Photobiomodulation to Improve Cognition in TBI, With fMRI

Traumatic Brain Injury Clinical Trial

Official title:

Transcranial Photobiomodulation to Improve Cognition in TBI, With Pre-/Post- fMRI Scans: A Pilot, Sham-Controlled Study

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT04230577
• Other study ID #: 0216aVielight
• Secondary ID: 3223
• Status: Recruiting
• Phase: Early Phase 1
• Start date: August 7, 2019
• Est. completion date: September 30, 2023

Study information

• Verified date: February 2022
• Source: Boston VA Research Institute, Inc.
• Contact: Paula I Martin, PhD
• Phone: 857-364-4029
• Email: Paula.Martin[@]va.gov
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

The purpose of this small, research study is to examine effectiveness of an at-home application of an experimental intervention, on thinking and memory in mild-moderate, closed-head, traumatic brain injury cases. The experimental intervention is light-emitting diode (LED) therapy, which is applied to the scalp and through the nose using a head frame device. Participants are expected to complete two, 5-week series of LED treatments, at home, 3 times a week. There will be a 1-month period between the two series. Each home treatment is 20 minutes. Participants will be trained to use the head frame device, in-office. The head frame device falls within the FDA category General Wellness, low-risk devices, and no medical claims are made. A two-hour paper and pencil testing (4 visits) and a one-hour MRI (3 visits) will be administered before and after each treatment series. Participants may be in the study for about 4 months. This study is supported by Vielight, Inc., Hayward, CA/ Toronto, Canada

Description:

Objectives: This small study examines effectiveness of an at-home experimental intervention that utilizes near-infrared (NIR) wavelengths of light (810nm) applied to the scalp, using light-emitting diodes (LEDs), to improve brain function. LEDs may directly improve the cellular activity of brain tissue that has been damaged by brain trauma. The intervention involves two series of 15 treatments, which are self-administered, at-home. Neuropsychological testing and structural and functional MRI (fMRI) scans will be administered to examine behavioral and brain changes before and after a series of LED treatments. MRI scans will examine some mechanism of LED intervention including changes in blood flow, functional connectivity and neurochemicals.

Research Design: This study is a blinded, randomized, sham-controlled, partial-crossover study, with 2 groups (n=10 per group (Sham, Real); ages 18-65). Participants are randomized, by computer into groups. At-home LED intervention is self-administered 3 times per week (20 minutes), for two 5-week series, with a one-month break between series. Group 1 receives both a series of Sham and a series of Real treatments and Group 2 receives two series of Real treatments. All participants will receive at least one series of Real treatments during participation.

Methods and General Study Procedure: Twenty veterans with traumatic brain injury, 18-65 years old, who are at least 6-months post- the latest mild-moderate traumatic brain injury (TBI) will be studied. A 1-hour, In-office neuropsychological (NP) screening, after consenting, will determine study eligibility and ensure participants meet the inclusion/exclusion criteria. Participants may be in the study for about 4 months.

Device Parameters: Vielight Neuro Alpha head frame device, NIR, 810nm, pulsed at 10 Hz, 50% duty cycle, 20-minute treatment with automatic shutoff. Total Energy Dose per head set plus intranasal: 225 J/cm2+ 15 J/cm2 = 240 J/cm2 per 20 min LED treatment. Total Energy Dose delivered (3x/Week, 5 Weeks) = 3600 J/cm2. The light from these LEDs is not visible to the eye. There is no potential for eye damage because the LEDs are not laser light.

Sham and Real devices are identical in look and feel, except no photons are emitted from the Sham devices. The head frame device falls within the FDA category General Wellness, low-risk devices, and no medical claims are made. It is approved for use by the VA Boston Healthcare System Safety and Human Subjects Committees.

Training: Each participant is assigned his/her own LED head frame device for hygiene reasons. The assigned device will be provided to each participant at a 1-hour in-office training session, after the first Neuropsychological (NP) Testing. Training that includes both verbal and written instructions will be provided, along with demonstration of use of the device. A treatment log, storage box and alcohol wipes for cleaning are provided. The first treatment is completed at the training session.

For each series of LED treatments, a 20-minute, LED treatment is completed at home, 3 times per week (Monday, Wednesday, and Friday), for 5 weeks. There must be at least 48 hours between treatments. There will be a total of 15 treatments in each series. The specific time of day is at the participant's convenience. Missed treatments will be completed at the end of the 5-week series, so all participants will complete all 15 LED treatments. If more than 1 treatment session in a week is not completed, due to unforeseen circumstances, the participant may be withdrawn from the study.

A staff person will telephone each participant weekly, to fill out a questionnaire about the intervention including inquiring if the LED treatments are being performed, if the treatment log sheets are being filled out, and note if there are any questions, concerns or problems.

Neuropsychological Testing: All NP testing is completed at the VA Boston Healthcare System, Jamaica Plain Campus, Boston, MA.

NP tests are administered at four time points (pre- intervention, with follow-up testing at 1 week and 1 month post- series 1, and 1 week post- series 2): The California Verbal Learning Test (CVLT), Long-Delay Free Recall (LDFR) is the Primary Outcome Measure which examines verbal learning, organization and memory. The subtest LDFR, CVLT-II specifically assesses long-delay (20 min), verbal memory, which can be affected after mild-moderate brain injury. Other NP, Psychosocial and General Health measures are considered Secondary Outcome Measures. To avoid practice effects, alternate versions of the NP tests will be used at the Post- LED testing times, when feasible.

