Signature wounds of war: a case study

Chapter 37

Signature wounds of war: a case study George Louis Lindenfeld1,2 and George Rozelle3 1

RESET Therapy Professional Training Institute LLC, Sarasota, FL, United States, 2RESET Therapy Professional Training Institute LLC,

Hendersonville, NC, United States, 3MindSpa Integrative Wellness Center, Sarasota, FL, United States

37.1

Introduction

Much progress in therapeutic applications has been made over the course of my 48 years as a clinical psychologist, however rarely in my career, have I encountered such a rapid and lasting transformative change. That is, until approximately 6 years ago when I was introduced to the bioacoustical utilization device (BAUD) patented in 2006 by Dr. Frank Lawlis. Delving into this new intervention and utilizing it fully in my practice, I found that amazingly, many of my patients recovered from a myriad of difficulties that plagued them. Furthermore, accompanying conditions such as: depression, sleep disorder, chronic pain, etc., improved as well. Looking deeper into the mechanisms of action of this tool, I came to understand that the binaural sound utilized by the BAUD, was able to quickly and permanently alter the emotional components of long-term stored memory. In contrast, it has only been a short time ago, that I was introduced to the world of infrared light, particularly in regards to its ability to improve the consequences of traumatic brain injury (TBI). Given that by 2007, it was noted in a RAND Corporation Report that: “1.64 million service members who had been deployed for OEF/OIF as of October 2007, we estimate that approximately 300,000 individuals currently suffer from PTSD or major depression and that 320,000 individuals experienced a probable TBI during deployment. . . Some specific groups, previously understudied—including the Reserve Components and those who have left military service—may be at higher risk of suffering from these conditions” (Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery—RAND_MG720. pdf, 2008). Given my relative newness to the field of photobiomodulation, some background information may be helpful in appreciating how I came to be invited to write a chapter in a book about this topic. In 2016, I was working on my latest book called: The Treatment of PTSD Comorbid Conditions. Two of the chapters (Dementia and Traumatic Brain Injury), focused on conditions that appear to be responsive to photobiomodulation. I took a giant leap and contacted Dr. Michael Hamblin, asking him to consider writing the forward to my newest undertaking. Graciously, he responded to my request, writing material pertinent to the entire book as well as to the subject matter of the two specified chapters. I thought that a good start to this chapter would be to share a portion of those comments as a way of appreciating Dr. Hamblin’s contribution to neuroplasticity’s transformative potential in the broadest sense. One of the most important concepts that has arisen in this emerging field of neuroscience is called ‘synaptic plasticity.’ In this sense, acoustical neuromodulation and Photobiomodulation share a common mechanistic foundation resting on neuroplasticity. As I read about the applications of RESET Therapy to the PTSD comorbid conditions . . . I was struck with an awareness of the inherent potential in each and every cell in our body to heal and restore itself . . . it is clear that . . . acoustical neuromodulation interrupts the memory reconsolidation process within the retention network of the brain thereby permitting it to reset to pre-trauma levels. . . . He (Lindenfeld), proposes that when we combine the treatment he calls RESET Therapy with Photobiomodulation, we emerge with a perfectly balanced, “peanut-butter and jelly sandwich.” The concept here is that intervention with RESET blocks the insidious effects of unresolved trauma from perpetuating damage to the body as a whole. On the other hand, PBMT triggers: an increase in regional cerebral blood flow; improves brain oxygenation; increases ATP levels that are crucial for effective brain function. Apparently, one shared function of both the light that induces photobiomodulation, and the sound that

Photobiomodulation in the Brain. DOI: https://doi.org/10.1016/B978-0-12-815305-5.00037-3 © 2019 Elsevier Inc. All rights reserved.

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returns the cells to their inherent growth potential, is their apparent ability to diminish neuro-inflammation. This phenomenon is especially damaging to the brain if excessively prolonged. Dr. Michael Hamblin

