Assessing Brain Activity
At Central Florida Neuropsychology we assess brain function through neuropsychological evaluation and brain activity through the Quantitative Electroencephalograph or Qeeg. This involves a non-invasive procedure where we record a computerized EEG and submit it to specialized analysis. By assessing both brain function and brain activity we can correlate the two in order to develop a program of intervention which address both behavioral manifestations of brain activity and abnormalities in the activity itself.
Analyzing Brain Activity
In short, computerized EEG with Brain Mapping is a procedure that records electrical activity within the brain from 24 channels. This tool gives us the ability to view the dynamic changes taking place throughout the brain during processing tasks (such as reading or while doing mental math) and assist in determining which areas of the brain are not fully engaged and processing efficiently. Over the past 30 years, a method of QEEG analysis called Quantitative analysis with database comparison has been developed .
Quantitative analysis aids in a more precise identification of subtle brain dysfunction. It provides information about the functional organization or disorganization of the brain and serves as a basis for identifying variations in brain function that are associated with different types of neurological disorders including Attention Deficit Disorder, Depression, Dementia, , Obsessive/Compulsive Disorder, Specific Learning Disabilities, and Traumatic Brain Injury to help insure that the true underlying dysfunction is addressed rather than just the behavioral , cognitive or emotional manifestations.. This process is used in select hospitals, clinics and research centers around the world, and Central Florida Neuropsychology is proud to be able to offer this state of the a 2 rt procedure in Highlands County.
At Central Florida Neuropsychology we use this more objective, accurate and detailed information to create more effective neurodevelopmental training protocols. This EEG with quantitative analysis, comparison to a database of individuals with normal brains and brain mapping provides us a baseline to work from while we retrain the brain.
The electrical activity of the brain behaves like any other electrical system. Changes in membrane polarization, inhibitory and excitatory post synaptic potentials, action potentials create voltages that are conducted through the brain tissues electrically within each cell and chemically between cells. These electrical voltages enter the membranes surrounding the brain and continue up through the skull to the scalp where we measure them in microvolts.
These potentials are recorded by electrodes that are is attached to the scalp via a stretchable cap with non-toxic conductive gel. The electrodes are fed into a sensitive amplifier. At Central Florida Neuropsychology, the EEG is recorded from many electrodes arranged according to the international 10/20 standard for describing these positions.
The "10-20 System" of Electrode Placement
The 10-20 system is based on the relationship between the location of an electrode and the underlying area of cerebral cortex. Each point on this figure indicates a possible electrode position. Each site has a letter (to identify the lobe) and a number or another letter to identify the hemisphere location.
The letters F, T, C, P, and O stand for Frontal, Temporal, Central, Parietal and Occipital. (Note that there is no "central lobe", but this is just used for identification purposes.) Even numbers (2,4,6,8) refer to the right hemisphere and odd numbers (1,3,5,7) refer to the left hemisphere. The z refers to an electrode placed on the midline.
The Rigid Brain versus Adaptatable Brain
Symptoms such as attention and focus problems, learning and memory difficulties, and mood disorders (anxiety and depression), and poor impulse control , impaired planning and deficit organization often occur when our brain's processing ability is dysfunctional because it is inadequate to do the required or desired task.
Based upon the brain's natural ability to adapt, a damaged brain will attempt to survive by releasing neuro-inhibitors to protect it's limited resources. In doing so, it locks itself into a particular electro-chemical pattern in an attempt to avoid making the situation worse. When this happens, we find ourselves losing attentional flexibility which reduces our ability to adapt to varying circumstances. As a result, we respond in ways that are not efficient and persist with those responses even though they are not working well for us.
Our personality generally becomes rigid as well and many people begin to feel that there are no solutions to for their problems. This is often the root of an overwhelming sense of helplessness, hopelessness and tends to drives us to mood extremes, such as depression, anger and even uncontrollable rage. Training the brain to increase its flexibility engages us to break out of this pattern and to respond to daily challenges and tasks in a more appropriate fashion.
Measurement with Quantitative analysis
At Central Florida Neuropsychology we use Quantitative analysis and database comparison in order to get a better view of how the brain is processing to determine if it is performing within normal limits.
