Haya Al-Joudi’s dissertation will do more than just help her meet her graduate obligation; she will collect her data in her home country of Saudi Arabia. Ms. Al-Joudi reports that Saudi Arabia is considered a leading country in the region in the areas of medical advances and mental health services. However, the use of neurofeedback, a method of training brainwaves in individuals to strengthen attention and focus, is not used.

Her work is sponsored by her government through the Saudi Cultural Mission program and she will collect her data at the King Faisal Specialist Hospital. “The hospital staff is very excited about my work and they will be adding me in the recruitment of appropriate subjects for my studym” reports Ms. Al-Joudi.

Ms. Al-Joudi states that it is her intention to gather evidence of the effectiveness of neurofeedback for children diagnosed with ADHD. Following her training and study at Widener University, Ms. Al-Joudi hopes to return to the region to conduct neuropsychological testing and neurofeedback with individuals diagnosed with ADHD and other neuropsychological conditions. She also plans to incorporate biofeedback techniques in therapy with these populations.

BCIA was formed as a non-profit organization in 1981 to establish and maintain professional standards for the provision of biofeedback services and to certify those who meet these standards. BCIA certification is the international gold standard for the selection of qualified biofeedback and neurofeedback professionals. Visit www.bcia.org for more information.

Material adapted from Association for Applied Psychophysiology and Biofeedback (AAPB).

The study is the world’s first investigation of how real-time functional Magnetic Resonance Imaging (fMRI) feedback from the brain region responsible for higher-order thoughts, including introspection, affects our ability to control these thoughts. The researchers find that real-time brain feedback significantly improves people’s ability to control their thoughts and effectively ‘train their brains.’

“Just like athletes in training benefit from a coach’s guidance, feedback from our brain can help us to be more aware of our thoughts,” says co-author Prof. Kalina Christoff, UBC Dept. of Psychology. “Our findings suggest that the ability to control our thinking improves when we know how the corresponding area in our brain is behaving.”

For the study, participants performed tasks that either raised or lowered mental introspection in 30-second intervals over four six-minute sessions. fMRI technology tracked real-time activity in the rostrolateral prefrontal cortex (RLPFC) – the region of the brain involved with higher-order thoughts.

The brain's rostrolateral prefrontal cortex region. (click to enlarge)

Participants with access to real-time fMRI feedback could see their RLPFC activity increase during introspection and decrease during non-introspective thoughts, such as mental tasks that focused on body sensations. These participants used the feedback to guide their thoughts, which significantly improved their ability to control their thoughts and successfully perform the mental tasks. In contrast, participants given inaccurate or no brain feedback did not achieve any improvement in brain regulation.

Professor Kalina Christoff, UBC Dept. of Psychology. (click to enlarge)

“When participants saw their brain reacting to their thoughts, they knew whether they were performing the task well or poorly, and they could adjust their thoughts accordingly,” says co-author Graeme McCaig, a graduate of UBC’s Dept. of Electrical and Computer Engineering’s Human Computer Interaction specialization. “As a result, participants who received the real-time feedback were able to focus on the mental task more consistently.”

Subjects viewed screens with real-time brain feedback.

The study points to the possibility of improving our everyday lives through fMRI-assisted advances in our ability to focus our minds on personal or professional matters, according to the research team, which includes Matt Dixon, Kamyar Keramatian and Irene Liu.

The findings also raise hope for clinical treatments of conditions that can benefit from improved awareness and regulation of one’s thoughts, including depression, anxiety, and obsessive-compulsive disorders, the researchers says.

Subject in an fMRI brain scanner. (click to enlarge)

For example, real-time brain feedback represents a potentially important complement to feedback provided by a therapist or a patient’s own self-monitoring ability given the increased availability of fMRI technology.

Material adapted from University of British Columbia.

This is welcome news for sufferers as the treatment effectiveness of migraine medications is reported to be discouraging. A large majority (84%) of people with migraines state that the drugs do not completely relieve their pain, and sometimes do not even work at all. Another 71% note that their headaches return after treatment, and more than a third report that the drugs are associated with excessive side effects.

Jonathan Walker, M.D., a Dallas, Texas neurologist, recently published a study in the journal Clinical EEG and Neuroscience in which he used quantitative EEG (QEEG) brain imaging to map the brain activity of 71 patients who came for migraine treatment. He discovered a brain activation pattern associated with systemic stress common to every single patient. He then offered to treat anyone in the group using neurofeedback, also known as EEG-biofeedback, instead of drugs. 46 patients elected to undergo neurofeedback and 25 patients decided to remain on medications.

Dr. Walker treated those who opted for neurofeedback with an innovative brain-computer interface developed by BrainMaster Technologies, Inc. of Bedford, Ohio, a leading provider of neurofeedback equipment and technology, for an average of 24 sessions. During treatment sessions, patients were attached to sensors, which tracked their brain waves and delivered real-time visual and auditory information as they entered a specified combination of brainwave conditions associated with relaxation and self-regulation.

At the end of the study, 54% of those participating in neurofeedback experienced a complete elimination of their migraine headaches with no side effects from the neurofeedback therapy. None of those in the pharmaceutical therapy group reported elimination of migraine activity. An additional 39% of the neurofeedback group reported a more than a 50% reduction in migraine frequency, while only 8% of people in the pharmaceutical therapy group reported similar improvement. One person in the neurofeedback group reported no change in headache frequency, while 68% of the pharmaceutical therapy group said their headache frequency had not changed. Statistical analysis reveals a 1 in 100,000 possibility the results were due to chance.

Dr. Walker’s study demonstrates the effectiveness of neurofeedback in treating patients with recurrent migraines with a moderate investment of time and energy, and no apparent risk of side effects.

Material adapted from The Neurotherapy Center of Dallas.

Reference
Walker, Jonathan E. (2011). QEEG-Guided Neurofeedback for Recurrent Migraine Headaches, CLINICAL EEG and NEUROSCIENCE, VOL. 42, NO.1.

Dr. Sterman demonstrated that cats who received SMR-neurofeedback became resistant to seizures when exposed to jet fuel. He further hypothesized that SMR-neurofeedback might be able to produce a similar protective effect in humans.

Future studies would show that SMR-neurofeedback, which typically targets increased SMR (sensori-motor rhythm; 12 – 15 Hz on the sensori-motor strip) and decreased slow waves (often Theta or 4 – 8 hertz), did indeed reduce the number of seizures in those with seizure disorders, such as epilepsy. Moreover, these reduction in seizures occurred even in those with treatment resistant epilepsy.

The release of this classic study is a positive development for the field of neurofeedback. There is a strong push to disseminate neurofeedback research (as well as to conduct more studies) to the general public by the International Society for Neurofeedback and Research, the parent organization of the Journal of Neurotherapy, and the release of this free journal article this certainly helps to meet this important goal.

Download / Reference
M. B. Sterman, R. W. LoPresti, & M. D. Fairchild. Electroencephalographic and Behavioral Studies of Monomethyl Hydrazine Toxicity in the Cat. Journal of Neurotherapy, 14:293–300, 2010.

Citations
Tobias Egner and M Barry Sterman. Neurofeedback treatment of epilepsy: from basic rationale to practical application. Expert Review of Neurotherapeutics, February 2006, Vol. 6, No. 2, Pages 247-257 , DOI 10.1586/14737175.6.2.247

M. Barry Sterman and Tobias Egner. Foundation and Practice of Neurofeedback for the Treatment of Epilepsy. Applied Psychophysiology and Biofeedback, Volume 31, Number 1, 21-35, DOI: 10.1007/s10484-006-9002-x

Recent studies have suggested a threefold increase has occurred in the incidence of these disorders in the last ten years. Schools and parents are wondering how to cope with increasing numbers of children who present with Asperger Syndrome, a constellation of traits first described by the Viennese paediatrician Hans Asperger in 1944.

According to Dr. Lynda Thompson, Ph.D. of the ADD Center in Toronto, “Brainwave patterns in those with Asperger’s syndrome differ from those of the same age peers. We have seen many people with Asperger’s syndrome at our ADD Centre over the past decade and have found that they respond well to neurofeedback training.”

Researchers using neurofeedback are looking at how changes in brainwave patterns indicate whether someone is paying attention to the outside world or drifting off into their own world. This type of research requires the use of specialized equipment to ensure correct measurement of brainwaves. Although this computer-based training looks promising, more research is required.

Biofeedback Foundation of Europe 15th Annual Meeting
Researchers will be attending the BFE Annual Meeting in Munich, Germany from February 22-26, 2011 to learn more about this topic from Drs. Lynda and Michael Thompson. In their 2-day workshop “Neuroanatomical Underpinnings of Effective Intervention with Asperger’s Syndrome & Autistic Spectrum Disorders – From Theory to Practice (Emphasizing the Synergistic Combination of NFB with BFB),” participants will learn to understand the basic symptoms of Asperger’s syndrome and Autism and how an assessment is carried out.

