Neurofeedback Training to Enhance Learning and Memory in Patient with 

Traumatic Brain Injury: A Single Case Study

R. P. Reddy^{1, 2}, J.Rajan^1,3, I Bagavathula.^{1, 4}, T. Kandavel^1,5

1. NIMHANS, India

2. M.Phil, Ph.D Scholar

3. Assistant Professor, Mental Health & Social Psychology

4. Professor, Neurosurgery

5. Associate Professor, Biostatistics

Citation:
Reddy RP,Rajan J, Bagavathula I, & Kandavel T. (2009).Neurofeedback Training to Enhance Learning and Memory in Patient with 
Traumatic Brain Injury: A Single Case Study. International Journal of Psychosocial Rehabilitation. Vol 14(1).  21-28
 

Abstract:
Road traffic injuries are the leading cause (60%) of brain injury. It is estimated that India would occupy third position for Traumatic brain injury (TBI) by 2020. The most vulnerable group of population is the young adults for TBI.

Primary objective: The purpose of the present study was to examine neurofeedback training (NFT) to enhance verbal and visual learning and memory in patient with traumatic brain injury (TBI).

Research design: Single case study was adopted. The neuropsychological profile of the patient was compared pre and post NFT.

Methods and procedures: Patient S, 30 yr male with mild head-injury was given 20 sessions of NFT, 45 min / day, 5 days a week. The training incorporated video feedback to increase the frequency of alpha waves (8-12 Hz): and to decrease theta waves (4-7 Hz). The pre assessment showed impairment in verbal learning and memory.

Main outcomes and results: Results indicated improvement in both verbal and visual learning memory in patient post NFT. The details will be presented.

Conclusions: The present study puts forward that NFT should be taken into account to plan for rehabilitation of patients with TBI for enhancement of learning and memory.

 

Introduction
Traumatic brain injury (TBI) is defined as an insult to the brain caused by an external force that may produce diminished or altered states of consciousness, which results in impaired cognitive abilities or physical functioning (Menkes, 1990). Primary damage occurs to structures at the point of impact or at the point opposite the impact point (i.e., contrecoup injury) as the brain is pushed against the interior of the skull. Secondary injury results from processes of vasodilation, edema, and increased intracranial pressure that can occur as a result of the primary injury. The frontal and temporal lobes, particularly anterior temporal regions, are the cortical areas most likely to be damaged (Fennell & Mickle, 1992).

TBI constitute a significant burden on health care resources. Road traffic injuries are the leading cause (60%) of brain injury, followed by falls (20-25%) and violence (10%). A vehicular accident is reported every 3 minutes on Indian roads. It is estimated that nearly 1.6 million people in India sustain head injuries annually (Gururaj, 2002). Road crash data from Delhi indicates that 41% of injured are pedestrians, 27% motorcyclists and 14% pedal cyclists. The state witnessed 9,083 road accidents in the year 2004. Data from Kerala indicates that 56% of road crashes involve riders of two-wheeled vehicles. Kerala leads the country in traffic injuries - 29 per 100,000 people (Fitzgerald et al., 2006). There is significant sex difference. Males were two to three times more likely to suffer brain injury than females’ low socioeconomic status constitutes independent risk factor for traumatic brain injury (Kraus & McArthur, 1996).

Memory Impairment Following TBI
Memory deficits are the most frequent chronic cognitive disturbance reported by patients and relatives in TBI, long-term memory impairment (Serino, ciaramelli, Santantonio et al., 2005), working memory, verbal and visual memory (Kumar, 1999). Memory dysfunction is characterized by anterograde and retrograde deficits, faulty sequencing of events, inefficient encoding, storage strategies and working memory (McDowell et al., 1997).

