Cerebral Palsy QEEG:
The American Academy of Neurology and the Practical Committee of the American Pediatric Neurology Association recommend that EEG should only be used if epilepsy or similar conditions are suspected.[1]

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Neurologists need to read psychiatric publications in Electrophysiology to change their perspective on the brain.

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In a controlled study with 93-99% accuracy, EEG brain mapping showed that children with Cerebral Palsy could be distinguished.[2]

 

 

There is a chance of seeing non-seizure epileptic activations in sleep EEGs performed after sleep deprivation.[3]

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The Effect of Neurofeedback Treatment in Cerebral Palsy:
In a controlled study conducted in Cerebral Palsy, Neurofeedback treatment was also found to be effective in this group. (Hong C, Lee YI., 2012)

There are case studies [4]-[5]-[6], randomized controlled trials [7], and studies showing that NF is effective in cases where traumatic brain injury and ADHD disorder coexist.[8] For 6 weeks, 14 children received NF while 14 control group children received rehabilitation therapy.

In all subtests of the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) test, the NF group showed a significant 50% improvement compared to the control group receiving rehabilitation therapy. In the control group, only the total score of the LOTCA test showed a significant increase, not the subtests.

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There are also successful studies showing the use of NF treatment in brain injury.[9]-[10] There are also studies showing that NF treatment is successful in brain injury and reading learning difficulties.[11] In the fMRI visual feedback study, they showed that the subjects were able to activate motor and sensorimotor areas with the given task. They recommended that this study could be used as a guide in real-time neurofeedback therapy. [12]

Progress After Cerebral Palsy Neurofeedback Treatment:

A 9-year-old girl was brought in with complaints of inability to walk and speak.

She couldn't even stand with assistance, and when she sat down, she couldn't keep her upper body upright and would fall. The family of the child, who receives special education, stated that their child had been staring fixedly since birth and had very little eye tracking. She had difficulty making eye contact, did not receive or understand commands, and could not distinguish situations that could be dangerous for her. Regarding her walking problem, the patient, who received physical therapy, would become afraid and tremble when trying to walk.

The family also stated that the child constantly drooled and constantly ground her teeth. The investigations revealed no signs of epilepsy.

They had applied for neurofeedback therapy.

QEEG NxLink Database Review: A QEEG NxLink database review conducted at our center before treatment showed a significant increase in beta waves throughout the cortex, particularly in the middle and posterior regions, compared to their age group. Beta hypercoherence disorder was prominent in the middle and posterior regions. This significant increase in beta waves suggested cortical damage.

Neurofeedback Therapy: Neurofeedback can provide very positive improvements in Cerebral Palsy. We explained to the family that we could not give a percentage for the success rate of the treatment, and they accepted and started the treatment.

The child did not receive physical therapy during neurofeedback treatment.

Initially, it was quite difficult to get the child to sit in the chair during neurofeedback sessions. Because she couldn't keep her neck and upper body in the midline when sitting, she would fall to the right or left. Psychologist Ayben Ertem worked hard with this girl to help her sit upright and to place electrodes on her scalp to help her keep her neck straight.

[20 NEUROFEEDBACK SESSIONS]

After 20 Neurofeedback sessions were applied to areas showing deviations from normal in the QEEG Neurometric analysis, positive developments were reported in a meeting with the family. The family stated that the child's teeth grinding habit had decreased and that her irritability when writing or dressing and undressing was less than before. They also said that their child's gaze had become more meaningful and that she understood commands better.

[40 NEUROFEEDBACK SESSIONS]

We achieved significant progress in walking. The child, who previously could only take a few steps with someone holding his hand, could now walk independently without fear and without getting tired. Similarly, it was observed that the child, who had difficulty sitting when he first came for treatment, could now do this easily.

Another patient with Cerebral Palsy and Mild Intellectual Disability, with epileptic activity on awake and sleep EEGs:

Complaint: 13-year-old boy with RA, attention deficit, forgetfulness, rushing during exams, giving up easily when solving math problems, lack of cause-and-effect reasoning and logic, being teased by his friends and taking it very seriously.