Imaging will be conducted on the 3T Philips MRI system located at the Boston University Center for Biomedical Imaging (BU CBI). One-hour scans are acquired at 3 time points, in all participants. No contrast or x-rays are used.

Participants are permitted to have an MRI brain scan, if it has been determined at Entry, that MRI scanning would be safe using an MRI safety checklist. On the day of the MRI scan at the BU CBI, the BU Safety Checklist will also be reviewed before any scanning will occur. The light therapy portion of the study may be completed, even if participants cannot undergo MRI scanning for medical or safety reasons.

Functional MRI: resting-state functional-connectivity Magnetic Resonance Imaging (rs-fc MRI) is the Primary Imaging Outcome Measure. Rs-fc MRI examines the correlation of low frequency signal between voxels in the brain in different areas. Rs-fc MRI abnormalities have been shown in mild-moderate TBI cases. Other imaging sequences are considered exploratory measures. These will provide information on brain structure, blood flow and neurochemicals.

Statistical Analysis Plan

Neuropsychological, Psychosocial, and Health Data Analysis: VA Biostatistician, Robert Lew, PhD.

This study has two 5-week Series (I and II). In Series I, 10 subjects will be assigned to (A), and 10 assigned to (B). In Series II, all remaining A-subjects will continue on A, and all remaining B subjects will switch to A. Switching increases power and reduces dropout. For subjects in treatment B and then A, the model will include a compound symmetry correlation term (r=0.30). Treated subjects are Series I A; and Series II, switch-to-A.

To test if the change between consecutive times, delta, is positive for A, we will model the response, as measured by the CVLT, LDFR in mixed design random effects model of analysis. The formal hypothesis test is a linear contrast, a t-test that assumes an effect size of 0.5. For all Secondary Outcome Measures, exploratory analyses will confirm or not the results for primary hypothesis, CVLT, LDFR. A mixed design random effects model should enable handling of missing data points.

Statistical Analyses for MRI/fMRI data MRI data will be analyzed using Matlab, parametric statistics, and available standard Imaging software. All analyses will be parametric and corrections for multiple comparisons will be made.

Between group comparison of MRI data for the active vs. control groups (at time points T1-T3) will be completed.

Longitudinal impact of treatment over time on MRI scans Analyses will be a within-subject design, which compares changes pre- to 1-week post- and 1-month post- Series 1 intervention.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 20
• Est. completion date: September 30, 2023
• Est. primary completion date: March 31, 2023
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years to 65 Years

Eligibility

Inclusion Criteria:

• 18-65 years old

• Must have had one (or more) closed-head, traumatic brain injuries

• Loss of consciousness 24 hours or less; or no loss of consciousness/ A period of altered mental status (post-traumatic amnesia)/mental confusion for 24 hours or less

• Must be able to come to VA Boston Healthcare System, Jamaica Plain Campus for testing visits and Boston University Center for Biomedical Imaging, Boston University School of Medicine for MRI scans

Must meet the following Screening requirements:

• Participants must score at least 2 SD below normal on at least 1 of the NP tests; or 1 SD below on at least 2 of these NP tests administer at Entry testing: Trail Making Test A & B; Controlled Oral Word Association Test (COWAT/FAS); California Verbal Learning Test II; DKEFS Color-Word Interference Test (Stroop).

Exclusion Criteria:

• Diagnosis of a neurological disease such amyotrophic lateral sclerosis (ALS), Parkinson's, Alzheimer's disease

• History of craniotomy or craniectomy

• A current life-threatening disease such as cancer

• Disease requiring organ transplant

• A severe mental disorder such as schizophrenia, bipolar disorder (not associated with clinically diagnosed PTSD)

• Current substance abuse or active treatment; within the last 6 months

• The Test of Memory Malingering is administered at screening; Participants must not have scores that indicate evidence of malingering, a score of less than 45 on either Part 1 or 2 would show evidence of malingering, with the following exception: If a participant fails Trial 1, but does not fail Trial 2, he/she would not be excluded if he/she also show evidence of poor learning on other NP Screening tests, such as the CVLT. If he/she fails Trial 2, alone, or Trial 1 and Trial 2, then this would exclude the participant from the study.

• Self-reported pain questionnaires (VAS Pain Rating and the Short Form McGill Pain Questionnaire) are also administered. Participants may not have a level of pain greater than 7/10 on VAS or 38/50 on the McGill pain questionnaires at the time of screening.

Exclusion for Magnetic Resonance Imaging Only

• A BU MRI safety screening form will be reviewed at the time of study screening, as well as at each MRI scan appointment to ensure the participant can safely have an MRI. Participants must tell the investigator about any operations and any metal in his/her body, so it can be decided if it is safe for you to proceed with the scan.

Participants cannot have a MRI scan:

• if pregnant.

• if he/she has pacemakers, ear implants, shrapnel injuries, or other types of metal or electric device in their body

Related Conditions & MeSH terms

• Brain Injuries
• Brain Injuries, Traumatic
• Closed Head Injury
• Cognitive Dysfunction
• Craniocerebral Trauma
• Head Injuries, Closed
• Traumatic Brain Injury
• Wounds and Injuries

Intervention

Device:
• Real LED Intervention
A series of Real at-home, transcranial LED treatments (3xWeek, 5 weeks), 20-minute treatment, 810nm (NIR), Vielight Neuro Alpha Head Frame Device (with NIR intranasal).
• Sham LED Intervention
A series of Sham at-home, transcranial LED treatments (3xWeek, 5 weeks), 20-minute treatment, Vielight Neuro Alpha Head Frame Device (with intranasal) with Sham LEDs that emit no photons. Sham and Real Devices look and feel identical.

