Understanding Concussion, mTBI, and Post-Concussion Syndrome

A concussion or mild traumatic brain injury (mTBI) is caused when there is excessive force applied to the head and it causes the brain to shake inside the skull. When the force is strong enough, the brain will actually hit the inside of the skull and cause a concussion or mTBI. The most common causes of a concussion are car accidents, sports related blows to the head, and falling down. As the brain shakes inside the skull some brain cells (neurons) can twist, stretch, or tear, and be damaged. This is known as diffuse axonal injury (DAI).

Concussions can affect the way your brain communicates with itself and other parts of your body and depends on where the brain has been hit. After a concussion people may have issues with balance, need to sleep more, or have foggy thinking known as brain fog. People may complain that their thinking feels a little fuzzy. Usually after a week or two these symptoms start to decrease and you may need physiotherapy to help recover your balance or strength. Sometimes a concussion can be a little more serious and symptoms do not go away.

People with who have suffered a concussion may also struggle with focus, concentration, executive functioning (tasks related to organization, planning, and working memory), emotional regulation, sleeping patterns, etc., can be affected. You may also struggle with sensitivity to light and sound, headaches, dizziness, and fatigue. Other ways to identify if someone has suffered a concussion or is struggling with post-concussive symptoms is to complete Neurocognitive Testing. This type of testing looks at the brain’s performance in multiple categories and compares the person to other people their age and gender. Someone who struggles with ADHD symptoms will usually have trouble with tests related to simple attention, complex attention, cognitive flexibility, processing speed, reaction time, and overall executive functioning. For more information on Neurocognitive Testing please visit our assessment page.

Concissions can also affect a person’s instrumental activities of daily living (IADLs) which can be simply defined as a person’s daily self care activities. Some IADLs include cooking, cleaning, communication, accessing transportation, laundry, shopping, and managing personal finances. Anxiety is usually diagnosed by a clinical psychologist or psychiatrist, but can also be diagnosed by your family physician. It is usually diagnosed after the symptoms related to concussion do not go away after 6 months. At this point you may be diagnosed with post-concussion syndrome.


Our Approach to Concussion and Post-Concussion Syndrome

We start with a Clinical Intake Interview to review background history, medical history, identify specific symptoms and their severity, review previous assessments and interventions, and identify if any other assessments are required. The next step is to complete a QEEG (Quantitative Electroencephalogram) assessment to analyze your brainwave patterns. The best way to understand brain waves is to compare them to each section of an orchestra. Every section of an orchestra needs to work together to make sure the music sounds good. Sometimes one section of the orchestra is more dominant than the other, but all sections are necessary to produce beautiful music. In the same way all brain waves are necessary to balance each other out, complement each other, and become dominant when necessary. For example, when you need to analyze and engage in higher level thinking you want your brain to be dominant in faster brain wave patterns to accomplish this task. When you are getting ready for sleep you want your brain to gradually slow down and be dominant in slower brain wave patterns.

People who have had a concussion or mTBI can have severely deviant brain wave patterns. Sometimes there is an excess of slow brain wave patterns near the areas where their brain injury. This can cause the symptoms related to brain fog, inattention, emotional regulation, and executive functioning. Depending on the injury there can be a global reduction in some or all brain wave patterns that causes global issues in brain wave balance, communication, and speed of communication. Other areas in the brain can be stuck in fast brain wave patterns such as beta and high beta as your brain tried to compensate for an excess of slow brain wave patterns. Once we figure out what brain wave patterns are related to your symptoms we can design a personalized program to target and improve them. During each session we monitor your brain waves in real time and when there is greater balance of brain wave patterns we reward you with video and sound. These audio and visual rewards help train and guide your brain to have improved balance and improve your symptoms.

Sometimes clients require additional support in conjunction with neurofeedback training. Some options are psychotherapy and somatic experiencing therapy.


Research Articles on Concussion

This section is meant to highlight research that has been done in the field. The following brief summaries are resources that we have gathered for the public. For an in-depth look at each research article we recommend using the citation to find and read the original article. We hope to add additional resources when possible!