Drs. Lynda & Michael Thompson
Dr. Lynda and Michael Thompson are based in Toronto, Canada where they run the ADD Centre. They have taught workshops in neurofeedback and biofeedback on five continents.
Lynda Thompson, Ph.D. is a licensed psychologist with a background in teaching. She has authored various books, like The A.D.D. Book: New Understandings, New Approaches to Parenting Your Child (1998) co-authored with paediatrician William Sears.

Michael Thompson, MD formerly practiced medicine in addition to serving as Associate Professor and head of post-graduate education in Psychiatry, University of Western Ontario, psychiatric consultant to The Hospital for Sick Children’s neurology department, examiner for the Royal College of Physicians (Canada) and chairman of their examinations committee in psychiatry.

Together they have authored two software suites Setting Up for Clinical Success and Specialized Application Scripts (both available from the Biofeedback Foundation of Europe). They have also written numerous professional publications and collaborated on The Neurofeedback Book: An Introduction to Basic Concepts in Applied Psychophysiology, which has become a basic text in the field of EEG Biofeedback.

Material adapted from Biofeedback Foundation of Europe.

Health care is regulated by state licensing boards; however, biofeedback is not a regulated modality. The goal is to have a recognizable credential that consumers, the health care industry, and professionals can use as a mark of excellence in the delivery of clinical services.

Additionally, the logos which refer to BCIA and to each specific program are trademarked and all certificants are encouraged to use the logo and the new terminology to refer to their certification.

BCB is Board Certified in Biofeedback.

BCN is Board Certified in Neurofeedback.

BCB-PMD is Board Certified in Biofeedback for Pelvic Muscle Dysfunction.

“We realize that recognition of the credential is not an overnight process,” remarked BCIA Board Chair, Fred Shaffer, PhD, BCB. “Our intent is to continue to set the standards of education and training and to provide a credential that will be recognized worldwide as criteria for selecting a provider.”

BCIA was formed as a non-profit organization in 1981 to establish and maintain professional standards for the provision of biofeedback services and to certify those who meet these standards. BCIA certification is the international gold standard for the selection of qualified biofeedback and neurofeedback professionals.

Visit www.bcia.org for more information.

Material adapted from Association for Applied Psychophysiology and Biofeedback (AAPB).

Additional Resources
Shaffer, F., & Crawford, J. (Winter 2009). Biofeedback Certification Institute of America goes global. Biofeedback, 37(4), 123-125.

Shaffer, F., & Crawford, J. (Fall 2009). What has Biofeedback Certification Institute of America been up to? Biofeedback, 37(3), 85-87.

Disclosure: This contributor, Christopher Fisher, PhD, is also BCN.

Briefly, Dr. Van den Bergh discusses his motivation for writing this excellent book. He explains how the “Berlin psychiatry school of the EEG vigilance” significantly influenced his training and research and helped guide him to many of the novel findings contained in his writings, particularly the relationship of sleep disturbance to ADHD.

He further expresses concern about the future of neurofeedback and calls on practitioners to make more reasoned claims about the treatment of various disorders with neurofeedback, as well as to adapt a theory-driven (as opposed to data-driven) interpretation of the EEG.

Read The Complete Interview
This report is only a brief summary of the original interview with Dr. Van den Bergh. Readers who are interested in the complete interview should visit BMED Press here.

Discount for BMED Report Readers
Discount Code: BMEDREPORT (20% off plus free shipping; Offer Extended until 08/31/11).

Reference
Werner Van den Bergh, M.D. (author) & Stephanie Clark (translator) (2010). Neurofeedback and State Regulation in ADHD: A Therapy Without Medication. Texas: BMED Press LLC.

Full Disclosure: Christopher Fisher, PhD is the managing editor of BMED Report and CEO of BMED Press.

Below are each of the 4-videos with a brief summary of the various topics discussed as well as some additional closing comments.

In Part 1, Dr. Jacobs explains that neurofeedback is a “brain wave biofeedback” technique that trains the brain to regulate attention, emotional states, and processing. He further discusses neurofeedback basics with specific relevance to attention deficit hyperactivity disorder (ADHD) and autism, including a review of common symptoms and behavioral problems. Dr. Jacobs’ does a good job explaining the always complicated topic of brainwaves (i.e., delta, theta, beta, etc.), their relevance to emotional and behavioral disturbances, and why neurofeedback can improve symptoms through modified brainwave activity.

Part two continues with an overview of how typical neurofeedback sessions are conducted, including the various types of feedback rewards (games, videos, etc.), treatment frequency, and learning curves. He also discusses the use of quantitative electroencephalography (QEEG) to guide and improve neurofeedback protocol selection.

Part 3 switches focus to autism, including current neurofeedback effectiveness research with this challenging population. Dr. Jacobs points out that neurofeedback will not “cure” Autism, but instead can improve core symptoms, such as poor social skills and emotional regulation. He also speaks about the challenges of public acceptance of neurofeedback and admits that a generally slow release of research is one contributing factor.

In Part 4, the benefits and potential drawbacks of ADHD medication, particularly stimulant medication, receive a brief comparison and contrast to neurofeedback. Dr. Jacobs talks about how the benefits of neurofeedback treatment are sometimes difficult for patients to detect and self-report, and that some patients’ initial awareness of gains may come about when family and friends start to make comments about positive behavioral changes. He also notes that many patients who receive neurofeedback experience sleep improvements even if they did not enter treatment for sleep-related difficulties.

These observations are consistent with an unpublished study from Johnson and Bodenhamer-Davis (2009) at the University Of North Texas who used a time-series analysis to show that many patients report sleep improvements (even if they did not have initial sleep complaints) as early as the 15th neurofeedback session.

Dr. Jacobs ends the Part 4 with a brief mention of hemoencephalography (HEG).

Last, this video series is excellent resource for clinicians who want to provide patients with a trustworthy introduction to the neurofeedback process and its potential benefits.

Reference
Johnson, M. L., & Bodenhamer-Davis, E. (2009). Neurofeedback improves sleep: A time series analysis, poster presentation presented at the Association of Applied Psychophysiology and Biofeedback Conference, Albuquerque, NM.

The authors present a brief discussion of FMS – a pain disorder that involves musculoskeletal pain. It is noted that serum tryptophan, a precursor molecule to the production of serotonin, is found to be lower in persons with FMS. The authors further discuss the use of neurofeedback, also known as EEG-biofeedback, and selective serotonin reuptake inhibitors (SSRI) in the treatment of FMS. The authors hypothesize that neurofeedback training increases inhibitory processes in the central nervous system.

A number of pre- and post-assessments are utilized in this research study, including visual analog scales for pain and fatigue, Hamilton and Beck Depression And Anxiety Scales, Fibromyalgia Impact Questionnaire, and Short Form 36. These measures were completed at baseline and the 2nd, 4th, 8th, 16th, and 24th week in the study (pg. 293). Raters were blind to the participant’s assigned group.

Results on all measures reveal significant (p < .05) improvements for the neurofeedback and anti-depressant groups. On each assessment, the neurofeedback treatment results were significantly better than the group who received anti-depressants. Further, the authors point out that the significant decrease in the theta/SMR ratios in the neurofeedback group may show ".... a concrete finding concerning the neurofeedback treatment" (pg. 300).

I believe that this study adds to the badly needed published research on neurofeedback for pain disorders. I am hopeful these authors follow these patients and assess them at 6-month, 12-month, etc. intervals after treatment for both groups have been completed.

Alan T. Fisher, PhD

Reference
Kayiran, S., Dursun, E., Dursun, N., Ermutlu, N., & Karamursel, S. (2010). Neurofeedback intervention in fibromyalgia syndrome; a randomized, controlled, rater blind clinical trial. Applied Psychophysiology and Biofeedback, 35, 293-302.

Briefly, NPR summarizes neurofeedback, also known as EEG-biofeedback, as “expensive, time-consuming, and still unproved, but has growing evidence it can help.” NPR nonetheless provides a generally balanced and slightly favorable overview of the potential benefits of neurofeedback and presents it as a promising alternative treatment for children with ADHD.

Katherine Ellison explains how she and her son discovered neurofeedback, the process of a typical neurofeedback session, and the benefits gained from treatment. Additionally, parents receive excellent suggestions from Cynthia Kerson, executive director of the International Society for Neurofeedback and Research (ISNR), on how to best select a neurofeedback practitioner (included in the online article only).

Link / Audio Download
Train The Brain: Using Neurofeedback To Treat ADHD by Jon Hamilton.