Locations

Country	Name	City	State
United States	VA Boston Healthcare System	Boston	Massachusetts

Sponsors (3)

Lead Sponsor	Collaborator
Boston VA Research Institute, Inc.	VA Boston Healthcare System, Vielight Inc.

Country where clinical trial is conducted

United States, 

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	CVLT-II, Long Delay Free Recall 1	California Verbal Learning Test-II Long Delay (20 mins) Free Recall; Measures Verbal Memory Min score of 0 and a max score of 16; higher score = better outcome. After a 20 minute delay (other tasks run during this delay), participant is asked to recall items from List A. Total is number of words recalled.; Alternate lists are used at each testing timepoint to avoid practice effect	Change from Pre-Treatment Baseline to 1-Week after Series 1
Primary	CVLT-II, Long Delay Free Recall 2	California Verbal Learning Test-II Long Delay (20 mins) Free Recall; Measures Verbal Memory Min score of 0 and a max score of 16; higher score = better outcome. After a 20 minute delay (other tasks run during this delay), participant is asked to recall items from List A. Total is number of words recalled.; Alternate lists are used at each testing timepoint to avoid practice effect	Change from Pre-Treatment Baseline to 1-Month after Series 1
Primary	CVLT-II, Long Delay Free Recall 3	California Verbal Learning Test-II Long Delay (20 mins) Free Recall; Measures Verbal Memory Min score of 0 and a max score of 16; higher score = better outcome. After a 20 minute delay (other tasks run during this delay), participant is asked to recall items from List A. Total is number of words recalled.; Alternate lists are used at each testing timepoint to avoid practice effect	Change from 1-Week to 1-Month after Series 1
Primary	CVLT-II, Long Delay Free Recall 4	California Verbal Learning Test-II Long Delay (20 mins) Free Recall; Measures Verbal Memory Min score of 0 and a max score of 16; higher score = better outcome. After a 20 minute delay (other tasks run during this delay), participant is asked to recall items from List A. Total is number of words recalled.; Alternate lists are used at each testing timepoint to avoid practice effect	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	CVLT-II, Short Delay Free Recall 1	California Verbal Learning Test-II Immediate Free Recall; Measures Verbal Memory Min score of 0 and a max score of 16; higher score = better outcome Participant is asked to recall items from List A. Total is number of words recalled.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	CVLT-II, Short Delay Free Recall 2	California Verbal Learning Test-II Immediate Free Recall; Measures Verbal Memory Min score of 0 and a max score of 16; higher score = better outcome Participant is asked to recall items from List A. Total is number of words recalled.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	CVLT-II, Short Delay Free Recall 3	California Verbal Learning Test-II Immediate Free Recall; Measures Verbal Memory Min score of 0 and a max score of 16; higher score = better outcome Participant is asked to recall items from List A. Total is number of words recalled.	Change from 1-Week to 1-Month after Series 1
Secondary	CVLT-II, Short Delay Free Recall 4	California Verbal Learning Test-II Immediate Free Recall; Measures Verbal Memory Min score of 0 and a max score of 16; higher score = better outcome Participant is asked to recall items from List A. Total is number of words recalled.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	CVLT-II, Short Delay Cued Recall 1	California Verbal Learning Test-II Immediate Cued Recall; Measures Verbal Memory Participants are asked to immediately recall items from a list, but are given cues by category. (4 categories, 4 items each). Total is score across all 4 categories.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	CVLT-II, Short Delay Cued Recall 2	California Verbal Learning Test-II Immediate Cued Recall; Measures Verbal Memory Participants are asked to immediately recall items from a list, but are given cues by category. (4 categories, 4 items each). Total is score across all 4 categories.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	CVLT-II, Short Delay Cued Recall 3	California Verbal Learning Test-II Immediate Cued Recall; Measures Verbal Memory Participants are asked to immediately recall items from a list, but are given cues by category. (4 categories, 4 items each). Total is score across all 4 categories.	Change from 1-Week to 1-Month after Series 1
Secondary	CVLT-II, Short Delay Cued Recall 4	California Verbal Learning Test-II Immediate Cued Recall; Measures Verbal Memory Participants are asked to immediately recall items from a list, but are given cues by category. (4 categories, 4 items each). Total is score across all 4 categories.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	CVLT-II, Long Delay Cued Recall 1	California Verbal Learning Test-II Long Delay (20 minutes) Cued Recall; Measures Verbal Memory Participants are asked to immediately recall items from a list, but are given cues by category. (4 categories, 4 items each). Total is score across all 4 categories.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	CVLT-II, Long Delay Cued Recall 2	California Verbal Learning Test-II Long Delay (20 minutes) Cued Recall; Measures Verbal Memory Participants are asked to immediately recall items from a list, but are given cues by category. (4 categories, 4 items each). Total is score across all 4 categories.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	CVLT-II, Long Delay Cued Recall 3	California Verbal Learning Test-II Long Delay (20 minutes) Cued Recall; Measures Verbal Memory Participants are asked to immediately recall items from a list, but are given cues by category. (4 categories, 4 items each). Total is score across all 4 categories.	Change from 1-Week to 1-Month after Series 1