Koberda, J. L. (2015). LORETA Z-score neurofeedback-effectiveness in rehabilitation of patients suffering from traumatic brain injury. Journal of Neurology and Neurobiology, 1(4), 1-9. This is a multi-case study involving 67 patients diagnosed with a traumatic brain injury that were subjected to Z-score neurofeedback therapy. Most of the patients were diagnosed with mild traumatic brain injury and treated within the first year after brain injury. A few patients were diagnosed with more severe traumatic brain injury and treated after one year or later following their head injury incident. Most of the patients complained of headaches and cognitive problems while some of them also suffered from dizziness and overlapping depression. Those who complained of cognitive problems were subjected to analysis with computerized cognitive testing before and after ten sessions of neurofeedback. In addition, QEEG maps were completed before each neurofeedback session initiation in order to see an objective improvement of QEEG abnormalities. Subsequent analysis revealed that 59 out of 67 patients noticed subjective improvement of their symptoms within 10 sessions of neurofeedback therapy, out of which most of them reported an improvement after only 1-3 neurofeedback sessions. 54 patients also had an objective improvement of QEEG maps manifesting as reduction of excessive beta activity and/or normalization of delta or theta power. 45 patients completed prior and post neurofeedback neurocognitive testing with 34 patients having significant cognitive enhancement. These results are very encouraging and indicate high potential of Z-score LORETA neurofeedback rehabilitation of patients suffering from traumatic brain injury.

May, G., Benson, R., Balon, R., & Boutros, N. (2013). Neurofeedback and traumatic brain injury: A literature review. Annals of Clinical Psychiatry, 25(4), 289-296. The purpose of this review was to assess the strengths of the available published literature on the therapeutic efficacy of neurofeedback for traumatic brain injuries and provide recommendations for future research in this area. Google Scholar was used to find 22 examples of primary research. Measures of symptom improvement, neuropsychological testing, and changes in subjects’ quantitative electroencephalogram were included in the analysis. A single reviewer classified each study according to a rubric devised by 2 societies dedicated to neurofeedback research. It was found that all studies demonstrated positive findings, in that neurofeedback led to improvement in measures of impairment, whether subjective, objective, or both. However, placebo-controlled studies were lacking, some reports omitted important details, and study designs differed to the point where effect size could not be calculated quantitatively. The authors conclude that neurofeedback is a promising treatment that warrants double-blind, placebo-controlled studies to determine its potential role in the treatment of traumatic brain injury.

Munivenkatappa, A., Rajeswaran, J., Devi, B. I., Bennet, N., & Upadhyay, N. (2014). EEG Neurofeedback therapy: Can it attenuate brain changes in TBI? NeuroRehabilitation, 35, 481-484. This study explores electroencephalogram neurofeedback therapy induced in vivo changes in traumatic brain injury patients.  2 patients with moderate head injury who had more than 7 post-concussion symptoms and poor cognitive performances were subjected to 20 sessions of electroencephalogram neurofeedback therapy. Neuropsychological test scores, post-concussion symptoms and MRI scan of the brain were recorded pre-post to electroencephalogram neurofeedback therapy. It was found that during electroencephalogram neurofeedback therapy the cognitive scores and concussion symptoms improved significantly suggesting significant potential to change and regulate impaired neural networks among patients with traumatic brain injury. Furthermore, the quality of life for moderate disability and poor cognitive performance can be significantly improved using electroencephalogram neurofeedback therapy.

Rostami, R., Salamati, P., Tarandi, K. K., Khoshnevisan, A., Saadat, S., Kamali, Z. S., et al. (2017). Effects of neurofeedback on the short term memory and continuous attention of patients with moderate traumatic brain injury: A preliminary randomized controlled clinical trial. Chinese Journal of Traumatology, 20, 278-282.

