This ERP technology is ready for prime time in TBI. The peer review and publication process is how science moves forward, and the use of ERP for TBI evaluations is now accepted by the peer review process, but not the EEG/qEEG yet fully, and definitely not EEG based discriminants for TBI, which are now counseled against in the peer reviewed literature.

Jay

ABSTRACT

Traumatic brain injuries are often associated with damage to sensory and cognitive processing pathways. Because evoked potentials (EPs) and event-related potentials (ERPs) are generated by neuronal activity, they are useful for assessing the integrity of neural processing capabilities in patients with traumatic brain injury (TBI). This review of somatosensory, auditory and visual ERPs in assessments of TBI patients is provided with the hope that it will be of interest to clinicians and researchers who conduct or interpret electrophysiological evaluations of this population. Because this article reviews ERP studies conducted in three different sensory modalities, involving patients with a wide range of TBI severity ratings and circumstances, it is dif!cult to provide a coherent summary of !ndings. However, some general trends emerge that give rise to the following observations and recommendations:

1) bilateral absence of somatosensory evoked potentials (SEPs) is often associated with poor clinical prognosis and outcome;

2) the presence of normal ERPs does not guarantee favorable outcome;

3) ERPs evoked by a variety of sensory stimuli should be used to evaluate TBI patients, especially those with severe injuries;

4) time since onset of injury should be taken into account when conducting ERP evaluations of TBI patients or interpreting results;

5) because sensory de!cits (e.g., vision impairment or hearing loss) affect ERP results, tests of peripheral sensory integrity should be conducted in conjunction with ERP recordings; and

6) patients’ state of consciousness, physical and cognitive abilities to respond and follow directions should be considered when conducting or interpreting ERP evaluations.

1. Introduction
Event-related potentials (ERPs) are types of electroencephalographic (EEG) recordings used to evaluate patients who experienced traumatic brain injury (TBI). “Potential” refers to the electrical potential difference (or voltage) between two points, de!ned as the electrical force that would drive an electric current between those points. In the case of ERPs and EEG, the “two points” are electrodes attached to the patient’s head that record voltages generated by neural activity from populations of neurons within a sensory pathway. These voltage changes result from movement of ions (e.g., K+, Ca++, Na+, and Cl?) and other charged particles within and between neurons in the brain. Evoked potentials (EPs), a subset of ERPs, are elicited by presenting stimuli (for example, light “ashes, sounds,electric shocks, images, words, odors or “avors) to the patient, then using a computer to average the EEG activity that is time-locked to the stimuli.

Traumatic brain injuries are often associated with damage to sensory organs and pathways. Because EPs are generated by neuronal activity, they are useful for assessing neural processing capabilities in TBI patients. Furthermore, EPs can provide information about the integrity of sensory pathways, including their ef!ciency for conducting input from the periphery to the central nervous system (CNS), the ability of CNS structures to process sensory input, and the ability of speci!c sensory systems to perceive and integrate stimuli. EPs and ERPs can also provide information about higher-order CNS processing, such as classi!cation and categorization of multi-modality stimuli, and decoding/interpretation of language, images and other complex stimuli. For TBI patients, EPs can provide valuable information related to the severity of injury and its impact on neuronal pathways. ERPs can
also provide information about patients’ states of consciousness and cognitive functions. In fact, one of the driving interests of using ERPs in TBI research is the possibility of predicting outcomes of these patients.

Read Full article – Electrophysiological assessments of cognition and sensory processing in TBI: Applications for diagnosis, prognosis and rehabilitation

Folmer, R.L., et al., Electrophysiological assessments of cognition and sensory processing in TBI: Applications for
diagnosis, prognosis and rehabilitation, Int. J. Psychophysiol. (2011), doi:10.1016/j.ijpsycho.2011.03.005

Robert L. Folmer a,b,!, Curtis J. Billings a,b, Anna C. Diedesch-Rouse a, Frederick J. Gallun a,b, Henry L. Lew c,d

a National Center for Rehabilitative Auditory Research, Portland VA Medical Center, Portland, OR, USA
b Department of Otolaryngology, Oregon Health & Science University, Portland, OR, USA
c Defense and Veterans Brain Injury Center (DVBIC), USA
d Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University (VCU) School of Medicine, Richmond, VA, USA

Article history:
Received 29 September 2010
Received in revised form 4 March 2011
Accepted 8 March 2011

International Journal of Psychophysiology
journal homepage: www.el sevier.com/ locate/ i jpsycho

It is no surprise when insurance companies find ways to restrict what they will cover as a service for their clients, whether flood insurance liability insurance, or any other branch of this financial industry.  This is especially true for medical insurance companies, which are always finding reasons to restrict payments.