Secondary	CVLT-II, Long Delay Cued Recall 4	California Verbal Learning Test-II Long Delay (20 minutes) Cued Recall; Measures Verbal Memory Participants are asked to immediately recall items from a list, but are given cues by category. (4 categories, 4 items each). Total is score across all 4 categories.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	CVLT-II, Total Trials 1-5 _1	California Verbal Learning Test-II, Total Trials 1-5; Measures Learning/Memory over 5 consecutive trials; with a min score of 0 and a max score of 80; higher score = better outcome Participant must immediately recall words from a 16 word list read aloud by the examiner. The same list is presented for each of the 5 trials. Total across 5 trials is scored.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	CVLT-II, Total Trials 1-5 _2	California Verbal Learning Test-II, Total Trials 1-5; Measures Learning/Memory over 5 consecutive trials; with a min score of 0 and a max score of 80; higher score = better outcome Participant must immediately recall words from a 16 word list read aloud by the examiner. The same list is presented for each of the 5 trials. Total across 5 trials is scored.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	CVLT-II, Total Trials 1-5 _3	California Verbal Learning Test-II, Total Trials 1-5; Measures Learning/Memory over 5 consecutive trials; with a min score of 0 and a max score of 80; higher score = better outcome Participant must immediately recall words from a 16 word list read aloud by the examiner. The same list is presented for each of the 5 trials. Total across 5 trials is scored.	Change from 1-Week to 1-Month after Series 1
Secondary	CVLT-II, Total Trials 1-5 _4	California Verbal Learning Test-II, Total Trials 1-5; Measures Learning/Memory over 5 consecutive trials; with a min score of 0 and a max score of 80; higher score = better outcome Participant must immediately recall words from a 16 word list read aloud by the examiner. The same list is presented for each of the 5 trials. Total across 5 trials is scored.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Color-Word Interference (Stroop) Test, Trial 3 _1	Delis-Kaplan Executive Function (DKEFS), Color-Word Interference Test; also known as the Stroop test; Trial 3 is a measure of Inhibition.; Measures Attention/Executive Function; inhibition Measure is Reaction Time lower = better outcome Trial 3 (Inhibition): Name the color ink each word is printed in for a series of words, as quickly as possible.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Color-Word Interference (Stroop) Test, Trial 3 _2	Delis-Kaplan Executive Function (DKEFS), Color-Word Interference Test; also known as the Stroop test; Trial 3 is a measure of Inhibition.; Measures Attention/Executive Function; inhibition Measure is Reaction Time lower = better outcome Trial 3 (Inhibition): Name the color ink each word is printed in for a series of words, as quickly as possible.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Color-Word Interference (Stroop) Test, Trial 3 _3	Delis-Kaplan Executive Function (DKEFS), Color-Word Interference Test; also known as the Stroop test; Trial 3 is a measure of Inhibition.; Measures Attention/Executive Function; inhibition Measure is Reaction Time lower = better outcome Trial 3 (Inhibition): Name the color ink each word is printed in for a series of words, as quickly as possible.	Change from 1-Week to 1-Month after Series 1
Secondary	Color-Word Interference (Stroop) Test, Trial 3 _4	Delis-Kaplan Executive Function (DKEFS), Color-Word Interference Test; also known as the Stroop test; Trial 3 is a measure of Inhibition.; Measures Attention/Executive Function; inhibition Measure is Reaction Time lower = better outcome Trial 3 (Inhibition): Name the color ink each word is printed in for a series of words, as quickly as possible.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Color-Word Interference (Stroop) Test, Trial 4 _1	Delis-Kaplan Executive Function (DKEFS), Color-Word Interference Test; also known as the Stroop test; Trial 4 is a measure of executive function: Inhibition/switching.; Measures Attention/Executive Function; inhibition/switching Measure is Reaction Time lower = better outcome Trial 4 (Inhibition and Switching): Name the color of the ink, however if there is a box around the word, read the word, as quickly as possible	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Color-Word Interference (Stroop) Test, Trial 4 _2	Delis-Kaplan Executive Function (DKEFS), Color-Word Interference Test; also known as the Stroop test; Trial 4 is a measure of executive function: Inhibition/switching.; Measures Attention/Executive Function; inhibition/switching Measure is Reaction Time lower = better outcome Trial 4 (Inhibition and Switching): Name the color of the ink, however if there is a box around the word, read the word, as quickly as possible	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Color-Word Interference (Stroop) Test, Trial 4 _3	Delis-Kaplan Executive Function (DKEFS), Color-Word Interference Test; also known as the Stroop test; Trial 4 is a measure of executive function: Inhibition/switching.; Measures Attention/Executive Function; inhibition/switching Measure is Reaction Time lower = better outcome Trial 4 (Inhibition and Switching): Name the color of the ink, however if there is a box around the word, read the word, as quickly as possible	Change from 1-Week to 1-Month after Series 1
Secondary	Color-Word Interference (Stroop) Test, Trial 4 _4	Delis-Kaplan Executive Function (DKEFS), Color-Word Interference Test; also known as the Stroop test; Trial 4 is a measure of executive function: Inhibition/switching.; Measures Attention/Executive Function; inhibition/switching Measure is Reaction Time lower = better outcome Trial 4 (Inhibition and Switching): Name the color of the ink, however if there is a box around the word, read the word, as quickly as possible	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Delis-Kaplan Executive Function Trails (Condition 2) 1	Number Sequencing; measures Attention/Executive Function, Sequencing, Visual Scanning Measure is Reaction Time with lower = better outcome Connect the numbers in consecutive order from 1 to 16, as quickly as possible.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Delis-Kaplan Executive Function Trails (Condition 2) 2	Number Sequencing; measures Attention/Executive Function, Sequencing, Visual Scanning Measure is Reaction Time with lower = better outcome Connect the numbers in consecutive order from 1 to 16, as quickly as possible.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Delis-Kaplan Executive Function Trails (Condition 2) 3	Number Sequencing; measures Attention/Executive Function, Sequencing, Visual Scanning Measure is Reaction Time with lower = better outcome Connect the numbers in consecutive order from 1 to 16, as quickly as possible.	Change from 1-Week to 1-Month after Series 1