The aim of this preliminary study was to evaluate the effect of neurofeedback training on the continuous attention and short term memory of  seventeen participants with moderate traumatic brain injuries using a randomized controlled clinical trial. Participants were randomly allocated in two intervention and control groups and then evaluated for continuous attention and short term memory at the start of the training period and at the end of the training period. The training period lasted for a total of four weeks. Although the results of the study yielded that  20 sessions of neurofeedback training has no effect on the continuous attention and short term memory of patients with mild traumatic brain injury, the authors call for more research to be done to explore the impact of different protocols including more sessions of treatment, longer time of follow-up and larger sample sizes of participants.

Popescu, M., Hughes, J. D., Popescu, E.-A., Riedy, G., & DeGraba, T. J. (2016). Reduced prefrontal MEG alpha-band power in mild traumatic brain injury with associated posttraumatic stress disorder symptoms. Clinical Neurophysiology, 127, 3075-3085.

The aim of this study was to address the long standing questions regarding resting state oscillatory brain activity in patients with a history of  mild traumatic brain injury (mTBI) and chronic post concussive symptoms who are stratified based on the severity of their PTSD symptoms. Primary analysis focused on alpha-band power, Participants on medication were not excluded from this study as the authors note that there is no significant difference in alpha frequency between medicated and non medicated patients with PTSD, although there are differences in power demonstrated at faster frequencies. Data generated from the study demonstrated a reduction in resting-state alpha activity involving much of the dorsolateral prefrontal cortex bilaterally in mTBI patients with significant PTSD symptoms compared to those without significant PTSD symptoms. It is that reductions in prefrontal resting-state alpha-band power may also be tested as a biomarker for the identification of those patients with PTSD who may benefit from a variety of treatments to increase prefrontal alpha-band power.

Thorton, K. E., & Carmody, D. P. (2008). Efficacy of traumatic brain injury rehabilitation: interventions of QEEG-guided biofeedback, computers, strategies, and medications. Applied Psychophysiology and Biofeedback, 33(2), 101-124. This paper reviews the empirical reports of changes in cognitive functioning after treatment and compares the relative effectiveness of several treatments including computer interventions, cognitive strategies, EEG biofeedback, and medications. The cognitive functions that are reviewed include auditory memory, attention and problem solving. The significance of the change in cognitive function is assessed in two ways that include effect size and longevity of effect. These analyses complement the previously published meta-reviews by adding these two criteria and include reports of EEG biofeedback, which is shown to be an effective intervention for auditory memory. The authors conclude that activation QEEG database guided biofeedback demonstrates effectiveness and the available research indicates a strong potential for positive impact for traumatic brain injuries resulting from a variety of situations including auto accidents, slip and falls or even war.

Conder, R., & Conder, A. A. (2014). Neuropsychological and psychological rehabilitation interventions in refractory sport-related post-concussive syndrome. Brain Injury, 29(2), 249-262. Due to the general lack of research on interventions for refractory sports-related concussions, this article seeks to review the known and emerging neuropsychological and psychological rehabilitation interventions for reducing morbidity among this population of patients. Despite the limited amount of empirical data available for review, the authors postulate that a mindful and ethical approach towards rehabilitation interventions are especially needed in the absence of evidence-based guidelines. Although neurofeedback rehabilitation with concussed athletes is still in its infancy, the authors suggest that it is ideal for neurofeedback treatment to be guided by a full quantitative brain map (QEEG 19 Chanel Analysis) done post-concussion to understand the neuroelectophysiologic correlates of concussion.

Ghaziri, J., Tucholka, A., Larue, V., Blanchette-Sylvestre, M., Reyburn, G., Gilbert, G., . . . Beauregard, M. (2013). Neurofeedback Training Induces Changes in White and Gray Matter. Clinical EEG and Neuroscience, 44(4), 265-272. doi:10.1177/1550059413476031

In this study, Health university students were randomly assigned to the experimental group, sham group or control group. Participants in the experimental group trained to enhance beta waves at F4 and P4. Attentional performance and MRI data were recorded one week before training and one week after training. Higher scores on auditory and visual sustained attention were present in experiment group. Gray matter volume increases were detected in cerebral structures involved in this type of attention. This study constitutes the first empirical demonstration that neurofeedback training leads to microstructural changes in white and gray matter.

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