This synthesis of two different interventions truly complement each other in the healing of body, mind, and soul. Through sound, we facilitate the erasure of the insidious effects of unresolved trauma with its accompanying neutralization of the neuroinflammatory consequences on the body and mind. Through light, we accelerate an increase in cerebral oxygenation and blood flow as well as increased ATP production. These two interventions truly supplement each other within the context of a transformative process made possible through, synaptic plasticity. As one who appreciates the magic of a peanut butter and jelly sandwich, particularly when the jelly is pineapple, I am thrilled to contribute to Dr. Hamblin’s newest effort. To be clear, let us consider the reconsolidation enhancement by stimulation of emotional triggers (RESET Therapy), aspect to be equivalent to the pineapple jelly part. My challenge was to conceptualize how to best integrate the joint utilization of these transformative treatments. After giving this much thought, I decided to first apply RESET Therapy to remediate the posttraumatic stress disorder (PTSD) symptoms in a combat veteran and then follow up with photobiomodulation for the residual, underlying TBI component. In regards to the peanut butter, I have earlier acknowledged that I am a newcomer to the field of photobiomodulation. I have recently celebrated my 79th birthday and decided about two years ago, to explore the potential that infrared light might offer me in sustaining my own cognitive abilities during aging. Simultaneously, my awareness of the signature wounds of our engaged military personnel, was becoming increasingly evident within the recent population of returning combat veterans with PTSD. This awareness emerged as my colleagues and I were engaged in a pilot project in the Sarasota, Florida region that to date has involved six combat veterans from three eras (Vietnam; Gulf Wars; Iraq/ Afghanistan). Without going into too much detail at this point, the results of this intervention were extremely impressive with each of the volunteer veterans receiving four treatment sessions of RESET Therapy. Their posttest results will be shown later indicating a significant reduction in their PTSD symptomatology to the point that they no longer meet diagnostic criteria necessary for the condition. We obtained approval from the QuietMind Foundation, an institutional review board, for our research noting that we would exclude veterans with a history of TBI or active substance abuse. We did this initially with the thought that we would avoid compounding our primary focus of remediating symptoms associated only with PTSD. With veterans from earlier eras, this was not difficult to do. However, with veterans from Iraq/Afghanistan, we found a much higher concurrence between the two conditions. While performing preliminary screening of veterans interested in participating in the study, it quickly became apparent that many of them had experienced mild to moderate levels of TBI. Therefore, with the approval of the QuietMind Foundation, study inclusion criteria were modified to allow veterans with mild to moderate cases of TBI to participate. Our inquiry into this matter revealed that the National Center for PTSD had noted an increase in TBI in the following 2017 update: “The conflicts in Iraq and Afghanistan have resulted in increased numbers of Veterans who have experienced traumatic brain injuries (TBI). The Department of Defense and the Defense and Veteran’s Brain Injury Center estimate that 22% of all combat casualties from these conflicts are brain injuries, compared to 12% of Vietnam related combat casualties. 60% to 80% of soldiers who have other blast injuries may also have traumatic brain injuries” (Traumatic Brain Injury and PTSD, 2017). Since we were now including veteran volunteers with this condition, I thought it would be prudent to explore what current remediative treatments were available for TBI. My basic impression was that these were primarily supportive or palliative rather than restorative interventions as noted in the following perspective: Effective treatment for postconcussive symptoms (PCS) immediately following mild traumatic brain injury (mTBI) includes reassurance, support, education about mTBI, and symptom management. However, effective treatments for chronic postconcussive-like symptoms, particularly with mental health comorbidities, remain unclear (Vanderploeg et al., 2019). Another investigator focusing on treatment for TBI found that: “Overall, counseling for adults with TBI has largely involved the use of behavioral, CBT, and other directive methods in the group and/or individual modalities. It tends to focus on skill development, symptoms management and reduction, social and interpersonal competence, and mood regulation. The counseling tends to be part of a larger treatment plan for the clients, as they struggle to re-attain proficiency in multiple areas of their lives, involving relationships, work, and self-efficacy (maucieri-2012). Other, more recent investigators, have found that interventions for the treatment of TBI are rather limited. They note that: “While there have been some encouraging reports of improvement with the use of hyperbaric oxygen, published military studies show no benefit. Pharmacology has been limited to symptomatic amelioration” (Morries et al., 2015). “Recent multi-site studies of pharmacological agents to directly treat concussion and brain injury have failed”