Secondary	Delis-Kaplan Executive Function Trails (Condition 2) 4	Number Sequencing; measures Attention/Executive Function, Sequencing, Visual Scanning Measure is Reaction Time with lower = better outcome Connect the numbers in consecutive order from 1 to 16, as quickly as possible.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Delis-Kaplan Executive Function Trails (Condition 4) 1	Number and Letter Sequencing; measures Attention/Executive Function, Sequencing, Visual Scanning Measure is Reaction Time with lower = better outcome Alternate connecting numbers and letters in consecutive order from 1 to P (1-A-2-B…) as quickly as possible.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Delis-Kaplan Executive Function Trails (Condition 4) 2	Number and Letter Sequencing; measures Attention/Executive Function, Sequencing, Visual Scanning Measure is Reaction Time with lower = better outcome Alternate connecting numbers and letters in consecutive order from 1 to P (1-A-2-B…) as quickly as possible.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Delis-Kaplan Executive Function Trails (Condition 4) 3	Number and Letter Sequencing; measures Attention/Executive Function, Sequencing, Visual Scanning Measure is Reaction Time with lower = better outcome Alternate connecting numbers and letters in consecutive order from 1 to P (1-A-2-B…) as quickly as possible.	Change from 1-Week to 1-Month after Series 1
Secondary	Delis-Kaplan Executive Function Trails (Condition 4) 4	Number and Letter Sequencing; measures Attention/Executive Function, Sequencing, Visual Scanning Measure is Reaction Time with lower = better outcome Alternate connecting numbers and letters in consecutive order from 1 to P (1-A-2-B…) as quickly as possible.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Benton Visual Memory Test; Trial 1 Immediate Recall 1	Immediate Recall for Visuospatial memory Min 0 and max 36; higher score better outcome Participant is presented with 6 figures. They are given 10 secs to view 6 pictures. Immediately asked to recall and draw the figures.; Up to 2 points per figure. Scoring based on accuracy and placement of figure parts: A score of 0, 1 recognizable and incorrectly placed, 1 accurate or correctly placed or 2 both accurate and correctly placed; 0 is given if part is omitted or unrecognizable.; Total possible 12 points	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Benton Visual Memory Test; Trial 1 Immediate Recall 2	Immediate Recall for Visuospatial memory Min 0 and max 36; higher score better outcome Participant is presented with 6 figures. They are given 10 secs to view 6 pictures. Immediately asked to recall and draw the figures.; Up to 2 points per figure. Scoring based on accuracy and placement of figure parts: A score of 0, 1 recognizable and incorrectly placed, 1 accurate or correctly placed or 2 both accurate and correctly placed; 0 is given if part is omitted or unrecognizable.; Total possible 12 points	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Benton Visual Memory Test; Trial 1 Immediate Recall 3	Immediate Recall for Visuospatial memory Min 0 and max 36; higher score better outcome Participant is presented with 6 figures. They are given 10 secs to view 6 pictures. Immediately asked to recall and draw the figures.; Up to 2 points per figure. Scoring based on accuracy and placement of figure parts: A score of 0, 1 recognizable and incorrectly placed, 1 accurate or correctly placed or 2 both accurate and correctly placed; 0 is given if part is omitted or unrecognizable.; Total possible 12 points	Change from 1-Week to 1-Month after Series 1
Secondary	Benton Visual Memory Test; Trial 1 Immediate Recall 4	Immediate Recall for Visuospatial memory Min 0 and max 36; higher score better outcome Participant is presented with 6 figures. They are given 10 secs to view 6 pictures. Immediately asked to recall and draw the figures.; Up to 2 points per figure. Scoring based on accuracy and placement of figure parts: A score of 0, 1 recognizable and incorrectly placed, 1 accurate or correctly placed or 2 both accurate and correctly placed; 0 is given if part is omitted or unrecognizable.; Total possible 12 points	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Benton Visual Memory Test; Total Trials 1	Total Trials 1-3. Learning Measure for Visuospatial memory Min 0 and max 36; higher score better outcome Total possible for each trial is 12 points. Sum of Total is learning score. Participant is presented with 6 figures. They are given 10 secs to view 6 pictures. Immediately asked to recall and draw the figures. This is repeated 3 times.; Up to 2 points per figure. Scoring based on accuracy and placement of figure parts: A score of 0, 1 recognizable and incorrectly placed, 1 accurate or correctly placed or 2 both accurate and correctly placed; 0 is given if part is omitted or unrecognizable.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Benton Visual Memory Test; Total Trials 2	Total Trials 1-3. Learning Measure for Visuospatial memory Min 0 and max 36; higher score better outcome Total possible for each trial is 12 points. Sum of Total is learning score. Participant is presented with 6 figures. They are given 10 secs to view 6 pictures. Immediately asked to recall and draw the figures. This is repeated 3 times.; Up to 2 points per figure. Scoring based on accuracy and placement of figure parts: A score of 0, 1 recognizable and incorrectly placed, 1 accurate or correctly placed or 2 both accurate and correctly placed; 0 is given if part is omitted or unrecognizable.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Benton Visual Memory Test; Total Trials 3	Total Trials 1-3. Learning Measure for Visuospatial memory Min 0 and max 36; higher score better outcome Total possible for each trial is 12 points. Sum of Total is learning score. Participant is presented with 6 figures. They are given 10 secs to view 6 pictures. Immediately asked to recall and draw the figures. This is repeated 3 times.; Up to 2 points per figure. Scoring based on accuracy and placement of figure parts: A score of 0, 1 recognizable and incorrectly placed, 1 accurate or correctly placed or 2 both accurate and correctly placed; 0 is given if part is omitted or unrecognizable.	Change from 1-Week to 1-Month after Series 1