The child presented with complaints of: restlessness, repeatedly saying and asking the same thing, asking nonsensical questions, inability to understand jokes, poor socialization, immediately trusting complete strangers, inability to use scissors properly, inability to draw, and limping in the right leg (short Achilles tendon).

Biography: Premature birth at 7.5 months, spent 9 days in an incubator.

Health History: Diagnosed with Cerebral Palsy at age 4.

Child and Adolescent Psychiatrist Prof. Dr. …………… saw the child at age 2 and recommended special education. At age 4, another Dr. …………… diagnosed the child with Cerebral Palsy.

In 2008, a sleep EEG performed at the university polyclinic, suspected of Atypical Autism and Pervasive Developmental Disorder, was found to be normal.

In a 2009 awake EEG, isolated sharp waves reaching an amplitude of 150 mcv were observed in the fronto-parietal region of the left hemisphere, occurring 1 to 3 times within a 1-minute recording.

In a sleep EEG, sharp wave sequences reaching an amplitude of 200-250 mcv were observed in the fronto-parietal region of the left hemisphere, occurring 5 to 7 times and 7 to 10 times within a 10-second recording.

In a 2010 EEG, the presence of rare sharp slow wave complexes originating from the left fronto-centroparietal region was noted. The family was told there were signs of epilepsy.

Neurology started on Trileptal, then Depakin. The psychiatry department prescribed Risperdal, and later requested a consultation to start Concerta alongside Depakin. The university's Department of Child Health and Diseases stated that there was no harm in giving Concerta.

Despite the child showing no improvement, they went to another university where Child and Adolescent Psychiatrist Prof. Dr. ……………….. diagnosed Attention Deficit Hyperactivity Disorder (ADHD) and advised them to continue using these three medications (Risperdal, Concerta, Depakin).

[Link to brain MRI: A 1998 MRI showed areas of high signal intensity in the posterior periventricular white matter with encephalomalacia characteristics and mild ventricular enlargement; the lesions were consistent with areas of leukoencephalomalacia.]

[Link to brain MRI: The family came to us seeking treatment using neurofeedback, a drug-free treatment method.]

[Link to brain MRI: The 1998 MRI showed areas of high signal intensity in the posterior periventricular white matter with encephalomalacia characteristics and mild ventricular enlargement; the lesions were consistent with areas of leukoencephalomalacia.]

[Link to brain]

The family came to us seeking treatment using neurofeedback, a drug-free treatment method.

[Link to brain]

REQUESTED TESTS: To understand the patient's general condition, QEEG, Sleep EEG, TOVA, WISC-R, Bender Gestalt Visual Motor Perception Test, Benton Visual Memory Test, Brain MRI, and laboratory tests were requested. Laboratory blood tests were found to be normal.

Brain MRI: A repeat brain MRI in 2010 revealed moderate dilation in the posterior corpus and atria of both lateral ventricles, and T2W-FLAIR hyperintena gliotic changes in the periventricular deep white matter at these levels.

Clinical complaints appeared to be learning difficulties, but illogical speech suggested possible intellectual disability.

The WISC-R IQ test showed a Verbal IQ score of 80, a Performance IQ score of 58, and a Total IQ score of 66. Mild intellectual disability was diagnosed.

In the Bender Gestalt Visual Motor Perception test, despite being 13 years old, the patient performed at the level of a child aged 8 to 8 years and 5 months. Psychomotor perception and coordination are "impaired".

QEEG ABNORMALITY: To aid in diagnosis and to identify electrical activity irregularities, and to determine the appropriate neurofeedback techniques if applicable, a QEEG-based neurofeedback study was performed (September 2010). The EEG revealed monophase spike slow-wave discharges of 100-200 mkv amplitude passing through the T3 derivation and irritating the P3, C3, and T5 regions. The sleep EEG showed a high concentration of single, double, or short-duration sequences of 100-150 mkv amplitude spikes, monophase or polyphase, passing through the T3 derivation and irritating the C3, F3, and F7 derivations, primarily T5.

 

After 40 Neurofeedback Sessions: We did not detect any monophase spike slow-wave discharges of 100-200 mkv amplitude passing through the T3 derivation and irritating the P3, C3, and T5 regions in the recorded EEG.