Van den Bergh, a Belgium neuropsychiatrist, provides an expert review of pediatric ADHD and neurofeedback research, and he illuminates the sometimes complex neurophysiological deficits in ADHD. In addition, the author provides a detailed examination of the quantitative electroencephalographic (EEG / QEEG) characteristics of people with ADHD, as well as coverage of a broad range of psychophysiological topics that include LORETA (low resolution electromagnetic tomographic activity) brain imaging and slow cortical potentials (SCP) neurofeedback.

A major contribution of this new work, and possibly a ground-breaking one, is that Dr. Van den Bergh identifies a relationship among sleep-disturbance EEG research and ADHD pathology. This lead to the discovery that children with ADHD have brainwaves that are similar to healthy people who are sleep deprived. Think about that for a second, and the behaviors that typify ADHD become less mysterious. The author explains why SMR- (sensorimotor rhythm) neurofeedback is an effective and long-lasting non-medication treatment for ADHD given that SMR brain waves are the daytime equivalent of nighttime sleep spindles, which are disturbed in ADHD. In short, Dr. Van den Bergh argues that SMR-neurofeedback targets and corrects the core neurophysiologic problems in ADHD.

Throughout the book, Dr. Van den Bergh further argues that ADHD is not a disorder of “will-power,” or the desire to misbehave, as it is so often perceived by others, but instead represents a distinct neurological condition that should receive compassion instead of scorn from parents and teachers. The author also outlines steps that clinicians, parents, and teachers can take to improve the lives of those with ADHD, particularly children.

Discount Code: BMEDREPORT (use all caps and one word; 20% off plus free shipping; Offer Extended until 08/28/11). The discount code is valid only for direct purchases from the publisher, BMED Press.

Neurofeedback And State Regulation In ADHD: A Therapy Without Medication is also available worldwide from major online book retailers, including Amazon and Barnes and Noble.

Link / Reference
Van den Bergh, W. (2010). Neurofeedback and State Regulation in ADHD: A Therapy Without Medication. Texas: BMED Press.

Full Disclosure: Christopher Fisher, PhD, the Managing Editor of BMED Report, is also CEO of BMED Press.

Overview
Research continues to provide empirical support for NFT efficacy and effectiveness. Despite advances in the quantity and the quality of NFT research, a comprehensive literature review only found a handful of experimental investigations into practitioner variables. Building upon previous practitioner research (Rubi, 2006; Hammond & Kirk, 2008; Thompson & Thompson, 2008; Aguilar-Prinsloo & Lyle, 2010) and our findings of 237 concepts organized into 23 categories within five frameworks (Larson, Ryan, & Baerentzen, In Press), we developed a survey to investigate factors influencing practitioner outcomes. Research significance includes uncovering the influence of process variables on practitioner outcomes.

Take The 10-Minute Online Survey
Visit the survey at Survey Monkey.

The research team will donate $10.00 to the ISNR Research Fund for each completed survey.

Thanks in advance for your participation,

Jon Larson, Laury Drandorff, Tom Cothran, Ana Salvatierra, Kelly Ryan, & Bill Baerentzen
Illinois Institute of Technology, Chicago

References
Aguilar, S., and Lyle, R. (2010). Client perception of the neurofeedback experience: The untold perspective. Journal of Neurotherapy, 14, 55-60.

Hammond, D.C. (2007). Comprehensive Neurofeedback Bibliography. Journal of Neurotherapy, 11, 45-60.

Hammond, D.C., and Kirk, L. (2008). First, do no harm: Adverse effects and the need for practice standards in neurofeedback. Journal of Neurotherapy, 12, 79-88.

Larson, J.E., Ryan, C.B., & Baerentzen, M.B. (In Press). Practitioner Perspectives of Neurofeedback Therapy for Mental Health and Physiological Disorders. Journal of Neurotherapy.

Rubi, M.C.M., (2006). Neurofeedback around the world. Journal of Neurotherapy, 10, 63-73.

Thompson, M., and Thompson, L. (2008). Achieving excellence with your staff: A consultant staff training program in Selected Abstracts of Conference Presentation at the 2007 International Society for Neurofeedback Research (ISNR) 15th Annual Conference, San Diego, California. Journal of Neurotherapy, 12, 75.

Cynthia Kerson, executive director of the International Society for Neurofeedback and Research (ISNR), and Robert Coben, a neuropsychologist in Massapequa Park, N.Y., provide brief, but expert commentary on neurofeedback. Cynthia Kerson cautioned about the misuse of neurofeedback and its potential consequences, adding that consumers should avoid the urge to purchase equipment on websites like Ebay. Dr. Coben, widely known in the field for his excellent work with pediatric Autism, discusses a case study of a child with pervasive developmental disorder who experienced significantly improved symptoms following extended neurofeedback sessions.

New York Times writer, Katherine Ellison, notes that some skeptics, such as Russell A. Barkley, a professor of psychiatry at the Medical University of South Carolina, have “warmed-up” to neurofeedback in light of recent positive research findings, while others like William E. Pelham Jr., director of the Center for Children and Families at Florida International University, believe that neurofeedback is akin to “snake oil.” There are no surprises here given the long history of apprehension toward a treatment that has the potential to reshape the delivery of healthcare services. In all fairness, neurofeedback research conducted via the purported “gold standard,” at least to those in the medical field (double blind, randomized controlled studies), was virtually non-existent over the years, although even randomized, controlled studies are on the increase with positive results.

Last, Ms. Ellison mentions SmartBrain Technologies. This company’s technology was at the heart of a heated dispute at the recent 2010 ISNR annual conference in Denver, Colorado. The presentation of initial findings from Ohio State University researchers triggered a long line of open microphone protests from noted experts and researchers in the field along with concerned clinicians that carried out into the hallways for hours after the formal presentation ended. The primary concern generally centered on whether SmartBrain Technologies actually delivers results using its proprietary, yet relatively untested technology, and the potential significant negative impact that may result if the Ohio State study ultimately finds small or no symptom improvements using SmartBrain Technologies.

Quite frankly, it is difficult to understand why Ohio State researchers, and media for that matter, give SmartBrain Technologies this level of attention. The current focus at this critical stage in neurofeedback research should be on industry standard devices and treatment approaches. This does not mean that SmartBrain Technologies should be abandoned or unfairly discredited as it could very well be an excellent approach to treatment, but now is not the time to use experimental equipment in the few funded, randomized placebo controlled studies that are underway.

Reference
Neurofeedback Gains Popularity and Lab Attention by Katherine Ellison.

Briefly, “Neurofeedback And State Regulation In ADHD” is an advanced look at Attention Deficit Hyperactivity Disorder (ADHD) and neurofeedback (EEG-biofeedback). The book discusses a broad range of psychophysiological topics related to ADHD, including a history of neurofeedback protocols and important researchers, quantitative EEG (QEEG), LORETA (low resolution electromagnetic tomographic activity), and slow cortical potentials (SCP) neurofeedback. Dr. Van den Bergh also provides a masterful integration of sleep research and its relation to ADHD and arrives at sometimes startling conclusions. Be sure to take a look at full table of contents at BMED Press for an overview of the wide range of topics discussed in this book.

In the interest of full disclosure, Christopher Fisher, PhD, the Managing Editor of BMED Report, is also the CEO of BMED Press.

Editorial Note (04/27/11): The 20% offer has been extended until 08/31/11. Use discount code: BMEDREPORT (20% off plus free shipping).

Front / Back Covers

Front cover of Neurofeedback and State Regulation in ADHD: A Therapy Without Medication by Werner Van den Bergh, M.D.

Back cover of Neurofeedback and State Regulation in ADHD: A Therapy Without Medication Author by Werner Van den Bergh, M.D.

It begins with what he calls the QuickQ assessment, summed up here by Susan Olding, from her book “Pathologies:” “Desperate, determined, undeterred by cost or lack of insurance coverage, undismayed by the doubts of conventional physicians, undaunted by the practitioner’s Dickensian-sounding name, I switched off my cell phone at the threshold of Dr. Swingle’s office and carried my daughter across.

“I had brought a medical and developmental history – the long litany of concerns that had brought us to his door – but Dr. Swingle waved the papers aside without even looking at them. Instead, he ushered Maia toward a computer screen on the other side of the room and told her to put her feet on the stool below. Then he fixed a couple of delicate wires to her ears.

“Then Dr. Swingle sent Maia to the “treasure chest” in the waiting room. He stared at the printout in his hand. “Here,” he said, and he pointed to an outline of the brain, “these numbers imply trauma.” He shrugged, palms up, waiting for my response. I nodded. “And here,” he continued, “too much theta. This is the hyperactivity people associate with ADHD. But it’s minor. In the ballpark I play in, she barely makes the field.” There was more: extreme stubbornness, a tendency to perseverate, lapses of short-term memory, attachment disorder, inability to read social cues, emotional reactivity, tantrums, explosions. One by one he read the ratios, divining my daughter’s character – more quickly, more accurately than any professional I’d yet encountered.”