Secondary	Benton Visual Memory Test; Total Trials 4	Total Trials 1-3. Learning Measure for Visuospatial memory Min 0 and max 36; higher score better outcome Total possible for each trial is 12 points. Sum of Total is learning score. Participant is presented with 6 figures. They are given 10 secs to view 6 pictures. Immediately asked to recall and draw the figures. This is repeated 3 times.; Up to 2 points per figure. Scoring based on accuracy and placement of figure parts: A score of 0, 1 recognizable and incorrectly placed, 1 accurate or correctly placed or 2 both accurate and correctly placed; 0 is given if part is omitted or unrecognizable.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Benton Visual Memory Test; Delayed Recall 1	Measures Delayed (20 minute) Recall for Visuospatial memory. {participant completes other tasks during delay) Min 0 and max 12; higher score better outcome Participant is asked to draw the figures from memory after a 20 minute delay (other tasks completed during this time).; Total possible: 12 Scoring is based on accuracy and placement: 0 if unrecognizable or omitted, 1 recognizable, 1 either accurate or correctly placed or 2 both accurate and correctly placed, per figure.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Benton Visual Memory Test; Delayed Recall 2	Measures Delayed (20 minute) Recall for Visuospatial memory. {participant completes other tasks during delay) Min 0 and max 12; higher score better outcome Participant is asked to draw the figures from memory after a 20 minute delay (other tasks completed during this time).; Total possible: 12 Scoring is based on accuracy and placement: 0 if unrecognizable or omitted, 1 recognizable, 1 either accurate or correctly placed or 2 both accurate and correctly placed, per figure.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Benton Visual Memory Test; Delayed Recall 3	Measures Delayed (20 minute) Recall for Visuospatial memory. {participant completes other tasks during delay) Min 0 and max 12; higher score better outcome Participant is asked to draw the figures from memory after a 20 minute delay (other tasks completed during this time).; Total possible: 12 Scoring is based on accuracy and placement: 0 if unrecognizable or omitted, 1 recognizable, 1 either accurate or correctly placed or 2 both accurate and correctly placed, per figure.	Change from 1-Week to 1-Month after Series 1
Secondary	Benton Visual Memory Test; Delayed Recall 4	Measures Delayed (20 minute) Recall for Visuospatial memory. {participant completes other tasks during delay) Min 0 and max 12; higher score better outcome Participant is asked to draw the figures from memory after a 20 minute delay (other tasks completed during this time).; Total possible: 12 Scoring is based on accuracy and placement: 0 if unrecognizable or omitted, 1 recognizable, 1 either accurate or correctly placed or 2 both accurate and correctly placed, per figure.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Beck Depression Inventory (BDI) 1	21 item Questionnaire; Measures mood symptoms. Min 0 and max 63 0-13 minimal; 14-19 mild, 20-29 moderate, 30-63 severe; lower scores = better outcome Score per item: 1-3.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Beck Depression Inventory (BDI) 2	21 item Questionnaire; Measures mood symptoms. Min 0 and max 63 0-13 minimal; 14-19 mild, 20-29 moderate, 30-63 severe; lower scores = better outcome Score per item: 1-3.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Beck Depression Inventory (BDI) 3	21 item Questionnaire; Measures mood symptoms. Min 0 and max 63 0-13 minimal; 14-19 mild, 20-29 moderate, 30-63 severe; lower scores = better outcome Score per item: 1-3.	Change from 1-Week to 1-Month after Series 1
Secondary	Beck Depression Inventory (BDI) 4	21 item Questionnaire; Measures mood symptoms. Min 0 and max 63 0-13 minimal; 14-19 mild, 20-29 moderate, 30-63 severe; lower scores = better outcome Score per item: 1-3.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Post Traumatic Stress Disorder (PCL) 1	17-item, symptom questionnaire Higher scores indicates greater endorsement of symptoms Min 17 and max 85 Reliable decrease 5-10 Clinically meaningful decrease 10-20 points Lower scores = better outcome Score ranges from 1-5 for each item.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Post Traumatic Stress Disorder (PCL) 2	17-item, symptom questionnaire Higher scores indicates greater endorsement of symptoms Min 17 and max 85 Reliable decrease 5-10 Clinically meaningful decrease 10-20 points Lower scores = better outcome Score ranges from 1-5 for each item.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Post Traumatic Stress Disorder (PCL) 3	17-item, symptom questionnaire Higher scores indicates greater endorsement of symptoms Min 17 and max 85 Reliable decrease 5-10 Clinically meaningful decrease 10-20 points Lower scores = better outcome Score ranges from 1-5 for each item.	Change from 1-Week to 1-Month after Series 1
