President Brain Injury Alliance of Kentucky (NKY
Branch)
Specialization in Behavioral Medicine / Neuro-
Cognitive Rehabilitation (TBI, LD, ADHD, Asperger’s, etc.)
Board Certified in Neurofeedback (BCIA-EEG)
Overview
1. What is a QEEG Brain Scan?
2. Why is it important?
3. How do we make sense of them?
4. How do we use it as a guide for tx?
5. What is Neurofeedback?
6. Case examples.
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What is the EEG?
� Electro = Electricity
� Encephalo = Brain
� Graphy = Write Down
EEG = A squiggly line representing the
brain’s electrical output.
EEG Assessment Setup
10-20 System
Inattention
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EEG: It’s in the Squiggles
Made you look
Multi-tasking
� Reduces your ability to take in information,
process that information & make decisions, and react
quickly to those decisions
EEG Quantified
1- Import of digital EEG data involves the following steps: 1- Down-sample or up-sample to 128 Hz, 2- Baseline the EEG by filtering at < 1 Hz and > 40 Hz (5th order Butterworth
filters and creating values from zero time to negative time to allow the filter to start at time point = 0); 3- After each edit selection baseline the spliced selections of EEG by filtering a second time at < 1 Hz and > 40 Hz.
2- Amplifier equilibration is computed as the difference between the normative database amplifier characteristics in microvolts based on the frequency response of a calibrated sine wave from 1 to 40 Hz. The equilibration ratio for each EEG machine manufacturer is a coefficient in all of the subsequent spectral computations in the list of EEG machines in
the File > Open window. The FFT (Fast Fourier Transform) parameters are: epoch = 2 seconds at a sample rate of 128 sample/sec = 256 digital time points and a frequency
range from 0.5 to 40 Hz at a resolution of 0.5 Hz using a cosine taper window. Each 2 second FFT is 101 rows (frequencies 0 to 50 Hz) X 19 columns (electrode locations) = 1,919 element cross-spectral matrix for each subject. NeuroGuide uses the same equations as used by the Key Institute (see Key Institute equations 10 to 19 in the Key
Institute Help Manual) and Bendat and Piersol, 1980; Otnes and Enochson, 1978 which are standard equations. The N in the Key Institute cross-spectrum equations 16 and
17 is the number of 2 second windows that are used in the computation of the average FFT which is the sum of the spectra from 2 second windows/N. The last whole integral of 256 points marks the end of window summation and averaging. The N sub T (Key Inst. equation 17) is the number of time frames per FFT window = 256 at 128 samples
per second. A detailed documentation of the mathematical equations for the Fourier Transform and the Power Spectrum and Power Spectral Density is available at
http://www.appliedneuroscience.com/Coherence&Phase-Web.pdf.
3- In order to minimize the effects of windowing in the FFT (Kaiser and Sterman, J. Neurotherapy, 4(3): 85-92, 2001) a EEG sliding average of the 256 point FFT cross-spectral matrix was computed for each normal subjects edited EEG by advancing in 64 point steps (75% overlap) and recomputing the FFT and continuing with the 64 point sliding window of
256 point FFT cross-spectrum for the entire edited EEG record. Each of the 101 frequencies for each 19 channels is log10 transformed to better approximate a normal
distribution. The total number of 2 second windows is the number that is entered into the analysis of variance and t-tests and it is used to compute the degrees of freedom for a given statistical test.
4- The FFT mean, variance, standard deviation, sum of squares, and squared sum of the real (cosine) and imaginary (sine) coefficients of the cross-spectral matrix is computed across the sliding average of edited EEG for all 19 leads for the total number of 101 frequencies and 1,919 log transformed elements for each subject at 0.5 Hz resolution.
