A Comparison of Generalized and Individualized Vestibular Rehabilitation Therapy in a Military TBI Sample.

OBJECTIVE: To compare clinical outcomes between active duty service members receiving generalized versus individualized vestibular rehabilitation treatment (GVRT and IVRT, respectively) for persistent vestibular-related symptoms following mild traumatic brain injury (mTBI). SETTING: An outpatient TBI rehabilitation clinic. PARTICIPANTS: Fifty-seven participants with persistent vestibular-related symptoms following mTBI were randomly assigned to the GVRT ( n = 28) or IVRT ( n = 29) group, stratified by dizziness-related impairment severity. Forty-two participants ( n = 21 per group) completed the posttreatment evaluation and were included in analyses. DESIGN: We employed a single-site, randomized, pre-/posttest experimental design. The GVRT program consisted of eight 45-minute group-based treatment sessions and IVRT consisted of three 30-minute one-on-one treatment sessions both to be completed within 8 weeks. Group assignment was not blinded to study personnel or participants. Research evaluations were completed approximately 2 weeks prior to treatment initiation and following treatment completion. MAIN MEASURES: Outcome measures included Dizziness Handicap Inventory (DHI) and Activities-specific Balance Confidence Scale (ABC) total scores, Sensory Organization Test (SOT) composite equilibrium and sensory input ratio scores, Head Shake SOT (HS-SOT) conditions 2 and 5, and horizontal and vertical Dynamic Visual Acuity. Separate mixed-effects models were used to compare clinical outcomes between the GVRT and IVRT groups. RESULTS: Both groups demonstrated significant improvement from pre- to posttreatment on self-reported dizziness-related impairment (DHI [ F(1,41) = 16.28, P < .001]) and balance performance with and without head movement (composite equilibrium score [ F(1,41) = 16.58, P < .001, effect size [ES] = 0.43], somatosensory [ F(1,41) = 6.79, P = .013, ES = 0.26], visual [ F(1,41) = 6.49, P = .015, ES = 0.29], vestibular [ F(1,41) = 22.31, P < .001, ES = 0.55], and HS-SOT condition 5 [ F(1,38) = 23.98, P < .001, ES = 0.64]). Treatment effects did not differ between groups on any of the outcome measures. CONCLUSIONS: We provide preliminary evidence that differences in clinical outcomes do not exist between participants receiving generalized versus individualized VR. Further research is needed to determine comparative effectiveness between these 2 treatment approaches for persistent vestibular-related symptoms following mTBI.

Changes in EEG Activity Following Live Z-Score Training Predict Changes in Persistent Post-concussive Symptoms: An Exploratory Analysis.

A specific variant of neurofeedback therapy (NFT), Live Z-Score Training (LZT), can be configured to not target specific EEG frequencies, networks, or regions of the brain, thereby permitting implicit and flexible modulation of EEG activity. In this exploratory analysis, the relationship between post-LZT changes in EEG activity and self-reported symptom reduction is evaluated in a sample of patients with persistent post-concussive symptoms (PPCS). Penalized regressions were used to identify EEG metrics associated with changes in physical, cognitive, and affective symptoms; the predictive capacity of EEG variables selected by the penalized regressions were subsequently validated using linear regression models. Post-treatment changes in theta/alpha ratio predicted reduction in pain intensity and cognitive symptoms and changes in beta-related power metrics predicted improvements in affective symptoms. No EEG changes were associated with changes in a majority of physical symptoms. These data highlight the potential for NFT to target specific EEG patterns to provide greater treatment precision for PPCS patients. This exploratory analysis is intended to promote the refinement of NFT treatment protocols to improve outcomes for patients with PPCS.

Changes in attentional processing following neurofeedback in patients with persistent post-concussive symptoms: a pilot study.

OBJECTIVE: Persistent post-concussive symptoms (PPCS) often include attention deficits, particularly orienting and executive attention. Research in other clinical populations has demonstrated that neurofeedback therapy (NFT) is effective at improving orienting and executive attention, although its effects on attentional networks in patients with PPCS are unknown. METHOD: In this single-group pilot study, we examined attention-related event-related potentials (ERPs) - N1 and P3 - and cognitive outcomes following Live Z-score training (LZT), a variant of NFT. RESULTS: No changes in early selective attention, as indexed by N1 amplitude, were observed; however, P3 amplitude, which indexes neural resource allocation, increased following LZT and returned to baseline by 3 months. Cognitive performance improved following treatment, which was sustained at 3 months. The magnitude of change in P3 and ANT performance did not differ between orienting or executive attention, suggesting LZT improved general attentional processing efficiency. CONCLUSION: Our results suggest that LZT may positively affect attention globally, but does not target specific attention networks. These pilot data warrant the initiation of a clinical trial evaluating the effectiveness of LZT for treating attention deficits in patients with PPCS.

Semi-Automated Neurofeedback Therapy for Persistent Postconcussive Symptoms in a Military Clinical Setting: A Feasibility Study.

INTRODUCTION: Neurofeedback therapy (NFT) has demonstrated effectiveness for reducing persistent symptoms following traumatic brain injury (TBI); however, its reliance on NFT experts for administration and high number of treatment sessions limits its use in military medicine. Here, we assess the feasibility of live Z-score training (LZT)-a variant of NFT that requires fewer treatment sessions and can be administered by nonexperts-for use in a military clinical setting. MATERIALS AND METHODS: A single group design feasibility study was conducted to assess acceptability, tolerance, treatment satisfaction, and change in symptoms after a 6-week LZT intervention in 38 Service Members (SMs) with persistent symptoms comorbid with or secondary to mild TBI. Acceptance and feasibility were assessed using treatment completion and patients' satisfaction with treatment. To evaluate changes in symptom status, a battery of self-report questionnaires was administered at baseline, posttreatment, and 3-month follow-up to evaluate changes in psychological, neurobehavioral, sleep, pain, and headache symptoms, as well as self-efficacy in symptom management and life satisfaction. RESULTS: Participants tolerated the treatment well and reported a positive experience. Symptom improvement was observed, including depressive, neurobehavioral, and pain-related symptoms, with effects sustained at 3-month follow-up. CONCLUSION: LZT treatment appears to be a feasible, non-pharmacological therapy amenable to SMs. Results from this pilot study promote further investigation of LZT as an intervention for SMs with persistent symptoms following TBI.