This decision restricts the payment for a qEEG to be an extension of the analysis of an EEG analysis, which makes the qEEG a medical procedure requiring licensure adequate to provide credentials to do a medical EEG interpretation. If further restricts the payments to applications that match the American Academy of Neurology position paper, which approves the technique in vascular cases, encephalopathies such as dementia cases, or for epilepsy, as well as longer term EEG monitoring, where quantitative analysis allows the selection of segments for review visually, assisting the electroencephalographer in eliminating long time segments from detailed analysis.

Specifically restricted from payment are these applications:

• Alcoholism
• Asperger’s syndrome and other autism spectrum disorders
• Attention disorders
• Depression
• Drug abuse
• Fibromyalgia
• Hypoxic ischemic encephalopathy
• Insomnia
• Learning disability
• Mild or moderate head injury
• Panic disorder
• Post-concussion syndrome
• Predicting response to psychotropic medication
• Schizophrenia
• Tinnitus

The list above is not an appropriate reason to do an EEG medically… at least not on the surface. In many of these cases the clinical decision may include ruling our an encephalopathy, a a vascular or epileptic process. As an example of this, approximately 30% of those with autism have undiscovered epileptiform discharges in the EEG, and respond well to anticonvulsants. An EEG is the only way to rule out epilepsy in such a case, and this may be allowed under the coverage listed, if the testing is ordered appropriately and the chart supports the order for the testing.

This is generally the same for TBI, where a post-traumatic vascular issue or epileptiform response to the TBI may be suspected, such as with contusion or post traumatic edema/ischemia.
In atypical clinical presentation, an alcoholic can be evaluated for dementia (Korsakov’s syndrome), as well as epilepsy (PLEDS are a common withdrawal pattern in chronic alcoholics). The chart needs to support the evaluation diagnostically for ruling out any of these covered categories.

The report can comment on medication implications, even if the testing was not done for that purpose diagnostically.

Attentional and affective disorders will not be covered, but if the physician is trying to rule out epilepsy (absence can mimic ADD) or an encephalopathy or dementia as the etiology of the psychiatric changes, then the insurance may cover the EEG and subsequent qEEG examination.

The important thing is to have the documentation in the chart to support the diagnostic/treatment question being posed with the testing.

The fact that they cover any of the qEEG at all is only due to the AAN position paper’s support for these areas. As the neuroscience is done to support more applications, then the carriers will have to amend their coverage statements. It is up to us to do the hard work to open these other areas up to payment…. and to argue for some other licenses to be covered for payment.

HOUSTON – A Houston doctor is working on something that could help the many service members who return from the battle field suffering from post-traumatic-stress disorder.

By its own admission, The Veterans Administration has had little success treating people who are suffering from both traumatic brain injury and post traumatic stress disorder.

“They end up not having any cognitive strategies to manage the therapy, and they’ll either get out of therapy, or end their lives and that’s what’s happening,” said Dr. Ron Swatzyna, a psychotherapist, neuro-therapist, and biofeedback therapist for Houston’s Tarnow Center. “I’ve been working on this issue for about four years now.”

He said resetting the brain, lining it back up through stimulation, is the key.  And by mapping the brain, he believes he can tell when the patient is ready for therapy.

“Not at the beginning. If you push them too quick that’s a problem. If they are pushed into therapy too quick,” he said.

Swatzyna said the defense department and the VA both realize more research is needed, and if he can get funding, and cooperation from a group in the Texas Medical Center, he would like to open up a research center in Houston.

Vietnam veteran Billy Miller, who one of Swatzyna’s patients, is now helping him pull it off.

“Everyone I had been to before, all 25 doctors had never had military experience, they didn’t know what I was going through,” Miller said.

Swatzyna was a captain in the Air Force, and now many believe he is the best in the country at understanding veterans.

Army soldier Joel Brasier, who suffers from TBI and PTSD, believes Swatzyna is on the right track and is hoping research will lead to better, faster treatment.

“It’s an ongoing process, but eventually they are going to make a breakthrough and get us the help we need,” Brasier said.

Full story from khou.com

No traditional structural neuroimaging was able to see this damage (like CT or routine MRI). The NY Times recently reported on soldiers injuries evading the M.R.I and CT Scans

The brain areas involved included the orbital surfaces of the frontal lobe and the temporal areas.