This creates the following eight basic spectral measurement sets and their derivatives 1- Cross-Spectral Power (square root of the sums of squares of the real and imaginary
coefficients); 2- Auto-Spectral Power which is the diagonal of the cross-spectral matrix where the imaginary coefficient = 0 and power = sine square; 3- Amplitude asymmetry of auto-spectral power = (A-B)/(A+B) x 200 where A = EEG channel 1 and B = EEG channel 2; 4-Coherence = square of the cross-spectrum divided by the product of the two
auto-spectra; 5- Phase = arctangent of the ratio of the real/imaginary components for frequencies from 0.5 to 50 Hz,; 6- Real coefficients; 7- Imaginary coefficients and 8 Peak
Frequency = sum (freq. x abs. power(freq))/sum abs. power(freq), e.g., (4.0x2+4.5x4+5.0x2)/(2+4+2) = 4.5 Hz). (Bendat and Piersol "Engineering applications of correlation and spectral analysis", John Wiley & Sons, NY, 1980; Otnes and Enochson "Digital time series analysis", Wiley-Interscience, 1978; Press et al, "Numerical recipes in C".
Mathematics
“Quantitative” EEG
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QEEG “Maps”
QEEG Maps cont...
EEG Qualities
oAmplitude = Size (Big or Small)
oFrequency = Speed (Fast or Slow)
oMorphology = Shape (Sharp, SquareO)
oConnectivity = Synchronicity (coherence)
0-4Hz 4-8Hz 8-12Hz 13-36Hz 36-42Hz
Delta Theta Alpha Beta Gamma
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Clinical Correlates
Delta = Deep sleep or brain lesion
Theta = Drowsiness and early sleep
Alpha = Relaxed, awake, internal focus
SMR = Turning off of the motor system
Beta = Aroused, active cortical processing
Gamma = The Binding Rhythm
MRI - Limitations
MRI is a snapshot of the
brain. It is a static
image that measures
large scale (gross)
abnormalities.
It is not able to detect
most brain injuries
What is Biofeedback?
Controlling your biology using electronic
monitoring equipment
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What is Biofeedback cont...
3 Necessary Steps:
1. Detect and measure biological process and amplify the
signal
2. Convert the electrical signals into an easily
understandable form (e.g. 77oF, 172 lbs.)
3. “Show” the signal to the subject as soon as possible after
the event has occurred
What is Biofeedback cont...
Types of Biofeedback
Temperature (Vasoconstriction)
EDR (ElectroDermal Response) (GSR, SC)
EMG (Electromyography)
BPM (Respiration)
HRV (Heart Rate Variability)
HEG (Hemoencephalography)
**EEG (Electroencephalography) – a.k.a.
Neurofeedback
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Biofeedback setup
EEG Feedback Setup
2 Channels of EEG
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History
Sterman’s Cats (Brain Research, 1967)
History cont9� Sterman and Fairchild tested NASA’s
rocket fuel on 50 cats, 10 from Sterman’s previous SMR training study.
� Inject same mg/kg of fuel into each cat
• Cats show usual toxic prodrome After 1 hr, all usually go into grand mal
� Of 50, 7 cats showed prodrome with delayed seizures and 3 without seizing.
� Examining his data carefully, including who made up his sample, he realized the seizure thresholds changed in cats who underwent SMR training
• Not explainable by placebo (“I shall please” in Latin) as cats didn’t know what to expect, and experimenter blind because effect was unexpected
History cont9
Sterman
NFB with humans with seizure
disorders.
Decrease in seizure severity and
frequency with SMR training.
Seizures and motor calmness.
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History cont9.
*Meta-Analysis (19 Studies)
82% demonstrated significant (>30%) seizure
reduction,
Average reduction exceeded 50%.
Studies reported reduction in seizure severity.
About 5% had complete control for up to one year
even when anticonvulsants were reduced or
entirely withdrawn.
* Sterman, MB (2000). Basic Concepts and Clinical Findings in the Treatment of Seizure Disorders with EEG Operant
Conditioning. Clinical EEG, 31(1), 45-55.
History cont9
Johnathan Walker, MD
Using QEEG as Guide
➢ 100% success with partial complex seizures
➢ All patients seizure free
➢ Many stopped anticonvulsants
(Walker and Kozlowski, 2005)
History cont9
5X/week
4X/year
16 yr old Teen Epilepsy
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History cont.