After the assessment, the neurotherapy begins. Neurotherapy assists the client in changing his or her brainwave architecture. From the amplitude and position of brainwave bands Dr. Swingle develops a therapy schedule that will assist the client in regaining control and getting back on track with life.

Dr. Swingle stated, “Our approach differs a little bit from some of the standard methods that are used. The first thing that we do is to do a brain assessment to see what condition the brain is in before we start to do any optimal performance training.”

ISNR – Denver – Wednesday, September 29, 2010
Dr. Swingle will present a Pre-Conference workshop at the ISNR Conference in Denver. This workshop introduces the QuickQ and Braindryvr methods. Methods for probing the client based on comparisons with the QuickQ clinical database are reviewed and many cases are studied to help participants learn how to capably use this remarkably efficient intake procedure. The details associated with selecting appropriate unconditioned stimuli for braindriving are reviewed and the methods for administering the less complex Braindryvr protocols are shown. Unique concerns regarding treating clients with severe emotional trauma, chronic depression and those who are heavily medicated are reviewed.

BST – Houston – October 15-17, 2010
In his keynote address “Biofeedback for the Brain” to be presented at the Biofeedback Society of Texas 36th Annual Conference, Dr. Swingle will introduce the wide range of disorders treated at his clinic in Vancouver, Canada. Dr. Swingle reviews in detail the initial brain assessments and treatment procedures for a wide spectrum of disorders including seizures, autistic spectrum disorders, attention and learning disorders, defiance disorders, as well as developmental delay, traumatic brain injury and other trauma.

He will also present a 6-hour workshop “Basics of the QuickQ Assessment and Braindriving” for anyone interested in further exploring this neurotherapy method.

IFEN – Munich – February 18-20, 2010
Next he travels to Germany for his first workshop in Europe. The 3-day workshop in Munich is hosted by the Institut für EEG-Neurofeedback.

BFE – Munich – February 22-26, 2010
His final stop in Munich is in February 2011, where he will be presenting at the Biofeedback Foundation of Europe’s 15th Annual Meeting. In the meantime, interested healthcare professionals are invited to learn more about Braindriving from the comfort of their home or office by attending one of Dr. Swingle’s online webinars.

Material adapted from PRWeb.

The scientists were interested in the signals generated by the insula, a brain region implicated in emotion regulation. While performing the test, the investigators provided the subjects with specific, unspecific, or no feedback about the extent of the activation of the insula.

They found that the individuals who received specific feedback were able to successfully increase the activity of the insula and perceived the negative pictures as being more unpleasant. The reverse was also true (i.e., a reduced sensitivity to negative stimuli was observed when the insula’s level of activity was decreased).

The two other groups, who received unspecific or no feedback, were not able to enhance insula activity and showed no changes in subjective emotional responses.

The lead author, Dr. Andrea Caria, commented, “Our study demonstrates that voluntary control of emotionally important brain systems is possible. More importantly, after learning to voluntarily regulate the insula, the participants experienced emotionally negative material as more aversive than before training. This means that individuals can modify their perception to aversive stimuli.”

“This technique may provide a mechanism to obtain some measure of voluntary control over the activity of particular brain regions, and thus mental processes, that are typically beyond our reach. It may open new avenues for cognitive and behavioral therapies,” added Dr. John Krystal, Editor of Biological Psychiatry.

The authors agree, noting that their findings may be relevant for the development of novel approaches for the clinical treatment of emotional disorders such as antisocial behavior or social phobia which have shown hypoactivity and overactivity, respectively, in the insular region. However, more research is necessary before such treatments may become available.

Material adapted from Elsevier.

In a follow-up investigation, a representative at the PracticeWise Evidence-Based Services (PWEBS) Database service (i.e., provided the research evidence to AAP) stated that the Level 2 recommendations apply only to EMG-biofeedback. Although PWEBS did not provide specific references to BMED Report, they stated that these evidence-based recommendations were established using two controlled studies from the early 1980′s.

Practitioners of neurofeedback will surely be disappointed with this announcement. However, it is vital that other scientists and the general public receive accurate statements about neurofeedback treatment efficacy. Erroneous public claims will only damage the credibility of future genuinely positive research findings.

On a side note, I wonder why PWEBS did not consider more recent studies of EEG-biofeedback for ADHD?

I am very interested to hear what others think about this topic. I encourage health-care practitioners who want to post comments at BMED Report to please contact me to have a quick and free subscriber account set-up.

The recommendations are published for the period of April 2010 to September 2010 using the PracticeWise Evidence-Based Services (PWEBS) Database.

The PWEBS rates psychosocial treatments, such as Cognitive Behavioral Therapy (CBT), assertiveness training, family therapy, and exercise, for numerous pediatric disorders based on a classification scheme that ranges from Level 1 (“Best Support”) to Level 5 (“No Support”). A Level 2 classification for biofeedback means “Good Support.”

There is debate in professional circles as to what “biofeedback” actually means since there are many different forms of biofeedback, such as EEG, EMG, and HRV. Given the increased positive outcomes of neurofeedback for ADHD reported in published research, EEG-biofeedback, or “neurofeedback,” is the likely primary contributor to the Level 2 classification; however, this cannot be confirmed at the present time.

Download
Visit The American Academy Of Pediatrics to download the Evidence-Based Child and Adolescent Psychosocial Interventions.

Schoomaker explained that with the increasing numbers of Soldiers returning from combat with severe wounds, reports of medication abuse and suicides with pain as a possible factor are troubling.

“While these issues might not be directly related to pain management, I felt a thorough evaluation and assessment of current pain-management practice was indicated,” Schoomaker said.

He said part of the problem is that severely injured Soldiers, like those in Warrior Transition Units, are often prescribed multiple medications and sometimes seen by several different doctors, which can cause inconsistencies in care. But he maintained that this is not just an Army problem – it is a problem throughout the U.S. healthcare system.

“This is a nation-wide problem … we’ve got a culture of ‘a pill for every ill,’” agreed Brig. Gen. Richard W. Thomas, assistant Army surgeon general.

“As a physician, the hardest thing to deal with is patients with chronic pain,” said Col. Jonathan H. Jaffin, director of heath policy and services, Army office of the surgeon general. “So many of us went into medicine to relieve suffering, and chronic pain is frustrating because we want to relieve that pain.”

The task force visited 28 military, Veterans Affairs and civilian medical centers between October and January to observe treatment capabilities and best practices. Schoomaker’s said his goal is to form a pain-management strategy that is holistic, multidisciplinary, and puts Soldiers’ quality of life first.

“This is an opportunity to change medical care and the way we take care of patients,” noted Thomas.

Schoomaker stressed that Army practices have always been in compliance with America’s medical regulations, but he thinks the Army can do better.

“Everything we do in the Army, even managing a toothache, is all in compliance with national standards … what we want to do is set the bar higher,” Schoomaker explained.

Schoomaker’s higher standards include offering treatment alternatives that might not yet be prescribed in average doctor’s offices, but which patients are already seeking out on their own, such as acupuncture. He said the Army has looked at research on the effectiveness of complementary techniques, and he would like to see them integrated into traditional medical treatment.

“Programs such as biofeedback and yoga have been subjected to scientific randomized trials and have been proven to be effective,” Schoomaker said.

Biofeedback involves measuring body signals — such as temperature, heart rate, muscle tension and brain waves — to help patients with relaxation techniques and pain reduction.

Schoomaker said he is hopeful that Soldiers will be receptive to alternative methods of care once they see that the treatments work.

“Seeing success is the best way to convince people of the usefulness and the need for other approaches,” agreed Jaffin.

The 109 recommendations are divided into four areas: to provide tools and infrastructure that support pain management, build a full spectrum of best practices, focus on Soldiers and families, and synchronize a culture of pain awareness, education and intervention.

Schoomaker said the recommendations that can be put into policy under his authority will be implemented in the coming months, and the 2010 National Defense Authorization Act asks the secretary of defense to integrate a pain-management policy into the military health-care system no later than March 2011.

Material adapted from the United States Army.

First, chronic pain is related to the supraspinal nervous system activity (ie. Thalamus, Insula, Sensory Cortices, Anterior Cingulate, and Prefrontal Cortex). Second, studies support that self-hypnosis has direct effects on the supraspinal sites. Third, self-hypnosis is effective in decreasing the severity of pain.