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(Willyard, 2015). “The overlap in symptoms between TBI and post-traumatic stress disorder has contributed to the use of medications which have been shown to be potentially harmful to the injured brain in those with a TBI”. (Henderson, 2016) “For example, anti-psychotic drugs have been shown to be neurotoxic and can potentially impede any neurological regeneration which might otherwise occur” (Phelps et al., 2015). The only treatment interventions noted in a 2016 article by Santos et al., that offer promise of TBI cortical remediation include: repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and transcranial led therapy. As my focus in this chapter is on the use of low-level laser therapy, I concentrated only on this particular intervention. The study authors noted that: “In humans the use of laser therapy has also started to be used with different focuses. A low-power laser therapy was used to verify the biostimulant effects of this therapy in tissue repair. It might be noted that after completion of the dental procedure patients undergoing therapy had vascular hyperemia increased local blood circulation, increased metabolism, collagen synthesis, stimulation produce endorphins, inhibiting nociceptor signals, which brought analgesic, anti-inflammation, tissue edema and reduction in healing effect. On the other hand, when specifically applied to the CNS, they have also had their related results to those found in animal models and in clinical use” (Santos et al., 2016). Researchers in a 2014 study explored the use of 4 weeks of light therapy to treat fatigue following TBI. They reported that: “After controlling age, gender, and baseline depression, treatment with high-intensity blue light therapy resulted in reduced fatigue and daytime sleepiness during the treatment phase, with evidence of a trend toward baseline levels 4 weeks after treatment cessation. These changes were not observed with lower-intensity yellow light therapy or no treatment control conditions. There was also no significant treatment effect observed for self-reported depression or psychomotor vigilance performance. Blue light therapy appears to be effective in alleviating fatigue and daytime sleepiness following TBI and may offer a noninvasive, safe, and nonpharmacological alternative to current treatments” (Sinclair et al., 2014). Returning to issues with our recently returning veterans, improvised explosive devices have become the: “weapons of choice for the insurgent enemy in Iraq and Afghanistan. More soldiers are surviving these blast injuries due to improved torso protection yet are sustaining head and neck injuriess in numbers that exceed those from previous wars. Although moderate and severe traumatic head injuries are easily identified and aggressively treated, mild traumatic brain injuries (m-TBIs), or concussions, had previously been deemed inconsequential and often overlooked. Recently, however, the U.S. Department of Defense and Veterans Health Administration have placed emphasis on identifying service members at risk for m-TBI because a select number continue to have disabling symptoms that can negatively affect quality of life. Research regarding the effects and treatment of blast injury are gaining momentum, but further work needs to be accomplished” (Snell and Halter, 2010). A 2016 study investigated mild TBI deficits in recently deployed veterans with mild traumatic brain injury (mTBI). “Veterans discharged from 2007 to 2012 were recruited from Veterans Affairs clinics. . . The mTBI group performed significantly worse on all of the executive and nonexecutive measurements with the exception of Category Fluency, after controlling for age, depression effort, and combat exposure. Depression and combat exposure were greater for the mTBI group” (Gaines et al., 2016). Furthermore, “The long-term effects of mTBI can leave service members with insomnia, anxiety, emotional distress, and impaired cognitive functioning. As of March 2015, there have been more than 320,344 diagnosed cases of traumatic brain injury (TBI) (in theater and in garrison) in the U.S. military since 2000” (Dickey, 2016). As noted earlier, since deciding to include those with mild to moderate TBI in our study, an opportunity arose to research into photobiomodulation devices when my colleague, Dr. George Roselle and I copresented in September 2016 at a Society for Neurofeedback and Research (ISNR) workshop in Orlando, Florida. While there, I had the occasion to meet with Dr. Lew Lim, representing VieLight, a firm which produces photobiomodulation devices. Dr. Lim and his colleagues previously researched and ultimately developed an intranasal photobiomodulation device as early as 1995. They consequently made it commercially available around 10 years later as a noninvasive method of introducing therapeutic photonic energy into the human body. After engaging in discussion related to our mutual interests and my personally trying out a VieLight device, I asked Dr. Lim for advice related to my work with combat veterans. He suggested consideration of the VieLight 810 which is a nonlaser, intranasal, brain photobiomodulation device. This instrument enables photonic transmission past the intranasal channel to the deep ventral brain areas. The device is pulsed at 10 Hz, 50% duty cycle. It shuts off automatically after 25 minutes of treatment time, operating on a single AA battery. The LED beam footprint spans the underside of the brain up into the midbrain area. With these specifications, the power density is 13 mW/cm2. In a 2014 study, “near infrared energy stimulation produced beneficial effects on frontal cortex functions including working memory and sustained attention” (Gonzalez-Lima and Barrett, 2014).

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Following the conference, I looked into Dr. Lim’s 2015, inventor’s notes focusing primarily on the following comments: “it is unlikely that photons from traditional transcranial positions on the head can reach the important primal regions of the brain that are located on the underside of the brain. In reality, these regions are much closer to the nasal areas than to the scalp. Amongst other functions, these areas govern memory, behavior and emotions. In a nutshell, they determine the “essence of the person” in everyone. The nuclei are located in these ventral areas (including the hippocampus, entorhinal cortex, and the ventral medial prefrontal cortex) and they form the important subdivisions of the key network of the brain called the default mode network (DMN). “Since light penetrates significantly more deeply in to the brain from an intranasal position (in the nose) than from transcranial (on the head) locations, it is logical that a light source located in the intranasal position is crucial if one is looking for a comprehensive PBM treatment of the brain. On its own merit, researchers have already found that Intranasal Light Therapy has positive outcomes with neurologic conditions in humans, such as insomnia, mild cognitive impairment. . . Unlike the transcranial method, photons from the nasal cavity area can be efficiently directed to the brain tissues, as there are no scalp and hair to act as barriers” (Microsoft Word—Neuro inventor notes draft 1 Hil 2—Neuroinventor-notes.pdf, 2015).