These results point to the need for a clinical diagnosis, not a reliance on any given technology to answer the clinical question.

The endocrine changes from supposed pituitary injury, and the presence of micro-emboli due to pressure wave impact on the thorax that are reported in blast injury is not at all dismissible with these findings.

Chronic Traumatic Encephalopathy(CTE) is associated with repeated head traumas — concussions or sub-concussive hits — that are not allowed to properly heal. It is a progressive degenerative disease found in individuals who have been subjected to multiple concussions and other forms of head injury. A variant of the condition, dementia pugilistica, is primarily associated with boxing. CTE has been most commonly found in professional athletes participating in gridiron football, ice hockey, professional wrestling and other contact sports, who have experienced head trauma, resulting in characteristic degeneration of brain tissue and the accumulation of tau protein. Individuals with Chronic Traumatic Encephalopathy may show symptoms of dementia such as memory loss, aggression, confusion and depression which may appear within months of the trauma or many decades later.

A number of athletes have been affected by the condition with serious consequences. Recently a former NFL lineman committed suicide after serious mental decline. His wife said it started with the nightmares and progressively got worse.

Bob Probert’s brain was examined after his early passing at the age and was found to have CTE (read more here).

A couple of years back with the Chris Benoit tragedy the issue of CTE and it’s effects were put on the map and other athletes began to take notice.

Other players are worried and should be about the possible effects of concussions not only during their playing career but also long after they have retired. CTE is a serious medical condition that should not be taken lightly. A brain injury that goes untreated can have serious long term consequences. We should applaud efforts by the NHL and the NFL to address vicious hits to the head but they need to go farther. Teams need to be proactive in helping to identify possible head injuries.

Often athletes and coaches will push to play even when there may be some lingering effects of a head injury. Athletes have long tried to play through injuries and in certain sports it is almost a crime to take yourself out of a game. Teams and / or the league need to mandate some sort of criteria for athletes they suspect may have head injuries. This can hopefully help prevent or lessen the possibility of CTE. While we may not be able to prevent CTE – following certain procedures (such as a qEEG and ERP) after an “event” may lessen the likelihood of CTE occurring in the first place.

The Pittsburgh Penguins forward Sidney Crosby recently has been out almost three months with post-concussion symptoms.  This is a great loss for hockey fans when you have one of the sports top performers not playing due to a head injury. A recent study shows that more players are losing playing time due to concussions (see the full story on ESPN.com) The NHL is finally addressing this issue. One big step is pulling players out of the game for at least 15 minutes for a concussion test. The new Concussion Removal Protocol is designed to keep players with head injuries out of the game.

It was great to hear that the Pittsburgh Penguins, as part of a new initiative, will offer free baseline concussion testing and educational programs to youth hockey players in the region. “Heads Up Pittsburgh” is a combination effort with the Pittsburgh Penguins Foundation and UPMC Sports Medicine, aimed at making more hockey families aware of concussions in the sport.  Hopefully more teams will follow suit.

more relevant links..

-NHL governors discuss player safety – PEBBLE BEACH, Calif. — NHL Commissioner Gary Bettman said Tuesday that there was not enough data yet to draw conclusions about the link between concussions and a degenerative brain ailment that has been found in four dead hockey players….(full story)

-CTE found in Lew Carpenter’s brain – (full story)

-Head injuries: A growing issue in hockey – ONALASKA, Wis. — Concussions have been a hot topic and a cause for concern in the sport of hockey recently. Head injuries have had serious effects on many NHL players including the face of the league, Sidney Crosby. (full story)

-Report: Derek Boogaard had CTE – NEW YORK — Rangers enforcer Derek Boogaard suffered from chronic traumatic encephalopathy, a degenerative brain ailment related to Alzheimer’s disease that is caused by repeated blows to the head, the New York Times reported…(full story)

- Concussions in Sports from ESPN

- A simple way to curb concussions from SI.com

- Former NFL players sue league over head injuries - Men accuse league of misleading them, failing to take action to reduce head injuries… (full story)

Researchers have discovered a correlation between increased activity among brain circuits and flashbacks among individuals with post-traumatic stress disorder (PTSD).

University of Minnesota investigators learned that an increased circuit activity in the right side of the brain is associated with the debilitating, involuntary flashbacks that often characterized PTSD.

The ability to objectively diagnose PTSD through concrete evidence of neural activity, its impact and its manifestation is the first step toward effectively helping those afflicted with this severe anxiety disorder.