Also of interest, brief information on EEG brain activity associated with hypnosis is discussed. Specifically, beta activity (faster brainwaves) tends to decrease, while alpha activity (mixed slow and mid-range brainwaves) shows increases. Neurofeedback research substantiates that individuals can learn to alter their brainwaves; hence it is likely that an individual may be able to create a “hypnotic-like” state through neurofeedback training to enhance response to hypnotic suggestions.

The author discusses three possible ways to enhance the effectiveness of self-hypnosis that includes:

• “using virtual reality hypnosis,
• combining hypnosis with EEG-biofeedback (neurofeedback) training, and
• providing self-hypnosis training much earlier in the course of the development of a chronic pain problem.” (pg. 236)

Readers interested to read more on chronic pain management and neurofeedback/hypnosis are referred the to the October – December, 2009 issue of the Journal of Neurotherapy (p. 196-213) for another article by Mark P. Jensen, Ph.D., et. al.

Alan T. Fisher, Ph.D.

Reference
Jensen, M. (2009). Hypnosis for chronic pain management: A new hope. Pain, 146 (3, 5), 235-237.

Some have worried that multivariable training with LZT is too complex for the trainee to comprehend.  Quite the contrary.  During the training, the subject is simply watching a DVD or animation, or playing a game, or listening to music or sounds.  The complex protocol calculations still control all feedback as if there were just another training variable.  The trainee experience can be whatever is conventional or familiar, relative to the “signaling” method.   The brain readily seizes on information that relates to a well-targeted state, regardless of the metrics underlying the state.  The fact that we can ride a bicycle demonstrates that we can readily integrate millions of bits of information into a cohesive whole, combined with the mind and body responses, and that it can become effortless.  The more comprehensive the information, the more likely the brain is to understand and interpret it.  And this is a brain process, not a conscious mental process.

This is not unlike the difference between simple muscle fitness training, versus a more comprehensive activity like dance or athletics.  When applied in a comprehensive whole-head training approach, live Z-scores transform neurofeedback into an entirely different kind of experience for the brain’s self-regulatory mechanisms.  Nonetheless, the trainee continues to watch movies, play simple games, listen to music, as before, and by allowing the training to occur, lets their brain learn a new and profound new set of activations and connections.

Currently, we encourage the majority of our users to use the comprehensive MVP method that incorporates all available Z-scores into a single metric.  We have enhanced it to include selective training functions, such as training only a specific metric (absolute power, relative power, etc), or training a certain class of metrics (“all connectivity metrics”).   In addition, we have included the ability to use different upper and lower limits.  This was necessitated by the experience with a man who had excessive amplitudes overall, reaching the level of 2-3 standard deviations in the dynamic scores.  When a window of + or – 3 standard deviations was used for training, the trainee’s EEG quickly changed to a very low amplitude EEG, and overshot the goal of zero.  Therefore, we offered the ability to provide different limits, and the trainee was trained using limits of +3 and -1 standard deviations.  This allowed effective feedback, while not rewarding the trainee for going too low.

Using a comprehensive approach, it also becomes possible to address the issue of normalization training versus peak-performance or mental-fitness training.  Based upon our experience with various peak-performers, we have identified certain combinations of features that are unique to them.  We also have subjective reporting data on individuals who undergo Z-score training, and who exhibit one or more of these characteristics.  Certain characteristics are generally identifiable as “good” and which reflect optimal functioning for that individual (but not necessarily all individuals).  Other characteristics may be observed, that are concordant with “complaints,” which might include issues with attention, mood, and so on (Collura et al., 2008).

The following figure shows an example of a display used in this approach.  Despite the complexity of the underlying computations, the display and its interpretation are relatively simple.  The system derives a metric which reflects a comprehensive analysis of all of the Z-scores, or a subset thereof.  The metric becomes the training variable, thus replacing the conventional amplitude or connectivity-based metric, and is significantly more comprehensive than a single Z-score.

The interpretation of the overall success rate is identical to that in any operant conditioning paradigm, and reflects the aggregate reward being experienced by the user.  The variables that can be adjusted to control feedback are the target size and the performance score required for the derived metric.  In the example shown, the required score is 70.0 percent, and the trainee is achieving this goal 50.4 percent of the time, on average.

Figure 2 (click to enlarge): Typical indicator screen used with a Multivariate Proportional (MVP) training protocol. Top: white: MVP training parameter; green: MVP target percentage threshold (70%), red: cumulative percent time above threshold (50.4%). Middle: size of target in standard deviations (1.2), Bottom: event flag indicating the times when the MVP parameter is above threshold.

One benefit of MVP-based protocols is that they can be biased for peak performance.  For example, among the attributes that may be selected for enhancement are global alpha coherence, resting motor strip SMR, reduced low-frequency coherence, or other variables.  These protocols thus combine the concept of brain normalization with that of brain optimization.

We refer to the example case presented by Mark Smith (April issue).  In this case, we have three NeuroGuide QEEG coherence maps obtained from a full 19-channel EEG assessment.  The first map shows the trainee at an early stage in this training experience.  Considerable coherence abnormalities (hypocoherences) are evident.  The second map shows the effects of conventional targeted coherence training, using the following plan:

1. Increase coherence of beta at F4/C4 to decrease seizures. (5 sessions)
2. Increase coherence of delta at P3/T5 to decrease seizures. (5 sessions)
3. Increase coherence of delta at F7/F8 to decrease seizures. (5 sessions)
4. Increase coherence of beta at C4/F8 to decrease seizures. (5 sessions)

The effects of the training are evident.  The targeted coherences have indeed moved toward normalization.  However, many coherences that were not targeted have changed, and not for the better.  Furthermore, delta coherences have become significantly worse.  This demonstrates the potential hazards of targeting single coherence measures along single connectivity paths.  The third (right) map shows the result after several sessions of z-score targeted coherence training.  It is evident that the z-score approach is indeed capable of targeting and normalizing coherences, leading to whole-brain normalization.

Figure 3 (click to enlarge): NeuroGuide coherence maps of case of Jack (Smith, April issue) showing High Beta (top) and Delta (bottom) coherences before training (left), after a conventionally targeted coherence training regimen (middle), and after z-score training (right).

These advanced z-score training methods are implemented in software, and are applied “on top” of the basic live Z-score software that is built into the ANI DLL.  This software is itself written in the form of a library, which can become available to other system developers who wish to incorporate this new form of training.

As an example of the ability to multivariate Z-Scores to resolve complex situations, the following pre- and post-treatment QEEGs are taken from a case that required only 23 sessions to produce the changes shown by Lambos and Stark (Collura et. al. 2008).  The trainee was a 12 year-old boy with problems related to impulsivity, behavior, discipline, and hyperactivity.  In amplitudes, he had abnormally high slow frontal activity, abnormally low fast frontal activity, and occipital abnormalities in delta and alpha.  These also manifested as many significantly abnormal asymmetries.  In addition, there was hypercoherence in essentially all frequency bands, and particularly at the very low and very high frequencies.

By using an MVP protocol, the clinicians were able to remediate essentially all of these abnormalities in 23 sessions, as shown on the QEEG.  Interestingly, one small emerging abnormality appears in the form of left frontal beta and high beta.  If anything, this slightly excessive activation of the left frontal lobe might reflect a benefit, which would be a brightening effect on the trainee’s mood.  These results are taken from the eyes-open condition, which was the training condition.  A different set of changes, also related to normalization of the EEG, was observed in the eyes-closed condition, indicating that the brain was learning self-regulation for both conditions, despite being trained with eyes-open only.

Figure 4 (click to enlarge): Pre- and Post-treatment NeuroGuide QEEG maps (eyes open) showing effects of 23 sessions of 4-channel Multivariate Proportional live Z-Score training.

Summary
The use of Z-Scores in itself is an important addition to neurofeedback, but it does not provide an “automatic” solution in and of itself.  It is not necessarily applicable to every trainee, and the idea of training everyone “to the norm” is not universally applicable.  It is necessary to understand and interpret the brain dynamics of the trainee, determine which types of normalization are appropriate, and design and use protocols that are suited to the case at hand.  In general, simply using a Z-Score as a target is not sufficient to produce normalization.  In many situations, it will be important to have a whole-head QEEG type of analysis for planning and interpretation of the LZT training.  It is also important to wisely use multiple channels and multiple targets, in order to give the brain the information it needs to achieve comprehensive improvements in self-regulation.

Thomas F. Collura, Ph.D.

Members of the International Society for Neurofeedback and Research (ISNR) receive NeuroConnections as a free benefit of membership. Healthcare professionals who specialize in neurofeedback, biofeedback or QEEG are encouraged to join ISNR to receive the full edition (in a full color printed format) of NeuroConnections and other member benefits. The above article was reprinted from NeuroConnections with permission from ISNR.