37.2

RESET Therapy

Shifting now to our RESET Therapy study entitled: A Paradigm Shift in The Treatment of Post-Traumatic Stress Disorder: A Pilot Study, our volunteer combat veterans were initially screened in a diagnostic intake process by the primary investigator (Lindenfeld), wherein they acknowledged experiencing a preponderance of PTSD symptoms. The volunteers denied having a major psychiatric disorder; complex PTSD; psychotic manifestations; active suicidal or homicidal ideation; severe brain injury interfering with speech, writing and purposeful action; ringing in the ears (tinnitus); or current addictive difficulties including the use of recreational agents. They provided their US Department of Defense Certificate of Release or Discharge from active duty (DD Form 214) documenting their service period and honorable discharge. Following their diagnostic intake, selected volunteers were seen by a single, independent doctoral-level psychometrician (Rosenfield). The exception was QEEG, brain mapping data acquired by another of the study’s principal investigators (Rozelle). Psychometric intervention began with the CAPS-5, which is considered to be the gold standard in PTSD assessment. (Weathers et al., 2001). It is used to assess the 20 DSM-5 PTSD symptoms on a 0 4 scale with a possible total of 80 points. Included in the CAPS-5 are questions that target the onset and duration of symptoms, subjective distress, impact of symptoms on social and occupational functioning, improvement in symptoms since a previous administration, overall response validity, overall PTSD severity, and specifications for the dissociative subtype (depersonalization and derealization). This was followed by a neuropsychological computer-based assessment called the CNS vital signs (CNSVS). This neuropsychological computer-based assessment is designed to evaluate the neurocognitive status of patients. A neurocognitive report is produced which represents the raw test scores, domain scores with a comparison of ageadjusted norms, and an overall neurocognition index. Specifically, the instrument measures eleven basic brain functions including composite memory, verbal memory, visual memory, executive function, processing speed, psychomotor speed, reaction time, complex attention, cognitive flexibility, simple visual attention, and motor speed. The psychometric characteristics of the tests in the CNSVS battery are very similar to the characteristics of the conventional neuropsychological tests upon which they are based. “CNSVS is suitable for use as a screening instrument, or as a serial assessment measure” (Gualtieri and Johnson, 2006). Finally, the RESET Therapy treatment was delivered by one PhD level clinical psychologist, (Lindenfeld) who had extensive experience in the treatment process. RESET Therapy is the treatment process utilizing the BAUD and its protocols developed by Dr. Frank Lawlis in 2006 that interfere with targeted trauma memories. Through the use of binaural sound, it blocks repeated restoration of trauma material through the reconsolidation process after it is selectively lit up in the emotional part of the brain through the patient’s intentional focus. I use the term target in RESET Therapy and suggest to my patient that we are going to turn off the switch in the brain that produces the PTSD symptoms (Lindenfeld and Bruursema, 2015). For those individuals whose trauma is specific rather than developmental such as that which occurs in adverse childhood experiences, remediation tends to be rapid and permanent. Two dials of the BAUD volume controller were initially adjusted by the patient with eyes closed to assure a balanced binaural sound effect. Then the counselor/therapist slowly adjusted the frequency knob, to a level where the patient noticed a resonance effect with the targeted trauma. Subsequently, the disrupter knob was adjusted across a beat

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TABLE 37.1 Pre and posttreatment (4 sessions) RESET Therapy CAPS-5 scores. ID

Pretest

Posttest

Difference (%)