Lubar & Shouse (1976)
First ADHD Study
Single Subject ABA
design
Increase SMR (12-14)
Decrease Theta (4-8)
Goal = Reduce
Hyperkinesis
History cont9
Lubar & Shouse (1976)
oSMR increased to 3X Baseline
oDecreased out of seat behaviors
oImproved Attention in class
oDecreased self-stimulation
History cont9
Lubar & Shouse (1976)
Procedure was reversed in
a blind fashion and the child
was trained to inhibit the
SMR and to increase the
theta
After 35 sessions, the child
had regressed completely to
baseline measured by EEG
and school performance
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History cont9
Lubar & Shouse (1976)
Child was retrained 28
sessions
Behavior gains returned
Medications were
removed – gains were
maintained
2 year follow up
History cont9
*Meta-Analysis (15 studies)
N= 1,194 ADHD individuals
Five RCG studies had been completedGevensleben et al, 09; Holtmann et al, 09; Bakhshayesh, 07; Levesque et al,
2006 ; DeBeus and Kaiser, in press.
One sham treatment control Three active controls:
Computerized attention training, EMG feedback
Level 5 – Efficacious and Specific (highest rating)
*Arns , Ridder, Strehl, Breteler & Coenen (2009) Efficacy of Neurofeedback Treatment in ADHD: The Effects on
Attention, Impulsivity & Hyperactivity: A Meta-Analysis. Clinical EEG and Neuroscience.
History cont9
Arns, et. al 2010
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Functional Localization
To some extent function is
localized
During activation of local
cell columns, increases in
glucose consumption and
oxygen utilization are
reflected in hemodynamic
and electrical activity.
e.g. PET scans....
Neurology Case Studies
Focal damage to the central parietal region in the area of the posterior cingulate (Pz) typically results in perseveration.
Posner & Raichle (1997) noted that this was the release component of the attentional network.
Coherence & White MatterA2 The Cingulum: Connects frontal and parietal lobes with the temporal lobes (thru cingulate gyrus from Fz toPz).
A3 The Uncinate: connects inferior frontal regions and orbital frontal regions (Fp1:BA 10/11) with anterior temporal (Visual/ Memory).
A5 The Arcurate: Connects Wernickes and Brocas (F7: BA 45,46,47) (Verbal/ Memory).
A6 The Superior Longitudinal Fasciculus.
A4 The Inferior Longitudinal Fasciculus.
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Blast Injuries
Evidence of disrupted functional connectivity in
the brain after combat-related blast injury
Scott R. Sponheim , Kathryn A. McGuire , Seung Suk Kang, Nicholas D. Davenport, Selin
Aviyente d, Edward M. Bernat e, Kelvin O. Lim
NeuroImage 54 (2011)
DAI in TBI with DTI
JOURNAL OF NEUROTRAUMA Volume 24, Number 5, 2007 Pp. 753–765
Diffuse Axonal Injury in Severe Traumatic Brain Injury Visualized Using High-Resolution Diffusion Tensor Imaging
JIAN XU, INGE-ANDRE RASMUSSEN, JR., JIM LAGOPOULOS, and ASTA HÅBERG
Coherence - Examples
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Coherence - Examples
Coherence - Examples
Coherence - Examples
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The Promise of Neurofeedback
60 yr old female
Nurse kicked and
beaten by patient
Part of mTBI wait-list
controlled Study
The Promise of Neurofeedback
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1 3 5 7 9 11
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Memory
Attention
Uncertainty
Worthlessness
Performance
Linear (Memory)
Linear (Attention)
Linear (Worthlessness)
Linear (Uncertainty)
Linear (Performance)
The Promise of Neurofeedback
Pre Mid Post
35
40
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Time
T-S
co
re
60 Year Old Female TBI
DEP
ANX
SOM
Pre-tx Mid-tx Post-tx
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55
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85
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Treatment Time
Se
ve
rity
of
Sym
pto
ms
60 Year Old Female TBI
Somatic Complaints
Functional Complaints
Muscular Bracing
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The Promise of Neurofeedback
Pre-tx Mid-tx Post-tx
40
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Treatment Time
Se
ve
rity
of
Sym
pto
ms
60 Year Old Female TBI
Tension
Cog Dysfx
Fx Deficits
Pain sensitivity
Pessimism
Intrvl Fragility
Pre-tx Mid Post F-up
70
75
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100