References:
Collura, T.F., Thatcher, R.W., Smith, M.L., Stark, C.R., and Lambos, W.A. (2008) Real-Time EEG Z-Score Training – Realities and Prospects, in: Evans, J., Arbanel, and Budzynsky, T., and Budzynski, H., Quantitative EEG and Neurofeedback, 2^nd Edition, Elsevier, in press.

Smith, M.L., (2008) Case Study – Jack, NeuroConnections, April issue

Stark, C. R. (2008) Consistent Dynamic Z-Score Patterns Observed During Z-Score Training Sessions—Robust Among Several Clients And Through Time For Each Client, NeuroConnections, April issue.

Thatcher, R., (2008) Z Score EEG Biofeedback: Conceptual Foundations. NeuroConnections, April issue

Walker, J.E.,  Kozlowski, G.P., and Lawson, R. (2007) A Modular Activation/Coherence Approach to Evaluating Clinical/QEEG Correlation and for Guiding Neurofeedback Training: Modular Insufficiencies, Modular Excesses, Disconnections, and Hyperconnections, Journal of Neurotherapy, 11(1) 25-44.

Acknowledgment:
The author wishes to thank Michael L. Smith for helpful comments and input on this article.

Disclaimer:
The author has a financial interest in BrainMaster Technologies, Inc. The advanced multivariate targeting method described herein is patent pending in the US, Canada, and Europe

Dr. Kirsch writes:
The Journal of Neurotherapy (JN) is seeking articles on neurotherapies used for soldiers and veterans. This population is in dire need of help and we can provide it but we need to organize data to establish proof of efficacy. If you see any patients for these or related diagnoses, please consider contributing to this special issue of the JN.

Articles should relate to neurotherapy theories and practice and may consist of original research, reviews, individual case reviews or case series and tutorials. Non-military uses of neurotherapies for these disorders are also welcomed, such as PTSD in civilian populations, EMTs, police and veterans. Potential contributors are welcome to contact Dr. Dan Kirsch, special editor for this issue of the JN which will be 14(4).

Please feel free to look at our submission guidelines HERE prior to submitting manuscripts. Submissions are due May 30, 2010.

We look forward to hearing from you.

Sincerely,

Daniel L. Kirsch, PhD, DAAPM, FAIS
d…@epii.com (click to verify and reveal email)
Direct: (817) 458-3280

We have been doing live Z-score training (LZT) with 1, 2, and 4 channels, since April, 2006.  Our initial implementation gave access to any of the possible Z-scores, through a general, flexible mechanism, called the “Event Wizard.”  This was used to construct basic protocols using single Z-scores, Z-score range training, and combined Z-score training such as “all coherences normal.” From there, we moved to “range trainin,” in which one or more Z-scores can be trained within a range.  These provided important starting points for clinical work, which then motivated additional developments.

The LZT DLL (Thatcher, this issue) that underlies this approach provides Z-scores for 6 important metrics: absolute power, relative power, power ratios for each channel, and coherence, phase, and asymmetry for each pair.  Thus, 1 channel of EEG provides 26 Z-scores, 2 channels provide 76 Z-scores, and 4 channels provide 248 Z-scores.  As we shall see, the use of 4 channels is a significant advancement, as it provides data on 6 simultaneous interconnectivity paths, not just 1, and thus provides a gateway to whole-brain training.

The simple LZT training worked well.  By adding the ability to specifically target connectivity measures, clinical benefits were observed (Smith, 2008).  In addition, we realized that additional power in the design of complex protocols would be of great value.  For example, training a single parameter from a single component band is effective, but may not be optimal.  Training all component bands in a given metric ensures a more comprehensive training for purposes of local neuronal activation or relaxation.  Similarly, when more than 1 channel of EEG is available, it is beneficial to incorporate all channels into the training, to provide greater coverage and specificity, and to address connectivity.  Multiple connectivity training is a significant capability of live Z-Score training, and may be its greatest strength.

Regardless of the number of channels used or the Z-score training strategy, feedback has generally consisted of animations, DVDs, games, sounds, music, and other typical displays.  The trainees are not necessarily aware that they are using an entirely new form of training.  They are only aware of the brain states into which they are being guided.

The combination of proper QEEG methods, along with a well-planned neurofeedback program of protocols based upon live Z-scores, can provide an accelerated and highly targetable regimen.

Jonathan Walker has emphasized the delicate nature of coherence training and the dangers inherent in overtraining any particular coherence.  Z-scores provide an important relief of this concern, by ensuring that coherence targets are appropriate for the individual.  We have found that, consistent with Walker’s observations, it is generally difficult to normalize connectivity of the brain.  Moreover, it is possible to cause abreactions of various types, whenever attempts are made to alter the coherence of one particular band in one particular direction.

An example of the importance of Z-scores connectivity training is presented by Smith (this issue).  As experienced in this study, a single coherence between two sites was targeted for traditional neurofeedback coherence training. The band of interest was effectively altered.  However, as that coherence normalized, other coherences in the brain became abnormal.  Even without the trained connection moving toward hypocoherence, the rest of the brain had maladapted to the training.

When I presented this to a former physics professor who had pioneered neural network research, he replied, “I am not aware of any conservation principle that would dictate a response like this.”  So that got us to thinking about how and why the brain would respond in this way to the information being fed back. The brain, like any dynamical system, will seek the minimum-energy pathway to satisfy external and internal constraints.  Indeed, one may posit a model of “brain hydraulics” in which various constraints are at work.  These may variously be regarded as tendencies or pressures, which give rise to the flow of information and control, thus reflecting the cybernetic activity of the brain.

Robert Thatcher has proposed a predator-prey model that describes the mediation between short-range connections and long-range connections in the brain.  According to his model, each neuron has a limited resource of inputs and outputs, which it must allocate between the various connections available, including both short-range and long-range connections.  As the brain trades off between these connections, changes in coherence and phase metrics will reflect this dynamic reorganization.

Therefore, it is reasonable to set forth a brain model in which the response to neurofeedback training is in the form of a variety of adjustments which, through learning, tend to have a lasting nature.  In the case of amplitude-based training, changes take the form of changes in cortical relaxation produced by alternating the strength of individual inhibitory connections, thus modulating cortical excitability, and thalamocortical cycling tendencies, for the affected cortical locations and pathways.  Other metrics are more related to connectivity, such as coherence and phase, and the changes they introduce are different in nature.  They include the structured rearrangement of the neuronal connection strengths, in order to comply with the training conditions.

When the conditions are limited, then the brain’s response may be similarly limited.

This does not mean that the training effect is limited to the training area.  Quite the contrary.  Both beneficial as well as adverse responses may occur.  Thalamic pathways, as well as various cortical interconnections are involved.  Stark (2008) has used Z-scores extensively, and has learned to see patterns and time-dependent shifts in the full complement of Z-scores.  He often sees phase as a primary adjuster, then wave of re-organization.

A single z score is just a target re-implemented.  Especially in cases of connectivity metrics, it provides a valuable aid to determining and using target values.  It can also be useful when used in a ranged fashion (high and low thresholds), to train within a range.  However, as we see it, targeting a single connectivity metric, although it may be trained within a normal range, can cause other reactions in the brain, which are not necessarily beneficial.

We therefore believe it is important to use multiple channels with Z-scores, and to use the information effectively.  A minimum of 2 channels are needed in order to see the pathway between them, and compute coherence, phase, and asymmetry metrics.  But when 4 channels are used, the number of connections is 6, which is significantly more information.

Four channels are sufficient to ensure coverage of the basic interconnections in a given training paradigm.  Examples of typical arrangements include F3-F4-P3-P4 and C3-C4-Fz-Pz.  With a MINI-Q, it is possible to define predefined layouts of 4 channels that emphasize different brain connections and activities.  Furthermore, these predefined “quads” can be used for assessment as well as training, providing a unified approach to whole-brain work.

In the case of F3-F4-P3-P4, for example, we have not only 4 important brain sites, but also 6 important connection pathways.  This 4-channel montage allows us to monitor both the left and right frontal areas, and the left and right posterior areas.  It also provides information relating to left intra-hemispheric function (language), right intra-hemispheric function (spatial, etc), frontal inter-hemispheric function (attention, planning), and posterior inter-hemispheric function (sensation, perception).  This is a very simple, yet comprehensive way to gain access to EEG information for training purposes.

The following figure shows an example of a 4-channel Z-score display from the system.  Our software automatically compiles, displays, and computes complex training statistics based on all of the available scores.  There are a total of 248 Z-scores available.  The indicated Z-scores are dynamically color-coded in a manner that makes it easy to spot deviations.  The power-based Z-scores are clustered at the top of the display, and the connectivity metrics are shown at bottom.