Mechanism of Recovery from TBI
The recovery of TBI would be maximized by appropriate rehabilitation, which occurs within months of the damage. The degree of recovery depends on many factors, including age, the brain area and amount of tissue damaged the rapidity of the damage, the brain’s mechanisms of functional reorganization, and environmental and psychosocial factors. The mechanisms of recovery are also through regeneration, diaschisis, and plasticity (Ricardo E., et al., 1997). The models of memory account for the relationship between the wider neocortex and the medial temporal lobe structures, which helps in rehabilitation. In the rehabilitation of memory the emphasis is typically on alleviating the impact of the memory impairment and as a consequence improving day-to-day functioning. Within the field of cognitive rehabilitation there is a tradition of cognitive retraining, which typically involves repeated exercise on tasks that make demands on the cognitive functioning being retrained. The methods were to (i) enhanced learning (making more effective use of residual memory skills); (ii) mnemonic strategies; (iii) external aids; (iv) environmental modification. Such restitutive approaches and the compensatory approaches have been shown to be helpful for people with memory impairment; however main problem with such approaches have been lack of evidence of its effectiveness (Goldstein & McNeil, 2004)

Neurofeedback Training (NFT)
Neurofeedback (NF) is based on specific aspects of cortical activity. It requires the individual to learn to modify some aspect of his/her cortical activity (Vernon, 2005). The procedure is based on operant conditioning whereby an individual modifies the amplitude, frequency or coherence of the electrical activity and learn to influence the electrical activity of their brain. The goal of neurofeedback is to train the individual to normalize abnormal EEG frequencies. With the neurofeedback approach, the brain frequencies that are in excess are reduced, and those with a deficit are increased (Hardt, 1975). Site–Frequency Specificity and the Self-Regulating Brain models of NFT address to improved ability to maintain homeostasis and to improve stability when responding to a sudden challenge or insult to the regulatory system (Othmer & Kaiser, 1999). The research has led to the conceptualization of neurofeedback as a mechanism is used to stimulate and or regulate cerebral activity, which in turn influence cognitive processing. Hoffman, Stockdale, Hicks and Schwaninger (1995) reported 80% of mildly posttraumatic head-injured patients demonstrate improvements in self-reported symptoms and neuropsychological measures after an average of 40 sessions of NFT. Thornton (2000) compared three patients’ with post-head-injury and reported 68–81% improvement in mean recall to paragraphs after amplitude and coherence NFT. A sample of 20 outpatients with mild to moderately severe closed head injury was treated with, Flexy Neurotherapy System FNS with a 16 20-minute sessions 3 years post trauma, significant improvement was reported (Schoenberger, et.al., 2001). Slowing of EEG, of varying degree and duration, scattered spike activity of varying intensities was frequently reported in patients with TBI (Engstrom & Winkler, 2006).

Case Report
Patient S was a 30-year-old married male from middle socio economic status, employed in a garment factory with nil significant personal, past and family history presented with complaints of poor memory, increased irritability associated with increased distress in meeting the demands of family. He had sustained a mild traumatic brain injury one year earlier following a road traffic accident. S demonstrated significant memory problems on an everyday basis. He frequently left his money at home, forgot information passed on from colleagues, forgot to bring articles from market. He experienced anxiety about his and low mood. Family members were critical about his memory difficulties. The patient’s pretraining revealed left hemisphere neuropsychological deficits.

Method
The study protocol consisted of assessment using the Rivermead Post-Concussion Symptoms Questionnaire (King et., al 1995), Rivermead Head Injury Follow Up Questionnaire (RHFUQ) (Crawford et al, 1995), Edinburgh’s  Handedness inventory (Old field, 1971), Quality of life Scale (WHO-QOL,1992), NIMHANS Neuropsychological Battery (Rao et al, 2004) was carried out three days prior to the start of NFT. S obtained profile scores, suggesting severe verbal memory impairment pre NFT; however there was a significant change in the post NFT sessions for verbal memory. Post assessment was carried out after one month of treatment.

Procedure
S completed a pre-intervention assessment. This baseline period was followed by neurofeedback training. The program consisted of 4 weeks of 45 minutes, 20 individual training sessions. Sessions were conducted in hospital setting. Gold electrodes were applied, with paste according to the 10– 20 International System of electrode placement on O1, O2, with two reference points on the ear lobes and one ground electrode on the forehead. Re-assessment followed completion of the program, along with a structured interview to obtain qualitative feedback from patient. The protocol was to enhance alpha and decrease the frequency of theta waves. The patient received visual feedback from a video monitor.