V-2

52

05

90

V-4

49

22

55

GW-1

47

04

91

GW-2

77

01

98

I/A-1

69

24

65

I/A-3

74

37

50

frequency in the 0 20 Hz range to a point where the veteran noticed a dropping out of the emotional component of the activated emotional material. The desired effect of the binaural sound was to disrupt the memory reconsolidation process. Because it was necessary to identify the trauma frequency, it was explained in detail to the subject that the treatment should light up the target in the emotional region (limbic system) of the brain. To accomplish this, it was necessary to use sensory aspects of a selected trauma rather than merely thinking about it. Thus, the subject was informed that the best way to create this experience was to imagine being in it fully and completely by bringing in all of the involved senses and thoughts that were present at the time of the experience, including sight, sound, smell, skin sensation, etc. An explanation was provided about the subjective units of distress scale (SUDS), which ranges from a level of 0 100 and has been used to determine the subjective level of intensity of the targeted trauma (Kaplan and Smith, 1995). An intensity score was determined by the veteran at the most intensive point during the period of imagery and then again following the treatment intervention. The therapist observed and monitored physiological reactivity including facial expression, respiration rate, muscle tension, etc. The veteran was instructed to hand signal at the point of selfactivation of a selected trauma at which time the therapist would begin to slowly adjust the frequency knob of the BAUD. The veteran was also instructed to hand-signal again when the discomfort level increased to a maximum level. His/ her observed physiological indicators and sense of self-awareness were also used to help verify the most sensitive frequency level. While, alternative means of tuning in for those who were dissociated from their bodily sensation were available through hands-on training opportunities leading to certification in this procedure, this intervention was not necessary. When there was certainty that the frequency setting resonated with the trauma target, the final stage of the tuning-in procedure took place. The final step involved the use of the disrupter knob of the BAUD, which was adjusted to a beat frequency at which the veteran perceived that the target was beginning to weaken in intensity. At this point, a 5-minute tuning in trial was begun. SUDS levels were acquired both prior to and following this 5-minute trial. Following four, 1-hour treatment sessions wherein the average administration of the binaural sound (RESET) was for a 15- to 20-minute period, we found that the largest effect of the treatment with this small sample came from the CAPS-5 data. All six subjects showed sharp reductions in their CAPS-5 score with the mean CAPS-5 score falling from 61.3 (SD 13.5) to 15.5 (SD 14.3). Sample median scores agreed well with the mean scores. Note the pretreatment versus the posttreatment changes on the CAPS-5 in Table 37.1 of our six volunteers following four RESET Therapy treatments. Typically, scores of 50 and above are confirmation of the presence of PTSD although indicators need to be present in all categories. The following represent the era the Veteran served in: V 5 Vietnam; GW 5 Gulf Wars; IA 5 Iraq/Afghanistan. Positive changes forthcoming from the treatment range from an amazing high of 98% to a low of 50% following the posttest. All veterans in the group no longer qualify for the diagnosis of PTSD according to the CAPS-5 criteria. The level of t-test significance was: P 5 .00025. Our volunteer veteran (GW-2), on his third CAPS-5 administration, 1 year from the first administration, indicated a score of 0. Two of our volunteers out of the six (GW-2, I/A-3), reported having the dual diagnoses of PTSD and TBI during their initial intake interview. When the treatment phase ended, only GW-2 indicated interest in later utilization of photobiomodulation treatment for his TBI condition. Paradoxically, his treatment results revealed the greatest degree of change from his pretreatment PTSD level (98%). Similar results were evident on his pre- and postbrain mapping material while his TBI indicators remained constant.

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Based on these results, we were able to assume that PTSD symptomatology were cleared from the current functioning level and consequently, difficulties related to memory, fatigue, and the sustaining of attention were likely associated with his remaining TBI condition. We now shift to the case study aspect of this chapter.

37.3

Case study

At his diagnostic intake, this veteran (GW-2) reported extremely high levels of intrusive memories, psychological distress, and emotional physiological reactivity. He also reported a great deal of anger toward his family and those around him. He reported an instance of threatening a driver and his passengers at a traffic stop with a handgun. His wife was extremely concerned about his behavior in the home. Historically, he reported a brief loss of consciousness in a service-connected vehicle accident where the vehicle he was in, rolled over. He recalls being nauseous and dizzy for a few days following this incident. In his younger years, he also engaged in a great deal of contact sports remembering being dinged a number of times. He denied any specific cognitive problems prior to treatment. While in Bosnia in 2002, as a member of the NATO peacekeeping force, this US army sergeant was involved in the discovery of as many as 10 holes in the ground where rampaging Serbs attempted to conceal their atrocities since 1995. One such site contained 417 corpses. The sergeant watched grieving survivors flock to the excavation sites, scouring the remains for clues to the identity of the victims. Even after 7 years in the ground, the handiwork of an “ethnic cleansing” massacre outside Srebrenica emitted a stench that made him gag. He took a toothbrush and tried scrubbing it from his nostrils until they bled. “But it was all up here,” he said as he pointed a forefinger to his head. “You can never forget seeing these mangled, dismembered bodies, especially the children,” recalls this 43-year-old father. “You could pull out a little shirt and you could shake bones from it. Or there’d be a little skull, and you could see where the machetes had hit them. Or a shirt might have a missing sleeve, and you knew what happened.” What this veteran saw, left an imprint that followed him home. His internalized anger evolved into road-rage. Most of those around him never saw a full portrait of his Jekyll-Hyde personality that: kept losing it in traffic; became hypervigilant for tailgaters; was ready to bolt from his SUV at the next intersection to physically confront the perceived offenders. They didn’t see the guns he planted around his home hidden beneath the kitchen sink, below the dining room table, behind the shower head, behind the refrigerator, some within reach of his young children. Nor were they around for the nightmares filled with imagery of Bosnian corpses—“it was like there was somebody pulling me down into that hole”—from which he awoke in panic, ready to swing. “Ultimately, I was Baker Acted, (involuntarily hospitalized) and found myself in the mental health ward at a VA hospital in footed pajamas and they’re checking me for scars, abrasions, needle marks. My psychiatrist was convinced I was an avid cocaine user because that’s how he said I was able to stay up at all hours to complete all my projects.” Following his completed RESET Therapy treatment sequence, this veteran reported that almost all of his distressing symptoms had abated. He added that certain stimuli could still elicit some distress, but that this effect was manageable. On post-RESET therapy testing, he no longer met the criteria for a diagnosis of PTSD although no cognitive measure was found to be lower on posttest results. He compared his computer-generated electroencephalogram (EEG) brain images, that were recorded as he revisited his own overseas trauma, to that of an electrical storm. “You know how the weather radar has looked in a storm with angry reds and orange? My initial brain map looked like I was in the middle of an intensive downpour. It was like six inches of rain and flooding over the next hour in every adjacent direction. After my treatment experience, my angry reds and oranges had dissolved into balmy greens. It was all clear skies—debilitating symptoms obliterated.” Most remarkable were the anecdotal reports of the man following the post-RESET therapy assessment. He reported that he went to the VFW for the first time, and has felt sufficiently comfortable and safe to resume using his nighttime CPAP. He reported that visiting family members who were unaware of the man’s participation in a PTSD treatment remarked that a behavioral change was evident. He quoted visiting family members as saying, “He seemed to be more eager to participate in group activities, such as going to the beach.” He described going on an “Easter egg hunt,” not for Easter eggs, but for the weapons he had secreted around his home. He reported removing six guns from hiding places in his house, in places where he felt vulnerable. He reported, “I didn’t know I had that many” in the shower, behind the toilet, in his shaving drawer, underneath the dining room table, and mounted in the cupboard behind the dishes. Reminded that he has children in the house who would have had access to these weapons, the veteran indicated that he now felt that he had narrowly escaped tragedy. “Now I sleep