Figure 1 (click to enlarge): Typical multivariate Z-Score display using 4 channels, providing 248 Z scores. The sensors happen to be placed at O1, Pz, T4, and P4.

It is not possible to understand the dynamics of brain response by watching a single Z-Score, or even a small number of Z-Scores.  It is necessary to simultaneously monitor the full range of variables in a suitable number of sites, in order to observe the dynamical brain processes (Stark, 2008).  To relieve these concerns, it is necessary to implement a comprehensive brain training method.  This method needs to simultaneously address issues of activation and relaxation, connectivity in the form of communication and control, and relative activation

To this end, we have designed a series of advanced multichannel, multivariate training methods, which are collectively described as “Multivariate Proportional,” or “MVP”.  These are comprised of algorithms that automatically incorporate all of the available Z-scores for all channels acquired, and compute continuous output values that are in essence figures of merit for the Z-score set.  The MVP score is thus truly a complex measure of “how normal” the EEG is, when accounting for all available information.

This article is the first in a 2-part series that explains the theory behind the use of Z-score training with multiple sites. Look for a practical description of training protocols based upon this [at The Behavioral Medicine Report in March].

Thomas F. Collura, Ph.D.

Editorial Note: You now find Part 2 of this series here.

Members of the International Society for Neurofeedback and Research (ISNR) receive NeuroConnections as a free benefit of membership. Healthcare professionals who specialize in neurofeedback, biofeedback or QEEG are encouraged to join ISNR to receive the full edition (in a full color printed format) of NeuroConnections and other member benefits. The above article was reprinted from NeuroConnections with permission from ISNR.

References:
Collura, T.F., Thatcher, R.W., Smith, M.L., Stark, C.R., and Lambos, W.A. (2008) Real-Time EEG Z-Score Training – Realities and Prospects, in: Evans, J., Arbanel, and Budzynsky, T., and Budzynski, H., Quantitative EEG and Neurofeedback, 2^nd Edition, Elsevier, in press.

Smith, M.L., (2008) Case Study – Jack, NeuroConnections, April.

Stark, C. R. (2008) Consistent Dynamic Z-Score Patterns Observed During Z-Score Training Sessions—Robust Among Several Clients And Through Time For Each Client, NeuroConnections, April.

Thatcher, R., (2008) Z Score EEG Biofeedback: Conceptual Foundations. NeuroConnections, April.

Walker, J.E.,  Kozlowski, G.P., and Lawson, R. (2007) A Modular Activation/Coherence Approach to Evaluating Clinical/QEEG Correlation and for Guiding Neurofeedback Training: Modular Insufficiencies, Modular Excesses, Disconnections, and Hyperconnections, Journal of Neurotherapy, 11(1) 25-44.

Acknowledgement:
The author wishes to thank Michael L. Smith for helpful comments and input on this article.

Disclaimer:
The author has a financial interest in BrainMaster Technologies, Inc. The advanced multivariate targeting method described herein is patent pending in the US, Canada, and Europe

Introduction/Background
Migraine is a common, disabling and often progressive disorder characterized by increased excitability of the central nervous system [1, 2]. It occurs in 18% of women and 6% of men in the US with peak prevalence in individuals between the ages of 25 and 55 [3]. Economic burden of migraine in the US is estimated to be approximately 13 billion annually [4]. Biofeedback is a common intervention in pain management. For migraine treatment, the most frequently used biofeedback methods have been peripheral skin temperature biofeedback, blood-volume-pulse and electromyography feedback [5].

Neurotherapy is a broad term referring to the many types of biofeedback used to deliver information about the central nervous system which involve blood flow, thermal output from the brain or electrical activity. Neurofeedback (also called neurobiofeedback or EEG biofeedback) usually refers to frequency-based biofeedback that uses an EEG to give clients information about their brainwaves and gradually and subtly teaches people how to alter their brainwave activity. Sensors are attached to the scalp and the raw EEG signal is amplified, the frequency spectrum is extracted via a Fourier transform and selected frequency components are displayed through a user interface such as a video game. Unlike peripheral biofeedback that monitors the status of peripheral aspects of the sympathetic and parasympathetic nervous systems (e.g. respiration, galvanic skin response), neurofeedback monitors central nervous system activity.

Abnormalities in electrophysiological activity have commonly been found in the brains of migraine patients [16-21], therefore it is plausible that interventions involving the EEG might be of benefit [16]. Children afflicted with migraine, those with and without aura, demonstrate increased theta frequencies compared to normal controls [17]. One popular neurofeedback protocol for migraine emphasizes protocols rewarding 12-15 HZ at the temporal lobes at sites T3 and T4 [22]. Siniatchkin and colleagues demonstrated a significant reduction in migraines in 10 young migraineurs after 10 sessions of neurofeedback at midline frontal and central areas teaching them to control slow cortical potential activity representing cortical sensitivity and reactivity [7]. Michael Tansey enabled four migraineurs to eliminate their migraines after neurofeedback training along midline frontal and central areas which showed that low frequencies became less dominant and higher frequencies were augmented [8]. An older study found that thermal biofeedback was no more effective than EEG alpha biofeedback and self hypnosis in treating migraine [9]

Neurofeedback training also includes a newer method called hemoencephalography, which targets the frontal lobe [23]. Passive infrared hemoencephalography (pIR HEG) is a form of biofeedback for the brain that measures and feeds back information on the thermal output of the frontal lobe [10,23]. Unlike electromyographic (EMG) feedback which involves lowering the tension of the frontalis or trapezius muscles, pIR HEG involves increasing the forehead temperature by watching a movie for feedback. The movie is in operation when the measured forehead temperature rises and the movie stops when the temperature drops. The therapist will increase the threshold as the client learns how to raise their forehead temperature. Clients are instructed to calmly concentrate on making the movie continue to play. Increases in the pIR HEG signal reflect a composite of thermal activity generated by vascular supply, vascular return and brain cell activity. 100 International Headache Society (IHS)-diagnosed migraineurs reduced the frequency of their headaches using this form of biofeedback [10, 24,25].

Methods
This is a single group outcome, open label study in a clinical setting where both the patients and those administering treatment were aware of the treatment being given. Patients were given Informed Consent for biofeedback methods administered as well as Informed Consent to Research as put forth by the lead author’s ethics committee of the American Psychological Association and the Association of Applied Psychophysiology and Biofeedback.

Participants
The total sample included 37 migraine patients (29 females and 8 males). Ages ranged from 9 to 79, with the majority (56%) between the ages of 16 and 52, and the remainder evenly split between the younger group (22% were between 9 and 15) and the older group (22% were between 55 and 79). In terms of medical history, most patients had long, stable histories of migraine and had tried multiple pharmaceutical treatments prior to neurotherapy. All were having at least one migraine per month and taking at least one type of medication (preventive, abortive or rescue) for their migraines and were not required to discontinue these during the study (See Table 1).

Table 1 (click to enlarge). Number of patients on each type of migraine medication

Initial Assessments
A personal and family headache history was taken at initial evaluation and a diagnostic interview was performed by a licensed psychologist to confirm the IHS-diagnosis of migraine with or without aura and to assess other symptoms and conditions. For patients who did not have at least two weeks of headache diaries, they were asked to wait two weeks to begin treatment in order to keep a baseline daily diary to record headache frequency and severity. At the first session and every 10 sessions thereafter, clients were asked to complete a non-standardized checklist to indicate changes in headaches as well as other symptoms (e.g., anxiety, insomnia, other pain types, depression, and behavioral problems).

Follow up data collection
The data reported in this study were collected 3 months to 2 years after patients stopped coming to the neurotherapy center, either because they had completed the recommended number of  treatment sessions or because they discontinued treatment on their own.  The data were collected through follow-up telephone surveys conducted by a research consulting firm not affiliated with The Better Brain Center.

Treatment Protocol

neurofeedback
The study involved treatment using EEG biofeedback, pIR HEG biofeedback and hand warming biofeedback for an average total of 40 sessions. Average length of time in treatment was 6 months. Subjects underwent an average of 30 frequency-based neurofeedback sessions and 10 pIR HEG sessions for 30 minutes at least twice weekly. Eleven patients had an interruption in their treatment after the initial 20 sessions of up to several weeks but returned for their remaining sessions.  Previously recorded baseline EEG measures were used to guide neurofeedback training protocols by targeting frequency ranges with the highest amplitude. All migraine patients were trained to reduce the amplitude of the targeted frequencies. The EEG training primarily occurred at 5 sets of homologous sites (T3-T4, C3-C4, F3-F4, FP1-FP2 and P3-P4). These homologous sites were chosen according to the lead author’s training in neurofeedback in which years of clinical experience in treating migraines by other experienced clinicians is taught [22].  Electrode placements at homologous sites were used and training always began as a single channel placement using the first site as the signal and the second site as reference (example: T3-T4).

pIR HEG biofeedback
For most patients 30 minutes of pIR HEG biofeedback was introduced at approximately their tenth visit. This involved the patients wearing a headset which is designed to be worn at FPZ (center of forehead) and watching a movie and being challenged to keep the movie playing as the reward threshold was re-set to higher temperatures.

thermal hand warming
Thermal hand warming biofeedback was also used simultaneously along with the EEG biofeedback during clinic sessions.