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Treatment Time
Co
gn
itiv
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bilit
ies
60 Year Old Female mTBI
GCF
GCP
IPS
IPA
Attn
Reas
Mem
Spat
RT
The Promise of Neurofeedback
Pre-tx Mid Post F-up
80
85
90
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Treatment Time
Te
st S
co
res
60 Year Female mTBI
GCF
Cog Avg
Coherence - Examples
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Case Study
24 yr old female
496 Individual tx sessions
Severe panic, depression,
cutting, binge eating
Multiple Hospitalizations
By 12th session, symptoms
getting steadily worse
Case Study cont9
24 yr old female
3x/wk Individual tx sessions
Multiple medication changes
during training – seeing
psychiatrist 1X/wk
Then, changed training to
F3: calm, happy “for several
hours”
By session 20, mood stable
for entire weekend
Case Study cont9
24 yr old female
2x/wk Individual tx sessions
By session 33, got a job,
planning return to work
By session 40, reports quick
return to baseline after
relational upset / nap
Maps look relatively stable,
so modify protocol to F7-Cz
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Case Study cont9
24 yr old female
1x/wk Individual tx sessions
Multiple medication changes
during training – seeing
psychiatrist 1X/wk
By session 40, mood stable
for entire weekend
Case Study cont9
24 yr old female
1x/wk Individual tx sessions
now. No emergency calls in
weeks.
By session 45 Better fxing
Happiest in her “entire life”
On session 54 “surge” of
flashbacks / memories
Change to Fz-Cz (FCz-POz)
Case Study cont9
24 yr old female
77 NFB session total over
10 months
Moved OOState to attend
Graduate school in
Psychiatric nursing
No cutting, no depression,
occasions anxiety, no panic,
occasional “emotional
eating” when stressed
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Case Study – Migraine
50 Year old Woman
2nd Car Accident
Diffuse excess theta
frontal focus
Excessive Hibeta
Central
Main prob = Migraines
High Anxiety –
Inattention / forgetful
Case Study – Migraine
Would come in with
Migraine / neck pain
By end of session, pain
totally gone “0”
17 Sessions total until
PIP insurance cut off
the txs, claiming not
medically necessary
They still pay for meds!
Case Study - Migraine
-60% -24% -19%
-61% -24% -42%
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Case Studies – Alexia 8 fem
Case Studies - Alexia
Case Studies - Alexia
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Case Study – Bipolar Teen
Case Study - Bipolar
Dramatic Improvements
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Case Study - Statistics
Case Study – Asperger’s
Case Study – Asperger’s
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Case Study – Asperger’s
Can NFB Make You Smarter?
Tansey (1991): Average of 20 points improvement
in IQ in 24 children
Linden (1996): Average of 9 IQ points
Thompson and Thompson (1998): Average of 12
IQ points
Lubar (1995): Statistically sign. increase in IQ
Othmer (1999): Average of 23 IQ points
Orlando and Rivera (2004): Statistically significant
improvement in verbal and full scale IQ scores.
Take Away Message
•Like muscles, your brain gets stronger with
training – these are permanent, physical
changes that are useful in all areas of life
–More intense & longer concentration
–Staying calm under stress
–Faster reaction times, higher IQ, etc.
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For More Information
www.ISNR.org (International Society for
Neurofeedback and Research)
www.bcia.org (Biofeedback Certification
International Alliance)
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Discussion
MENSA, 12-6-14
Neuroplasticity
It is now clear that the intrinsic
circuitry of the nervous system can
be modified throughout life.
Encyclopedia of Neuroscience
B. Kolba Neuronal Plasticity after Cortical Damage, pp. 727-731
University of Lethbridge, Canada
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Neuroplasticity
Plastic Modification of Surviving Neurons
•Augmented dendritic branching
•Synaptogenesis
•Modified receptor density
•Modified transmitter uptake
P. Rapp, 2010
Neuroplasticity cont9
The CNS is constantly adjusting to
experience
E.g. Taxi Driver’s Brains on the job
With Practice, Brain’s Grow
BRODMANN (SKIL)
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Enduring Effects Autism-Coben, 2014