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great. I went from driving this big-ass V-8 Tundra with god knows how many guns I had in it, praying for a confrontation on the road, to driving a four-cylinder Honda Hybrid getting 49 miles a gallon in the right lane. How about that?” A meeting was scheduled with the veteran in order to discuss the next phase of his treatment. He understood that he would be provided with a VieLight 810 intranasal, brain photobiomodulation device. The use of this instrument was fully explained and he agreed to use it at least one to two times per day over the course of a threemonth period in order to maximize the effect. He also understood that he would be reevaluated after approximately three months of use in order to compare EEG brain maps and CNSVS changes. Following his 3-month trial, subjectively, he reported that: “medically, my cholesterol levels have reduced by around 20% as measured against my prior blood test at the VA so that’s one less medication (Simvastatin), that I’m required to take daily. My doctor’s first response was to pat me on the shoulder for being a good soldier for taking my medication as I was supposed to. I told him that I was taking part in this intranasal light study for soldiers with TBI. He thought that I was involved with some ‘do it yourself’ kit. I’m also off the blood pressure medication” (Lisinopril). “Typically, around this time of year, I experience a nasal infection and in fact, I was contemplating some kind of nasal surgery. I have not experienced the kind of nasal problem I have had in recent years. With my sleep apnea, typically I used it for seven days a week and currently, I’m using it three times a week. It started off with a ‘No Mask Monday’ and then proceeded to a ‘Without It Wednesday’ to a ‘Take It Off Thursday’. The cool thing about this treatment is not knowing what to expect and then being able to tell you what I got”. “My fatigue experience has reduced from a full two-hour movie to a one-half hour sitcom. My prior experience with headaches have minimized to at least 40% below when I started using the light. This makes me much more productive with favorable household chores. I’ve also experienced an increased interest and productivity in intimacy matters.” “With short-term memory matters, previously I had four little units that, when I pressed them, they would activate some location that would be revealed on my phone through an app, such as locating my keys. Within the last three to four weeks, I haven’t had to use the memory device at all. With long-term memory, it seems like I can retain information for a longer period of time. It hasn’t been necessary for others to remind me of things like dental appointments that are scheduled in the future. Additionally, my patience seems to have increased particularly with my kids. My driving has improved. I’ve come to realize that I don’t always need to be driving at around 90 mph. I can’t think of any particular recent incident where someone cut me off and me becoming emotional about it like I did in the past. Overall, this light stuff is amazing.” Treatment results: The CNSVS is a computerized neuropsychological test designed to evaluate the neurocognitive status of patients. It covers a range of mental processes. A neurocognitive report presents the raw test scores, domain scores with a comparison of age-adjusted norms, and an overall neurocognition index. Specifically, the instrument measures eleven basic brain functions including composite memory, verbal memory, visual memory, executive function, processing speed, psychomotor speed, reaction time, complex attention, cognitive flexibility, simple visual attention, and motor speed. The psychometric characteristics of the tests in the CNSVS battery are very similar to the characteristics of the conventional neuropsychological tests upon which they are based. Our volunteer’s scores were all determined to be valid in all three treatment administrations. In looking at the data, the neurocognition index appears to have improved between the first and second test remaining in the average range across all administrations. Tests that measure higher levels of cognitive functioning reveal an upward trend including the following: verbal memory; cognitive flexibility; executive functioning; complex attention. The scores in this particular cluster increased from the average range to above average. Our speculation is that the volunteer’s use of the VieLight 810 at least, partially contributed to this change. Weakening tendencies were also evident in a number of scores including: composite memory and simple attention. Slippage is also present in reaction time (Low) as well as visual memory (low average). Certainly, some of findings may be due to natural variation in scoring. As noted with the higher cognitive functioning scores, the overall trend is encouraging particularly we only used the intranasal unit. All standard scores on the CNSVS for the three evaluation experiences are provided in Table 37.2. Neuropsych questionnaire: The NPQ-short form (NPQ-45) is used to scores patient responses in terms of 20 symptom clusters: inattention, hyperactivity-impulsivity, learning problems, memory, anxiety, panic, agoraphobia, obsessions and compulsions, social anxiety, depression, mood instability, mania, aggression, psychosis, somatization, fatigue, sleep, suicide, pain, and substance abuse. The NPQ is not meant to be a diagnostic indicator but it is reliable (patients tested twice, patient-observer pairs, two observers) and discriminates patients with different diagnoses. Scores generated by the NPQ correlate reasonably well with commonly used rating scales, and the test is sensitive to the effects of treatment (Gualtieri, 2007). Scores are based on a scale of 0 (not a problem) to 300 (severe). As a rule, scores above