PTSD often stems from war, but also can be a result of exposure to any psychologically traumatic event. The disorder can manifest itself in flashbacks, recurring nightmares, anger or hypervigilance.

Using a technique called Magnetoencephalography (MEG), a noninvasive measurement of magnetic fields in the brain, researchers found differences between signals in the temporal and parieto-occipital right hemispheric areas of the brain among those with PTSD.

The temporal cortex, in accordance with earlier findings on the effects of its electrical stimulation during brain surgery, is thought to be responsible for the reliving of past experiences.

The research – led by Apostolos Georgopoulos, M.D., Ph.D., and Brian Engdahl, Ph.D., both members of the Brain Sciences Center at the Minneapolis VA Medical Center and University of Minnesota — is published today in the Journal of Neural Engineering.

It’s a major scientific and medical discovery, Georgopoulos said, because the MEG tests reveal a clear difference in activity among the circuitry in the brains of PTSD sufferers in comparison to those without the condition. The findings are something conventional brain scans such as an X-ray, CT, or MRI have failed to demonstrate.

Besides diagnosing those with PTSD, the researchers also are able to judge the severity of a patient’s suffering, which means the MEG may be able to be used to gauge the how badly patients are impacted by other brain disorders.

“Having a diagnostic exam capable of confirming post-traumatic stress disorder is critical in treating these patients properly,” Georgopoulos said.

Also of particular interest to the scientists: During the study, the brains of PTSD sufferers were in the hyperactive state despite the lack of any immediate external stimulation, evidence found through trial subjects being purposefully put into a “task-free state.”

This finding is significant because it confirms that PTSD sufferers can relive terrifying memories at any moment regardless of what they are doing.

“Remarkably, the differences we found between the PTSD and the control groups were documented in a task-free state without evoking traumatic experiences, and therefore reflects the status of steady-state neuronal interactions,” Georgopoulos said.

The trial involved 80 subjects with confirmed PTSD, many of whom suffer the affliction following military service in Vietnam, Afghanistan and Iraq; 18 subjects in PTSD remission; and 284 healthy subjects.

All participants were required to wear the MEG helmet while fixating on a spot 65 cm in front of them for 60 seconds.

The research is one further step in the attempt to ‘biomark’ PTSD, particularly as the results gathered from subjects in remission followed a similar but less pronounced pattern to those with PTSD confirmed as their primary diagnosis, in contrast to the healthy subjects.

Source: University of Minnesota

Direct link to article here from Psychcentral.com

Concussion is a common consequence of trauma to the head in contact sports, estimated by the Centers for Disease Control and Prevention to occur three million times in the United States each year. Among people aged 15 to 24 years, sports are now second only to motor vehicle accidents as the leading cause of traumatic brain injury. While the majority of concussions are self-limited injuries, catastrophic results can occur and the long-term effects of multiple concussions are unknown.

Members of the AAN specialize in treating disorders of the brain and nervous system, and some members have particular interest and experience caring for athletes and are best qualified to develop and disseminate guidelines for managing athletes with sports-related concussion. Based on the clinical experience of these experts, the AAN supports the implementation of policy that supports the following recommendations:

Recommendations

1. Any athlete who is suspected to have suffered a concussion should be removed from participation until he or she is evaluated by a physician with training in the evaluation and management of sports concussions
2. No athlete should be allowed to participate in sports if he or she is still experiencing symptoms from a concussion.
3. Following a concussion, a neurologist or physician with proper training should be consulted prior to clearing the athlete for return to participation.
4. A certified athletic trainer should be present at all sporting events, including practices, where athletes are at risk for concussion.
5. Education efforts should be maximized to improve the understanding of concussion by all athletes, parents, and coaches.

Position Statement History
Approved by the AAN Sports Neurology Section, Practice Committee, and Board of Directors
October 2010 (AAN Policy 2010-36).

ISNR invites you to their 18th Annual Conference for Health Professionals, Education Professionals, Researchers & Students. This conference offers workshops by the leading clinicians and researchers in the field of neuroscience. There will be many workshops and keynote talks on clinical as well as theoretical applications in the neuroscience field.

Letter from the Conference Chair:

It is with great pleasure that I welcome you to an ISNR conference for the third year as the conference chair. For this 18th Annual International Conference of the International Society for Neurofeedback and Research I am delighted to host you in Denver, Colorado, one of the few cities in history that was not built on a road, railroad, lake, navigable river or body of water when it was founded. It just happened to be where the first few flakes of gold were found in 1858. ISNR, like Denver, has grown from golden ideas and holds a bright and rich future.  With this spirit I invite you to join in a collective reflection on what our field has accomplished during these past 18 years, and on the scholarly challenges before us.

