Evaluation of differentiated neurotherapy programs for a patient after severe TBI and long term coma using event-related potentials

Abstract

Background: This article examines the effectiveness of differentiated rehabilitation programs for a patient with frontal syndrome after severe TBI and long-term coma. We hypothesized that there would be a small response to relative beta training, and a good response to rTMS, applied to regulate the dynamics of brain function.

Case report: M. L-S, age 26, suffered from anosognosia, executive dysfunction, and behavioral changes, after a skiing accident and prolonged coma, rendering him unable to function independently in many situations of everyday life. Only slight progress was made after traditional rehabilitation. The patient took part in 20 sessions of relative beta training (program A) and later in 20 sessions of rTMS (program B); both programs were combined with behavioral training. We used standardized neuropsychological testing, as well as ERPs before the experiment, after the completion of program A, and again after the completion of program B. As hypothesized, patient M.L-S showed small improvements in executive dysfunction and behavioral disorders after the conclusion of program A, and major improvement after program B. Similarly, in physiological changes the patient showed small improvement after relative beta training and a significant improvement of the P300 NOGO component after the rTMS program.

Conclusions: The rTMS program produced larger physiological and behavioral changes than did relative beta training. A combination of different neurotherapeutical approaches (such as neurofeedback, rTMS, tDCS) can be suggested for similar severe cases of TBI. ERPs can be used to assess functional brain changes induced by neurotherapeutical programs.

Figure 1

Brain MRI. 2007. FLAIR and frFSET2 sequences, axial plane. Gliotic posttraumatic changes in the right hemisphere with dilatation of right lateral ventricle.

Figure 2

Brain MRI. 2008. FrFSET2 and FLAIR sequences, axial plane. Gliotic posttraumatic changes in the right hemisphere more prominent than in 2007 with atrophy of brain parenchyma (external porencephaly).

Figure 3

Perseverations in the performance of the TMT (A) and in writing (B) in Exam. 2

Figure 4

ML-S’s results on the Frontal Behavioral Inventory in the category “Impaired social conduct” over three examinations (see text).

Figure 5

ML-S’s results on the Frontal Behavioral Inventory in the category “Impaired personal conduct” over three examinations (see text).

Figure 6

ML-S’s results on the Frontal Behavioral Inventory in the category “Mood disorders” over three examinations (see text).

Figure 7

ML-S’s results on the Frontal Behavioral Inventory in the category “Control disorders” over three examinations (see text)

Figure 8

Schematic representation of the two stimulus GO/NOGO task. From top to bottom: time dynamics of stimuli in four categories of trials. Abbreviations: A, P, H stimuli are “Animals”, “Plants” and “Humans” respectively. GO trials are when A-A stimuli require the subject to press a button. NOGO trials are A-P stimuli, which require suppression of a prepared action. GO and NOGO trials represent “Continue set” in which subjects have to prepare for action after the first stimulus presentation (A). Ignore trials are stimuli pairs beginning with a P, which require no preparation for action. Novel trials are pairs requiring no action, with presentation of a novel sound as the second stimuli. Ignore and Novel trials represent “Discontinue set”, in which subjects do not need to prepare for action after the first stimulus presentation. Time intervals are depicted at the bottom.

Figure 9

ERP recordings in examination 1^st, 2^nd and 3^rd in comparison to norm.