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TABLE 37.2 CNS-vital signs. Domain scores

Pre-RESET

Post-RESET

VieLight 810

Standard score 3/01/17

Standard score 3/27/17

Standard score 3/01/18

Neurocognition index

94

103

101

Composite memory

104

114

100

Verbal memory

95

109

112

Visual memory

110

113

89

Psychomotor speed

95

104

107

Reaction time

76

88

74

Complex attention

103

108

111

Cognitive flexibility

92

103

112

Processing speed

90

101

101

Executive function

92

103

112

Simple attention

106

94

94

Motor speed

102

105

109

TABLE 37.3 Neuropsych questionnaire (NPQ) SF-45. Pre-RESET 3/01/17

Post-RESET 3/27/17

VieLight 810 3/01/18

Attention

280 (Severe)

140 (Mild)

0 (Not a problem)

Memory

250 (Moderate)

200 (Moderate)

0 (Not a problem)

Panic

267 (Severe)

0 (Not a problem)

0 (Not a problem)

Mood stability

300 (Severe)

100 (Mild)

0 (Not a problem)

Fatigue

300 (Severe)

100 (Mild)

0 (Not a problem)

Suicide

233 (Moderate)

33 (Not a problem)

0 (Not a problem)

Impulsive

240 (Moderate)

120 (Mild)

40 (Not a problem)

Anxiety

267 (Severe)

133 (Mild)

0 (Not a problem)

Depression

260 (Severe)

100 (Mild)

0 (Not a problem)

Aggression

275 (Severe)

75 (Mild)

0 (Not a problem)

Sleep

300 (Severe)

50 (Not a problem)

0 (Not a problem)

Pain

225 (Moderate)

100 (Mild)

0 (Not a problem)

225 indicate a severe problem; scores from 150 to 224 indicate a moderate problem; scores from 75 to 145 indicate a mild problem. Our volunteer’s results on this instrument parallel his other comorbid measures. His primary complaint pertaining to aggression is dramatically reduced. Other measures appear to relate to his assumed TBI condition such as his memory score, which is the only remaining item still in the moderate range following his treatment experience. His score on the suicide item is noteworthy in that he no longer views this as a primary problem for him. The same may be said for his prior sleep issues (Table. 37.3).