Quantitative analysis with database comparison is a mathematical technique that compares the EEGs of normal brain functioning individuals with your brain waves. Using Quantitative analysis as a tool the neurotherapist has a sound, objective measure to help determine the areas and nature of underlying cerebral dysfunction leading to emotional, cognitive and behavioral symptoms. This is especially true with those sensitive to psychiatric illnesses, often characterized by disturbances of brain organization rather than by abnormal brain structures that would be revealed by an MRI.. But, it is also true of those who are suffering from injury to their brain following an accident or illness that affects the brain.
Each Qeeg report includes extensive statistical tables of univariate and multivariate measures of absolute power and relative power, power asymmetry and synchronization (coherence), and color-coded topographic brain maps. This data is used to help identify normal and abnormal brain electrical activity. Selected EEG features from across different brain regions quantify the organization within the brain to identify disturbances in brain processing.
The Specifics -
How are the tables used?
When we are considering a set of symptoms from a brain processing point of view, the contribution of each brain wave dysfunction can often be quite revealing. When looking at the brains of individuals with learning disabilities, focial slow wave are often present. For example, in those with Dyslexia, slow brain wave activity may be found in one or more key areas.
· The occipital lobes at the back of the brain, where incoming visual information is received and processed,.
· Wernicke's area located in the left Parietal lobe, where the brain processes words for understanding
· Broca's area located in the left Frontal lobe, where words are put together for expression;
· The sensorimotor area, where speech is converted from a feeling for verbalization of thoughts.
Our brain uses its 8 - 13 cycles per second Alpha waves to idle in a state of readiness. When alpha waves predominate the brain is resting areas that are not required at that movement to activity process information. While this alpha predominance is a normal and favorable phenomenon for the idling brain, if an area of the brain becomes stuck in an pattern of Alpha predominance , active participation of vital brain areas cannot occur with efficiency.
The frontal lobes are the region most commonly affected by excesses or deficiencies in Alpha waves. Our brain uses its frontal lobes to focus attention outside itself and to understand the complexities of the world, and to project into the future. It is not unusual to find high amplitude, frontal Alpha in those failing academically or vocationally . in those who appear to act without consideration of the consequences, or in those who are depressed.
To effectively process incoming information that requires us to think and act consciously, our brain uses faster waves (13 hertz and above) called Beta waves. As a fast brain wave frequency it energizes specific areas in the cortex. If Beta is deficient, either all over or in small areas, the brain may have insufficient electrical resources to perform classroom or workplace tasks at expected levels.
There is no single diagnostic brain wave pattern seen in all of those with a specific disease, disorder, or inefficiency . For example, the Qeeg in those with Attention Deficit Disorder, may involve excessive frontal theta, excessive frontal alpha or even decreased frontal beta. All of these patterns, however, are consistent with an under activation of the frontal lobes. A trained clinician needs to integrate the Qeeg data with history and neuropsychological data in order to form a through diagnostic picture and to formulate an effective program of remediation.
Clinical or behavioral manifestations of many disorders are often similar, thus making diagnoses difficult. For example, a very anxious child may have problems sitting still and paying attention in class, but a child with ADHD may also show the same behaviors. In the former case, however, there is a pattern of excessive fast wave activity that should be treated with relaxation therapies and anxiolytics, while in the latter case, there is a pattern of excessive slow wave activity on the Qeeg which should be treated with neurofeedback or stimulant medication . Judging simply on behavior without looking at the quantitative EEG data and neuropsychological data, it may not be possible to make this differentiation, and therefore, the wrong interventions might be utilized. It is the Qeeg that helps the Neurotherapist determine what is causing the symptoms in any particular individual.
Brain processing problems often reveal themselves in the Qeeg in one or more of the following brain wave categories:
· Absolute Power - How much Brainpower is Available?
Absolute Power measurement aids the Neurotherapist in determining whether enough brainpower within a particular frequency range is present at each recording site.
· Relative Power - Who's In Charge Here?
The Relative Power measurement aids the Neurotherapist in determining whether a particular frequency is overpowering other vital brain frequencies.
· Mean Frequency – Are they within acceptable ranges?
Each frequency band is measured between specific ranges. The average frequency tells us whether or not that specific bandwidth is operating within normal ranges. For example the alpha frequency is measured between 8hertzz and 13hertz. It typically peaks around 10 hertz. Often when we observe it peaking at lower levels, we observe individuals being tired, error prone or simply misunderstanding vital input information.