Secondary	Post Traumatic Stress Disorder (PCL) 4	17-item, symptom questionnaire Higher scores indicates greater endorsement of symptoms Min 17 and max 85 Reliable decrease 5-10 Clinically meaningful decrease 10-20 points Lower scores = better outcome Score ranges from 1-5 for each item.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Visual Analog Pain Rating Scale (VAS) 1	Current Pain Rating scale of 1-10 Lower score = better outcome *must be lower than 7 at entry into study for study inclusion Participant rates current level of pain (includes body, muscular, headache etc) by marking a line on a continuous scale from 1-10.	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Visual Analog Pain Rating Scale (VAS) 2	Current Pain Rating scale of 1-10 Lower score = better outcome *must be lower than 7 at entry into study for study inclusion Participant rates current level of pain (includes body, muscular, headache etc) by marking a line on a continuous scale from 1-10.	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Visual Analog Pain Rating Scale (VAS) 3	Current Pain Rating scale of 1-10 Lower score = better outcome *must be lower than 7 at entry into study for study inclusion Participant rates current level of pain (includes body, muscular, headache etc) by marking a line on a continuous scale from 1-10.	Change from 1-Week to 1-Month after Series 1
Secondary	Visual Analog Pain Rating Scale (VAS) 4	Current Pain Rating scale of 1-10 Lower score = better outcome *must be lower than 7 at entry into study for study inclusion Participant rates current level of pain (includes body, muscular, headache etc) by marking a line on a continuous scale from 1-10.	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Short Form, McGill Pain Questionnaire 1	Pain Rating (for the last 30 days) Min 0 and max 45; lower = better outcome Participant rates 15 categories of pain type (None = 0, mild = 1, moderate = 2, severe = 3).; Sum totaled for all categories	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Short Form, McGill Pain Questionnaire 2	Pain Rating (for the last 30 days) Min 0 and max 45; lower = better outcome Participant rates 15 categories of pain type (None = 0, mild = 1, moderate = 2, severe = 3).; Sum totaled for all categories	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Short Form, McGill Pain Questionnaire 3	Pain Rating (for the last 30 days) Min 0 and max 45; lower = better outcome Participant rates 15 categories of pain type (None = 0, mild = 1, moderate = 2, severe = 3).; Sum totaled for all categories	Change from 1-Week to 1-Month after Series 1
Secondary	Short Form, McGill Pain Questionnaire 4	Pain Rating (for the last 30 days) Min 0 and max 45; lower = better outcome Participant rates 15 categories of pain type (None = 0, mild = 1, moderate = 2, severe = 3).; Sum totaled for all categories	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Pittsburgh Sleep Quality Index (PSQI) 1	9 item questionnaire- made up of 7 component scores (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction) Min of 0 and max of 3 per component. Global Sleep Score is total of 7 components Min score of 0 and max score of 21; lower score = better outcome	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Pittsburgh Sleep Quality Index (PSQI) 2	9 item questionnaire- made up of 7 component scores (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction) Min of 0 and max of 3 per component. Global Sleep Score is total of 7 components Min score of 0 and max score of 21; lower score = better outcome	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Pittsburgh Sleep Quality Index (PSQI) 3	9 item questionnaire- made up of 7 component scores (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction) Min of 0 and max of 3 per component. Global Sleep Score is total of 7 components Min score of 0 and max score of 21; lower score = better outcome	Change from 1-Week to 1-Month after Series
Secondary	Pittsburgh Sleep Quality Index (PSQI) 4	9 item questionnaire- made up of 7 component scores (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction) Min of 0 and max of 3 per component. Global Sleep Score is total of 7 components Min score of 0 and max score of 21; lower score = better outcome	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Quality of Community Integration Questionnaire Total CIQ Score 1	CIQ Cognitive Integration Score: 22 Questions Higher Score = better outcome Participant self-report of Current Level of Functional independence and satisfaction level of that ability on various cognitive and social/work/family interactions.; Score 0-2 points for each item Composite Score: Sum of Home Integration 5 items, Social Integration 6 items and Productivity Scores 2 items; Range 0-29	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Quality of Community Integration Questionnaire Total CIQ Score 2	CIQ Cognitive Integration Score: 22 Questions Higher Score = better outcome Participant self-report of Current Level of Functional independence and satisfaction level of that ability on various cognitive and social/work/family interactions.; Score 0-2 points for each item Composite Score: Sum of Home Integration 5 items, Social Integration 6 items and Productivity Scores 2 items; Range 0-29	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Quality of Community Integration Questionnaire Total CIQ Score 3	CIQ Cognitive Integration Score: 22 Questions Higher Score = better outcome Participant self-report of Current Level of Functional independence and satisfaction level of that ability on various cognitive and social/work/family interactions.; Score 0-2 points for each item Composite Score: Sum of Home Integration 5 items, Social Integration 6 items and Productivity Scores 2 items; Range 0-29	Change from 1-Week to 1-Month after Series
Secondary	Quality of Community Integration Questionnaire Total CIQ Score 4	CIQ Cognitive Integration Score: 22 Questions Higher Score = better outcome Participant self-report of Current Level of Functional independence and satisfaction level of that ability on various cognitive and social/work/family interactions.; Score 0-2 points for each item Composite Score: Sum of Home Integration 5 items, Social Integration 6 items and Productivity Scores 2 items; Range 0-29	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Quality of Community Integration Questionnaire (QCIQ) Score 1	Quality of Community Integration (QCIQ) Score (Patient Satisfaction Level) 0-4 for satisfaction level on each item Range: 9 - 36 (Self-Report of satisfaction of home and social integration and productivity Higher Score = better outcome	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Quality of Community Integration Questionnaire (QCIQ) Score 2	Quality of Community Integration (QCIQ) Score (Patient Satisfaction Level) 0-4 for satisfaction level on each item Range: 9 - 36 (Self-Report of satisfaction of home and social integration and productivity Higher Score = better outcome	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Quality of Community Integration Questionnaire (QCIQ) Score 3	Quality of Community Integration (QCIQ) Score (Patient Satisfaction Level) 0-4 for satisfaction level on each item Range: 9 - 36 (Self-Report of satisfaction of home and social integration and productivity Higher Score = better outcome	Change from 1-Week to 1-Month after Series