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Photobiomodulation: In our study, prior to the use of intranasal photobiomodulation, (VieLight 810) and after this treatment, nineteen channels of raw EEG data were collected from our volunteer utilizing a BrainMaster Discovery amplifier using an ElectroCap with standard international 10 20 electrode placements. Baseline recording conditions were eyes closed resting for 5 minutes. Our volunteer then was asked to trigger a traumatic memory (same for each recording) for another 5 minutes by experiencing it on a sensory level similar to when the event actually occurred. The collected data was imported into Neuroguide for visual inspection, selection of artifact free EEG, and statistical analysis (LSNDBweb.pdf, n.d.) The data were then compared to the Neuroguide reference normative data base matched for age, gender, and handedness (Thatcher, 2011). We found that prior to the provision of photobiomodulation, the RESET therapy intervention produced significant changes in the volunteer’s PTSD trigger conditions resulting in the remediation of his trauma-related symptoms. However, the resting QEEG baseline remained stable, thus serving as a pretreatment baseline for the current investigation of the effect of near-infrared (nIR) neuromodulation on his TBI condition. The QEEG test is used to evaluate the nature and severity of deregulation in the brain such as in mild to moderate traumatic brain injury (MTBI). It provides a quantitative assessment of areas of brain dysfunction and information on impaired conduction and connectivity between different regional neural networks in the brain. The assessment of impaired connectivity is based on abnormal measurements of coherence and phase. Furthermore, the TBI discriminant and concussion index provides information on the presence of a pattern in the EEG that is often found in patients with a history of mTBI. The TBI discriminant and concussion index also provides information about connectivity and excitability of brain regions. The initial prephotobiomodulation treatment summary analysis revealed significant slowing with elevated bitemporal delta (1 4 Hz) and bilateral elevated theta (4 8 Hz), especially in parietal and temporal areas. Asymmetry measures pointed to right temporal dysregulation. Hypo-coherence was evident in delta. As noted earlier, the post-PTSD intervention resting baseline showed no discernible difference. As evident in Fig. 37.1, the TBI discriminant places the subject solidly in the mild brain injury group with a moderate level of severity. Ramifications for daily living include reduced executive functioning, sleep impairment, short-term memory impairment, emotional dysregulation, and poor impulse control. He reported particular difficulties with higher level cognitive functioning. As also reported in his narrative, he specified particular problems with short and long-term memory. As evident in Fig. 37.2, posttreatment nIR application revealed impressive diminishment in the volunteer’s TBI discriminant and concussion index. Also, post-nIR brain mapping revealed significant reduction in delta and a slight reduction in theta. Amplitude asymmetry improved. There was an increase in left posterior temporal hypo coherence. Furthermore, the TBI discriminant analysis was significant at the 97.5 probability level with moderate level of severity before nIR home treatment. After nIR treatment the TBI analysis showed improvement with an 85% probability and mild level of severity (Fig. 37.2). This means that statistical markers commonly found in mild brain injury have moved toward normalization. Discussion: The central theme of this chapter is the utilization of dual, sensory based forms of clinical intervention that appear to enhance synaptic plasticity in a complementary manner. The choice of beginning treatment intervention with RESET therapy first derived from the author’s clinical experience and candidly, comfort level with the procedure. This leads to the question of: would similar results have been forthcoming if the photobiomodulation procedure were used initially or solely? Furthermore, one might ask, does the apparent slippage in some of the scores on the CNSVS derive from the sole use of an intranasal infrared light procedure. A follow-up question would focus on the role that the DMN has within overall cognitive functioning and how it might contribute within the context of the remediation process. This DMN is perceived to be a system of highly correlated interacting brain regions that are distinct from other networks in the brain. The network has been found to be most active when the brain is awake but, in a resting state. It has also been found to be active: “when the individual is thinking about others, thinking about themselves, remembering the past, and planning for the future” (Buckner et al., 2008). “The network activates by default when a person is not involved in a task. . . The DMN has been shown to be negatively correlated with other networks in the brain such as attention networks” (Broyd et al., 2009). A VieLight Neuro Gamma unit designed to enhance the DMN has been personally utilized by one of the authors (Lindenfeld). This cranial placed unit delivers a 40 Hz pulse that correlates with gamma brainwave oscillations. It is intended to enhance the functioning of the cortical nodes of the DMN (bilateral mesial prefrontal cortex, precuneus/posterior cingulate cortex, angular gyrus, and hippocampus). The device is known to enhance memory function and cognition. Specifically, we wonder if the VieLight 810 intranasal unit and Neuro Gamma unit were to have been used in concert, might we have seen improvement rather than slippage in visual memory, reaction time, and simple attention on the CNSVS.

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FIGURE 37.1 Traumatic brain injury pre-nIR.

Included in this chapter was reference to a pilot study wherein six combat-veterans from three different eras experienced rather dramatic remission of their PTSD symptoms including comorbid features. We are in the process of submitting our findings to peer reviewed journals in order to make this intervention more widely available to the professional community. With 20 veterans and active military personnel continuing to take their lives on a daily basis, RESET

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FIGURE 37.2 Traumatic brain Injury Post nIR.

therapy may potentially begin to alter this stark reality. In a similar spirit, our first responders experience cumulative stress within the context of their service to our communities. We are unable to capture their incidence of suicide due to the way in which data is collected for each of the professions involved in the first responder system. Shifting now to TBI, current estimates exceed 20% among returning veterans. While infrared light offers promise, more intensive, well-funded research is clearly necessary to establish that this approach is able to ameliorate the

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signature wounds of war. As earlier described, we have found in our studies of combat veterans that symptoms of both PTSD and MTBI are commonly present. In this single case study, we have shown that a noninvasive simple home training option using nIR light can demonstrate change in a treated TBI combat veteran. It goes without question that based on this tentative finding that additional research with more subjects is needed to further this line of investigation.

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