In addition to the parallel oral presentations, panel sessions, and workshops, here are a few highlights of the plenary sessions:

• Keynote Speaker- Norman Doidge, MD, NY Times best-selling author, will present “The Brain That Changes Itself: The Neuroplasticity Revolution and Film Clips of People Undergoing Plastic Change”
• Keynote Speaker- Alvaro Pascual-Leone, MD, PhD- “Multimodal Brain Imaging: Combining Brain Stimulation and Functional Neuroimaging to Understand A Changing Brain”
• Keynote Speaker- Jonathan Marks, MA, BCL- “Beyond Neurotherapy: The Ethics of National Security Neuroscience”

Invited Speakers:

• Dirk DeRidder, MD, PhD – “Alcohol Addiction: A Clinical Pathophysiological Approach”
• Matthew Nock, PhD – “Single-Case Experimental Design: A Valuable Method for Evaluating Neurofeedback in Clinical Practice”
• Hartmut Heinrich, PhD – “Theta / Beta and SCP Training in Children with Attention-Deficit/Hyperactivity Disorder: Behavioral and Neurophysiological Results from a Randomized Controlled Trial”
• Michael Schmidt, PhD – “Nutrient Modifiers of Neuroplasticity and Performance and the Exploration of Novel QEEG Assessment Metrics”
• Donald Cooper, PhD – “Single Cell Memory: How individual Neurons Route and Store Temporary Information to Maintain Attention”
• Paul Rapp, PhD – “Could Neurofeedback Reconstruct Synchronous Networks Lost Following Traumatic Brain Injury?”
• Jason Soss, MD- ” Neural Network Mapping”

As in our previous conferences, you can expect the opportunities to network with a diversity of colleagues from a variety of institutions. On Wednesday, there will the ISNR golf tournament with a portion of the proceeds going to the INSR Research Foundation. The tournament and Wednesday pre-conference workshops will be followed by an evening reception and our now traditional special panel Neurofeedback: The Past, Present and Future from the “Pioneering Women’s Perspective” featuring Genie Bodenhamer-Davis, PhD, Judith Lubar, MSW, and Lynda Thompson, PhD.

On Thursday evening, there will be a reception during the poster presentations and a first time evening plenary session. Our conference wouldn’t be complete without a Saturday evening presentation of honors, dinner and entertainment this year by Swing Essence, where attendees will enjoy conversation and dining with live jazz that you would expect in the finest clubs, featuring a jazz-inspired rhythm section, and accomplished instrumentalists.

During the past few years, the ISNR conference has achieved steady growth as evident from the support received from professionals, academia and industry. I would like to express sincere thanks to all the presenters and the members of the conference committee that has made this event a success. Also I would like to thank Deymed Diagnostic (Platinum), BrainMaster (Gold) and Nova Tech EEG, Thought Technology and Stens Corporation (Silver) for their sponsorship of the conference. Because of all of your efforts, the conference program is very rich with exciting papers and events.

Finally, I hope that you will find the presentations and discussions to be a valuable resource in your professional, research, and educational activities whether you are a student, academic, researcher, or a practicing professional. I encourage you to take part in this international conference, and I very much look forward to welcoming you personally to Denver in September!

Leslie Sherlin, PhD
2010 Conference Chair

A model of consciousness will be illustrated with physiological data from EEG and Event related potentials. Using millisecond level time resolution, a working model of the interaction between the mind and the brain will be constructed.

The Slow Cortical Potentials generated by Glial activity and the faster gamma activity reflecting activity of bound neural networks will be used to illustrate this model. The physiological correlates of concepts like intention, attention, memory, perception, awareness, sensory differentiation and conscious awareness will all be discussed within the framework of this model. Advanced concepts like neural network binding, nested rhythms, cross-spectral correlation, and the bispectrum will be discussed.

The DC potentials cause an instantaneous phase resetting and binding of a neural network, which can initiate synchronous activity within these neural networks. Current work using this model in clinical work on severe disorders of consciousness, including work by the International Brain Research Foundation on recovery of consciousness in coma cases will be reviewed. The simplest expression of the model: when the DC potentials reflecting activity of the mind interact with gamma activity reflecting neural activity in the brain, the emergent property of this interaction is consciousness.

Click here to view the embedded video.

From The Society for Scientific Exploration (SSE)