After 60 Neurofeedback Sessions: In the sleep EEG, no spikes of 100-150 mkv amplitude, monophase or polyphase spike-slow waves, predominantly passing through the T3 derivation in single, double, or short-duration sequences and irritating the C3-F3-F7 derivations, especially T5, were detected.

The antiepileptic drugs he was using (Depakin, Tegretol) did not reduce these non-epileptic epileptic activities, nor did they contribute to his attention and learning. Studies show that treating these types of activations, even if they do not cause seizures, can have a positive effect on the treatment of cerebral palsy.

The family said there have been significant improvements in the clinical picture.

He's no longer irritable, he doesn't defy anyone anymore, he doesn't have tantrums, his attention and concentration have increased, he studies, he can solve puzzles in 25 minutes that used to take him 55 minutes, he doesn't leave homework unfinished, and he now reads 150 pages of books a day, his logical and appropriate speech has greatly improved, he asks questions repeatedly less often, he's started to understand jokes, he wakes up refreshed in the mornings, he never ate pastries before and he ate them for the first time.

His teacher said he's changed a lot. His science teacher said that he used to forget what he learned last year, even a small mistake.

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"I did the test and saw that he hadn't forgotten," he said.

POSITIVE QEEG CHANGES AFTER TREATMENT:

Relative power showed an increase in fronto-central alpha, increased relative beta throughout the cortex, and parietal-occipital, frontal delta, and theta hypocoherence, as well as temporal-occipital alpha and beta hypocoherence. After NF treatment, relative beta decreased, alpha increased, and hypocoherences normalized except for parietal delta hypocoherence.

TOVA test: Before treatment, the Visual TOVA test showed complete disengagement after the 10th minute, impulsive errors in the first 5 minutes, and borderline slow conduction variability. After 60 hours of Neurofeedback treatment, the TOVA was completely normalized.

Before treatment, the Auditory TOVA test showed very slow conduction velocity. After 60 hours of Neurofeedback treatment, it became normal.

In the WISC-R test repeated after 6 months: a 13-point increase in Verbal IQ score, a 14-point increase in Performance IQ score, and a 15-point increase in Total IQ score were achieved. Before treatment, the Verbal score was 80, Performance score 58, and Total score 66; after 6 months, the Verbal score was 93, Performance score 72, and Total score 81.

When repeated after 6 months, the Bender Gestalt Visual Motor Perception test was found to be "Normal." This represents a 4.5-5 year advancement in 6 months.

Special education was recommended during NF treatment, but neither the mother nor the patient had any faith in special education anymore. This was because, before coming to us, they had received continuous special education without any progress.

These results are the best clinical evidence that neurofeedback naturally contributes to brain maturation.

DISCUSSION: Tegretol and Depakin may be suitable for use in the treatment of Cerebral Palsy, but their effectiveness in patients with CP is limited. Researchers compared the effective dose of carbamazepine in 20 children with CP and epilepsy.[26]

If we recall that epilepsy medications have low success rates and side effects in treating this non-seizure epileptic activation, negatively impacting cognitive functions and not contributing positively to learning difficulties, and that there are scientific articles showing negative effects, it is clear from the history taken and from the scientific tests we measured when he first arrived that Tegretol and Depakin did not contribute to the maturation of his brain. When they looked at the difference in the brains of 89-92 children with CP and those with normal maturation using fMRI, it was found that the left dorsal cingulate gyrus was more activated in CP children, which was thought to be related to changes in brain plasticity. In normally developing children, the left frontal lobe and right cerebellum were more activated than in children with CP. [27] In another fMRI study, the brains of children with CP were more stimulated than those of normally developing children during the activity. [28]

There are no publications regarding the use of Risperdal in CP. Off-label drug use exists. In one CP patient, when the antipsychotic drug Risperdal, which we know is used in the treatment of hiccups, was discontinued and Abilify was started, uncontrollable hiccups occurred. [29]

If you examine the existing evidence for pediatric drug use under the Psychotropic Drug Management in Children and Adolescents program at the Oregon State University School of Pharmacy, you will find that the evidence levels for polypharmacy (the simultaneous use of 3 or more psychotropic drugs such as Risperdal, Concerta, Depakin) in post-school children (7-18 years) are weak.