Secondary	Quality of Community Integration Questionnaire (QCIQ) Score 4	Quality of Community Integration (QCIQ) Score (Patient Satisfaction Level) 0-4 for satisfaction level on each item Range: 9 - 36 (Self-Report of satisfaction of home and social integration and productivity Higher Score = better outcome	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Quality of Community Integration Questionnaire Cognitive Satisfaction Score 1	Cognitive Satisfaction Score: Sum of 6 items related to cognitive satisfaction Range 6 - 24	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Quality of Community Integration Questionnaire Cognitive Satisfaction Score 2	Cognitive Satisfaction Score: Sum of 6 items related to cognitive satisfaction Range 6 - 24	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Quality of Community Integration Questionnaire Cognitive Satisfaction Score 3	Cognitive Satisfaction Score: Sum of 6 items related to cognitive satisfaction Range 6 - 24	Change from 1-Week to 1-Month after Series
Secondary	Quality of Community Integration Questionnaire Cognitive Satisfaction Score 4	Cognitive Satisfaction Score: Sum of 6 items related to cognitive satisfaction Range 6 - 24	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Quality of Community Integration Questionnaire Cognitive Quality of Life Score 1	Cognitive Quality of Life Score: Cognitive Satisfaction Score x score on item 16. Range: 6 - 72	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Quality of Community Integration Questionnaire Cognitive Quality of Life Score 2	Cognitive Quality of Life Score: Cognitive Satisfaction Score x score on item 16. Range: 6 - 72	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Quality of Community Integration Questionnaire Cognitive Quality of Life Score 3	Cognitive Quality of Life Score: Cognitive Satisfaction Score x score on item 16. Range: 6 - 72	Change from 1-Week to 1-Month after Series
Secondary	Quality of Community Integration Questionnaire Cognitive Quality of Life Score 4	Cognitive Quality of Life Score: Cognitive Satisfaction Score x score on item 16. Range: 6 - 72	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Dysexecutive Functional Index (DEX) 1	Self-Report of psychosocial problems that participant may be experiencing in everyday life.; 20 Questions Scale of 0-4 for each item Total Possible: 80 Lower Score = better outcome	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Dysexecutive Functional Index (DEX) 2	Self-Report of psychosocial problems that participant may be experiencing in everyday life.; 20 Questions Scale of 0-4 for each item Total Possible: 80 Lower Score = better outcome	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Dysexecutive Functional Index (DEX) 3	Self-Report of psychosocial problems that participant may be experiencing in everyday life.; 20 Questions Scale of 0-4 for each item Total Possible: 80 Lower Score = better outcome	Change from 1-Week to 1-Month after Series
Secondary	Dysexecutive Functional Index (DEX) 4	Self-Report of psychosocial problems that participant may be experiencing in everyday life.; 20 Questions Scale of 0-4 for each item Total Possible: 80 Lower Score = better outcome	Change from Pre-Treatment Baseline to 1-Week after Series 2
Secondary	Tinnitus Functional Index 1	25 items; rated on a scale of 1-10 Lower score = better outcome Max = 10 per item; Max possible =250 overall Average across all valid responses Overall Score = Average*10 Max of 19 items must be marked >0 to be valid for tinnitus Subscores (each 3-4 items totaled) address 8 domains related to negative impact of tinnitus Intrusive, Sense of Control, Cognitive, Sleep, Auditory Difficulties, Relaxation, Quality of Life, and Emotional Distress	Change from Pre-Treatment Baseline to 1-Week after Series 1
Secondary	Tinnitus Functional Index 2	25 items; rated on a scale of 1-10 Lower score = better outcome Max = 10 per item; Max possible =250 overall Average across all valid responses Overall Score = Average*10 Max of 19 items must be marked >0 to be valid for tinnitus Subscores (each 3-4 items totaled) address 8 domains related to negative impact of tinnitus Intrusive, Sense of Control, Cognitive, Sleep, Auditory Difficulties, Relaxation, Quality of Life, and Emotional Distress	Change from Pre-Treatment Baseline to 1-Month after Series 1
Secondary	Tinnitus Functional Index 3	25 items; rated on a scale of 1-10 Lower score = better outcome Max = 10 per item; Max possible =250 overall Average across all valid responses Overall Score = Average*10 Max of 19 items must be marked >0 to be valid for tinnitus Subscores (each 3-4 items totaled) address 8 domains related to negative impact of tinnitus Intrusive, Sense of Control, Cognitive, Sleep, Auditory Difficulties, Relaxation, Quality of Life, and Emotional Distress	Change from 1-Week to 1-Month after Series
Secondary	Tinnitus Functional Index 4	25 items; rated on a scale of 1-10 Lower score = better outcome Max = 10 per item; Max possible =250 overall Average across all valid responses Overall Score = Average*10 Max of 19 items must be marked >0 to be valid for tinnitus Subscores (each 3-4 items totaled) address 8 domains related to negative impact of tinnitus Intrusive, Sense of Control, Cognitive, Sleep, Auditory Difficulties, Relaxation, Quality of Life, and Emotional Distress	Change from Pre-Treatment Baseline to 1-Week after Series 2