· Ratios - Relationships are extremely important!
Relationships between the various brain frequencies are compared to those individuals with normal brain functioning. Ratios lower or higher than normal are a sign of inefficiency, in either the brain's ability to process incoming information, or in attending to and executing specific tasks.
· Asymmetry - The Brain's Balancing Act.
Asymmetry scores reveal to us whether the brain waves between the various parts of the brain are balanced. Excessive activity in a given area may indicate an overexertion of brain cells. Insufficient activity may suggest brain cells are not firing sufficiently to maintain proper brain function.
· Coherence – Communication Within the Brain?
In order for us to understand the complexity of the world and to make and execute decisions the different parts of the brain must share information. Coherence is one of the measurements on how well the brain is able to perform this inner self-talk. This measure gives us an indication of how efficiently our brain is working to connects and disconnects different parts of itself to accomplishes a particular task.
Excessive Coherence tends to indicate two or more areas of the brain are "overly connected or locked together." That is, the brain has become overly dependent on those centers and is not efficiently processing and executing information. This tends to result in poor day-to-day performance.
Deficient Coherence is the EEG sign of a brain not able to efficiently connect cortical areas to perform specific tasks.
Learning Disabilities may show either (or both) excessive and deficient Coherence characteristics; serious traumatic brain injury classically results in excessive Coherence.
· Phase - Tortoise or the Hare?
Many of the brain's functions are timed events, the energy from one part of the brain arriving at another area at just the right moment to perform a specific task. The Qeeg measurement is called Phase. Excessive Phase statistics mean the signals arrive too early; deficient, too late. In either case, the brain is not able to do its job with peak efficiency.
As you can see, the Qeeg provides us valuable information necessary to customize a program of neurofeedback to address your brain’s unique needs. The test is non-invasive and pain free. It requires about two hours of your time for set up and data collection. It requires approximately another four hours of the doctor’s time for artifacting, statistical analysis, interpretation and report preparation.
How do I prepare for the Qeeg?
Unless advise otherwise, get a full night sleep. Come to the office in comfortable clothes, with clean hair that has no conditioners, gels, mouse or hairspray. You may have breakfast before coming but should not consume any caffeinated products. The most accurate results are obtained from a medication free brain. Therefore, if you are taking any prescribed medications alert Dr. Crum and she will speak with your physician to determine whether you can be weaned off of these before we do the brain map and then restart the medication afterwards. If this is not possible, we at least, ask that you do not take your morning dose of your medication until the Qeeg has been completed.
A doctor’s prescription is not legally required for a Qeeg. We suggest, however, that you obtain one both to keep your physician in the loop and so that your insurer knows this is medically necessary for you.
What will I be doing during the Qeeg?
During the Qeeg you will be asked to performed simple tasks such as the following:
· Sit with your eyes closed for five minutes
· Sit with your eyes open for five minutes
· Read silently, read out loud
· Do some math
· Hyperventilate
The specific tasks that you will be asked to do will be determined by your evaluator based upon your presenting symptoms, but will be similar to the tasks mentioned above.
Payment for the Qeeg
Payment for the Qeeg, as with all other services, is due the day of the evaluation and may be paid via personal. check, credit card, paypal or through our payment plan if you are approved by the lender. To facilitate your reimbursement from your insurer, Central Florida Neuropsychology will submit your bill to your provider electronically if they accept electronic claims. If not, we will print a receipt that you may submit to your company.
If you wish to obtain a predetermination of benefits from your insurer for the QEEG, the CPT code is: 95957
According to the American Medical EEG Association (AMEEGA) the Qeeg is not a substitute for conventional EEG, but is of value when analyzed by clinicians competent in Qeeg. Dr. Crum holds a diplomat in Qeeg from the Board of Quantitative Electroencephalography. In a letter from the AMA to physician Michael P. Krieger, M.D., the AMA stated that "inclusion of a descriptor and its associated specific five-digit identifying code number in CPT, is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations."1' Regardless, your insurer may exclude coverage for this procedure.
1 American Academy of Neurology, Assessment: EEG Brain Mapping, 39 NEUROLOGY 1100 (1989).