In their study, Holmes and Santini presented very strong evidence that if treatment corrects EEG abnormalities, there will be improvement in cognitive functions.[30]

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[1] Ashwal S, Russman BS, Blasco PA, Miller G, Sandler A, Shevell M, Stevenson R; Quality Standards Subcommittee of the American Academy of Neurology; Practice Committee of the Child Neurology Society. Practice parameter: diagnostic assessment of the child with cerebral palsy: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2004 Mar 23;62(6):851-63.

[2] Lee NG, Kang SK, Lee DR, Hwang HJ, Jung JH, You JS, Im CH, Kim DA, Lee JA, Kim KS. Feasibility and test-retest reliability of an electroencephalography-based brain mapping system in children with cerebral palsy: a preliminary investigation. Arch Phys Med Rehabil. 2012 May;93(5):882-8. doi: 10.1016/j.apmr.2011.10.028. Epub 2012 Mar 9.

[3] Mattson RH, Pratt KL, Calverley JR. Electroencephalograms of epileptics following sleep deprivation. Arch Neurol 1965;13:310–5.

[4] Ayers, M. E. (2004). Neurofeedback for cerebral palsy. Journal of Neurotherapy, 8(2), 93-94.

[5] Bachers, A. (2004). Neurofeedback with cerebral palsy and mental retardation. Journal of Neurotherapy, 8(2), 95-96.

[6] Rex L. Cannon, Monica K. Crane, Paul D. Campbell, John H. Dougherty Jr., Debora R. Baldwin, Joel D. Effler, Lisa S. Phillips, Felicia Hare, Matthew Zachary, Kelli E. Cox & Dominic J. Di Loreto. A 9-Year-Old Boy with Multifocal Encepha

lomalacia: EEG Loreta and Lifespan Database, Magnetic Resonance Imaging and Neuropsychological Agreement. Journal of NeurotherapyVolume 15, Issue 1, February 2011, pages 3-17

[7] Yu J, Kang H, Jung J.Effects of Neurofeedback on Brain Waves and Cognitive Functions of Children with Cerebral Palsy: a Randomized Control Trial Released: Journal of Physical Therapy Sci.December 01, 2012, p.809-812

[8] Keller, I. (2001). Neurofeedback therapy of attention deficits in patients with traumatic brain injury. Journal of Neurotherapy, 5(1,2), 19-32.

[9] Laibow, R E., Stubblebine, A. N., Sandground, H., & Bounias, M. (2001). EEG neurobiofeedback treatment of patients with brain injury: Part 2: Changes in EEG parameters versus rehabilitation. Journal of Neurotherapy, 5(4), 45-71

[10] Thornton, K. E., & Carmody, D. P. (2008). Efficacy of traumatic brain injury rehabilitation: Interventions of QEEG-guided biofeedback, computers, strategies, and medications. Applied Psychophysiology & Biofeedback, 33(2), 101-124.

[11] Thornton, K. E., & Carmody, D. P. (2005). Electroencephalogram biofeedback for reading disability and traumatic brain injury. Child & Adolescent Psychiatric Clinics of North America, 14(1), 137-162.

[12] Yoo, S. S., & Jolesz, F. A. (2002). Functional MRI for neurofeedback: feasibility study on a hand motor task. Neuroreport, 13, 1377–1381.

[13] Gururaj AK, Sztriha L, Bener A, Dawodu A, Eapen V. Epilepsy in children with cerebral palsy. Seizure 2003;12(2):110–4

[14] Aldenkamp AP, Arends J. Effects of epileptiform EEG discharges on cognitive function: is the concept of “transient cognitive impairment” still valid? Epilepsy Behav 2004;5(suppl 1):S25–34.

[15] Zeng L-H, Rensing N, Sinatra P, Rothman S, Wong M. Kainate seizures 62 cause acute dendritic injury and actin depolymerization in vivo. J Neurosci 63 2007;27(October):11604–13.

[16] Jaseja H.Treatment of interictal epileptiform discharges in cerebral palsy patients without clinical epilepsy: hope for a better outcome in prognosis. Clin Neurol Neurosurg. 2007 Apr;109(3):221-4. Epub 2006 Dec 8.