Results:
The post NFT demonstrated marked changes from the pre training in the verbal learning and memory. Tables 1, 2 and 3 are showing the scores on RPQ, RHIFQ, WHO- QOL, verbal and visual learning and memory of the pre- and post training. The patients score 

Table 1 shows the scores of Rivermead Post concussion Symptoms (RPQ) & Rivermead Head Injury Follow up Questionnaire (RHFUQ) Pre & Post intervention.

RPQ Pre	RPQ Post	RHIFQ Pre	RHIFQ Post
40	25	32	26

Graph 1 Shows Pre & Post scores of RPQ & RHIFQ

The scores clearly indicate that there was reduction of scores in post concussion symptoms.

Similar results are shown in quality of life. There were positive results in areas of physical, social, psychological and environmental factors.

Table 2 shows the Percentiles of Auditory Verbal Learning & Memory Pre & Post intervention.

Pt S	Total AVLT		Immediate Recall		Delayed Recall
	Pre	Post	Pre	Post	Pre	Post
	5	60	5	30	5	75

 

There was significant improvement for verbal learning and memory which was assessed by AVLT, where as for visual learning and memory which was assessed by CFT had a marginal improvement of scores.

Graph 2 shows the scores Auditory Verbal Learning & Memory Pre & Post intervention across 5 trials.

.

Graph 3 shows the scores total, immediate and delayed recall in Auditory Verbal Learning & Memory Pre & Post intervention

 

Table 3 shows the Percentiles of Auditory Verbal Learning & Memory Pre & Post intervention

CFT IR Pre	CFT IR Post	CFT DR Pre	CFTDR Post
90	95	90	95

 

 

Table 4 shows the scores Complex Figure Test Pre & Post intervention

Graph 5 showing the pre post Alpha & Theta scores

Discussion
The purpose of this study was to examine neurofeedback training in enhancement of verbal and visual memory in TBI. S, a 30 -year-old male who suffered from mild head injury was assessed on measures of handedness, post concussion symptoms, quality of life, verbal and visual memory. The results indicate severe impairment in verbal memory prior to treatment protocol. At the termination of training the patient demonstrated clinical improvements in verbal recall. Pre-and post-intervention scores in Table indicate that S improved in performance on verbal learning and memory and visual learning and memory. Qualitative feedback indicated that S found the training beneficial. At a time when an increasing number of people are concerned with negative effects from relying solely on medication treatments, neurofeedback may offer an additional treatment alternative for many conditions (Hammond, D. C, 2007). Research suggests that theta activity (4–7 Hz) has an influence on the cellular mechanisms of memory through its role in facilitating long-term potentiation (Pavlides, Greenstein, Grudman, & Winson, 1988). The link between recognition memory processes and theta activity is also reported (Burgess & Gruzelier, 1997). Research focusing on alpha (8–12 Hz) show that upper alpha is primarily associated with semantic memory processes. Examination of the interplay between working memory and long-term memory has suggested that theta activity (4–8 Hz) reflects the processes of working memory, whilst upper alpha (9.5–12 Hz) reflects retrieval from long-term memory (Klimesch et al., 1997).

The aim of rehabilitation is to optimize independence while ensuring that environmental support is available to assist for those areas that the individual is unable to achieve independently (Burke et al., 1994). This case study has demonstrated that for S the use of neurofeedback training improved ability to perform day to today tasks and better quality of life. Neurofeedback is an emerging neuroscience-based clinical application. The study has demonstrated the importance of NFT for the memory enhancement to aid to the patient’s needs. However there is greater need for further work which is required using group designs to establish training methods. Additional neurofeedback studies with control groups, large numbers of neurotherapy patients, and long-term follow-up are necessary to fully ascertain the effectiveness of this therapy.

 

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