[17]Ronen GM, Richards JE, Cunningham C, Secord M, Rosenbloom D. Can sodium valproate improve learning in children with epileptiform bursts but without clinical seizures? Dev Med Child Neurol 2000;42:751–5.

[18] Jaseja H. Treatment of interictal epileptiform discharges in cerebral palsy patients without clinical epilepsy: hope for a better outcome in prognosis. Clin Neurol Neurosurg 2007;109(3):221-4.

[19] Bjorgaas HM, Hysing M, Elgen I. Psychiatric disorders among children with cerebral palsy at school starting age. Res Dev Disable. 2012 Jul-Aug;33(4):1287-93.

[20] Shank LK, Kaufman J, Leffard S, Warschausky S.Inspection time and attention-deficit/hyperactivity disorder symptoms in children with cerebral palsy. Rehabil Psychol. 2010 May;55(2):188-93.

[21] Shank LK, Kaufman J, Leffard S, Warschausky S. Inspection time and attention-deficit/hyperactivity disorder symptoms in children with cerebral palsy. Rehabil Psychol. 2010 May;55(2):188-93. doi: 10.1037/a0019601.

[22] McDermott S, Coker A, Mani S, Krishnaswami S, Nagle R, Barnett-Queen L, Wuori D. A population-based analysis of behavioral problems in children with cerebral palsy. Journal of Pediatric Psychology 1996;21:447–463.

[23] Parkes J, White-Koning M, Dickinson HO, Thyen U, Arnaud C, Beckung E, Fauconnier J, Marcelli M, McManus V, Michelsen SI, Parkinson K, Colver A. Psychological problems in children with cerebral palsy: a cross-sectional European study. J Child Psychol Psychiatry. 2008 Apr;49(4):405-13. Epub 2007 Dec 12.

[24] Symons FJ, Tervo RC, Kim O, Hoch J. The effects of methylphenidate on the classroom behavior of elementary school-age children with cerebral palsy: a preliminary observational analysis. J Child Neurol. 2007 Jan;22(1):89-94.

[25] Gross-Tsur V, Shalev RS, Badihi N, Manor O.Efficacy of methylphenidate in patients with cerebral palsy and attention-deficit hyperactivity disorder (ADHD). J Child Neurol. 2002 Dec;17(12):863-6.

[26] Gerasimiuk DL, Gusel' VA, Klimenko VA, Korovin AM. [The use of phenobarbital and carbamazepine (finlepsin) in children with epilepsy and cerebral spastic palsy with epileptic syndrome]. Zh Nevropathol Psikhiatr Im S S Korsakova. 1990;90(8):25-7. [Article in Russian]

[27] Van de Winckel A, Verheyden G, Wenderoth N, Peeters R, Sunaert S, Van Hecke W, De Cock P, Desloovere K, Eyssen M, Feys H.Does somatosensory discrimination activate different brain areas in children with unilateral cerebral palsy compared to typically developing children? An fMRI study. Res Dev Disable. 2013 Mar 7;34(5):1710-1720. doi: 10.1016/j.ridd.2013.02.017. [Epub ahead of print]

[28] Van de Winckel A, Klingels K, Bruyninckx F, Wenderoth N, Peeters R, Sunaert S, Van Hecke W, De Cock P, Eyssen M, De Weerdt W, Feys H. How does brain activation differ in children with unilateral cerebral palsy compared to typically developing children, during active and passive movements, and tact

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with stimulation? An fMRI study. Res Dev Disable. 2013 Jan;34(1):183-97. doi: 10.1016/j.ridd.2012.07.030. Epub 2012 Aug 30.

[29] Yeh YW.Persistent hiccups associated with switching from risperidone to aripiprazole in a schizophrenic patient with cerebral palsy. Clin Neuropharmacol. 2011 Jul-Aug;34(4):135-6. doi: 10.1097/WNF.0b013e31822046bc.

[30] Holmes GL, Lenck-Santini PP. Role of interictal epileptiform abnormalities in cognitive impairment. Epilepsy Behav. May 2006; 8(3):504-15. Epub 2006 Mar 15.