Please review the original article for a more detailed explanation for treatment rationale, neurofeedback/pIR HEG/biofeedback protocol, and reward/inhibit criteria.

Results
Table 2 shows the age and gender of everyone in the full sample and the pre-treatment and post-treatment migraine frequency estimates. The estimates are based on participant reports of the average number of migraines they experienced per month in the 6 months prior to treatment, and the 6 months immediately preceding the follow-up telephone survey.

The small number of participants (n=7) who had completed treatment only 1 to 5 months before the follow-up interview, reported migraine frequency for this shorter post-treatment time period. The pretreatment mean frequency was 7.6 migraines per month (S.D = 5.1) the post-treatment mean was 2.9 migraines per month (S.D=2.8), and the mean difference was 4.72 (S.D.=4,32) few migraines per month. The standardized effect size (derived by dividing the mean difference score by the standard deviation of the difference scores) is 1.09, an effect size considered in the literature to be very large. Since many migraine studies include only those who experience 2 to 14 migraines per month we also calculated effect size eliminating the 5 patients with 15 to 20 migraines/month and the 4 who experienced only one per month. This produced and even larger effect size: 1.23. We next added in 3 “dummy” cases showing no change to address concerns that those who fail to complete the minimum number of sessions (the minimum was 20, most had at least 40) might have been non-responders. This effort to approximate an “ intention to treat” analysis, assuming a 10% non-completer rate, reduced the 1.23 effect size in the restricted , 2 to 14 migraine sample, to 1.00, still a very large effect size.

Table 2 (click to enlarge). Sample characteristics and average number of migraines per month pre- and post-treatment

For each individual we also calculated the percent reduction in migraine frequency by dividing the difference between that individual’s pre- and post-treatment migraine frequency estimates by the average number of pre-treatment migraines they experienced. As illustrated in Figure 1, 70% of the sample (or 26/37) showed a 50% or greater reduction in the frequency of their migraines, and only 16% (or 6/37) failed to improve at all.

The significance of the observed changes was examined using the Wilcoxon signed ranks test, a non-parametric alternative to the t-test for small sample studies where the dependent variable is not normally distributed. In the Wilcoxon signed ranks test the differences between pre- and post-treatment scores are rank ordered, and the significance test is based on ranks, eliminating the potential biasing effects of large, spurious differences in either direction. If the treatment has no effect the sum of the ranks where the difference is positive should be nearly equal to the sum of the ranks where the difference is negative.

Figure 1 (click to enlarge). Percent reduction of migraine frequency.

In the present case, there was a large difference; in 31 cases post-treatment scores (average number of migraines per month) were less than pre-treatment scores, in 6 cases scores were equivalent, and there were no cases where post-treatment scores were greater than pre-treatment scores. The resulting z-score of -4.86 was statistically significant at the p<.001 level. Although the focus of this study was on migraine headaches, patients seeking neurotherapy are typically experiencing more than one problem, and migraine patients are no exception.

In the follow-up interviews we asked participants to (a) indicate which of several other common symptoms they were experiencing when they first sought treatment, and then (b) use a 5-point scale to rate the level of improvement they experienced following neurotherapy treatment. The response scale options were “no improvement” (0), “slight (10-30%) improvement” (1), “moderate (40%-60%) improvement” (2), “major (70-90%) improvement” (3), and “total (90- 100%) improvement” (4). Table 3 shows the number of individuals rating the 6 most common symptoms (migraine is included and the N of 34 indicates that we did not get ratings from 3 of the migraineurs who provided headache frequency data), and the percent reporting three levels of improvement. The first group includes those who selected either the “No improvement” or the “Slight (10-30%) improvement” response options, the middle group includes those who selected the “Moderate (40-60%) response option, and the third group includes those who selected “Major (70-90%) or Total (100%) improvement. Migraines were the most improved symptom based on this scale, with 62% or 23/37 reporting major or total improvement, followed by “other headaches,” where 50% or 19/37 reported major or total improvement. The percent reporting major or total improvement on other symptoms ranged from 32% to 41%. Sleep problems were least likely to be substantially improved.

Discussion
The concept of an under or over-aroused nervous system was first proposed by Nobel Laureate Walter Rudolph Hess who in the 1950s experimented with electrical stimulation of the brain which led to changes in arousal [26]. It has been theorized that disorders of attention, affect and pain are due either to over or underaroused brain states, and that neurofeedback is effective for a variety of symptoms or symptom clusters because it improves the brain’s ability to regulate these arousal states [13]. Neurofeedback treatment protocols address the underlying arousal problem, obviating separate validation studies for every medical diagnosis [13].

In this study, it appears that the biofeedback enabled the patients to gradually learn to control their susceptibility to getting headaches. Generally, they began to notice gradual improvements early on in treatment, particularly in their ability to manage stress, which was impetus for continuing treatment. This was assessed every 10 sessions by a written checklist and by interviews with a psychologist at each session. By session 20, most began to be aware of their ability to control or prevent their headaches. In most cases, by session 40, patients felt a sense of increased mastery over being better able to recognize when they were at risk (increased autonomic arousal in reaction to stress) and to take appropriate measures to be able to prevent headaches. 40 sessions happened to be the average number of sessions undertaken in the study.

Number of sessions ranged from 20-67 and was determined by what treatment provider and each patient felt they needed in order to ultimately learn to control migraines. These patients described the biofeedback as helping them to acquire the ability to better self-regulate by learning to control their EEG and reducing muscle tension, slowing the rate of their breathing and warming their hands and forehead, all of which were necessary for the types of biofeedback they had undergone. When asked how they thought they were better able to prevent headaches during interviews at each session and on checklists after every 10 sessions, many would explain that during potentially stressful conditions they would imagine hearing or visualizing the neurofeedback games and this appeared to help them invoke the physiological state elicited during the actual sessions.

We have observed that thermal biofeedback devices (pIR HEG machine and the hand warming units) can often be powerful migraine abortives once patients learn to raise their hand or forehead temperatures. All clients, whether or not they were successful at reducing their migraines, demonstrated an ability to warm their hands and foreheads and decrease their elevated EEG amplitudes of both slow and fast-wave activity. Patients related during session interviews that these techniques have eventually enabled them to automatically learn to abort their headaches without having to use the actual devices. Of the 37 patients in the study, five had fifteen or more migraines a month and all five improved significantly which may show promise that these methods can be useful for preventing the progression from episodic to chronic migraine.

Central nervous system dysfunction may play a key role in the pathogenesis of migraine [16-21]. As there are no apparent structural disturbances, clinical neurophysiological methods may be well-suited to study its pathophysiology [16]. In both migraine with and without aura, somatosensory evoked potential studies show that lack of habituation in cortical information processing between attacks is a reproducible central nervous system abnormality with this population [19]. Siniatchkin et al demonstrated the vulnerability of the migraine brain by measuring the effects of experimentally-induced stress on the contingent negative variation (CNV) response, which is a slow cortical potential believed to reflect altered excitability. This study showed a susceptibility to stress-induced migraine provoking agents before an actual attack [20]. Additionally, it has been observed that abnormal behavioral patterns such as hypersensitivity and perfectionism are often characteristic among migraine sufferers yet these psychological features may be the result of an innate cortical hypersensitivity in addition to associated social learning processes [21]. In this study neurofeedback appears to have improved stress resilience and susceptibility to migraines in the migraine participants. This may be due to the increase in self regulation brought about by the process of long term potentiation that may result from the operant conditioning of the EEG during the neurofeedback training [12].

Migraine has a comorbid association with a number of psychiatric conditions, including bipolar disorder, anxiety states, and depression, all of which are associated with perturbations in the serotonin and norepinephrine neurotransmitter substances [27,28]. Depression is often comorbid with migraines and anti-depressants are often used to treat both conditions [29]. Evidence that many neurological conditions are comorbid and alleviated by identical or very similar drugs supports three important principles in the spectrum paradigm: a) different symptoms are often manifestations of the same underlying instability or in balance, b) symptoms manifest differently depending on where they fall along the continuum of the underlying dysfunction, c) treatments need not be “disease specific” to be helpful [13]. Neurologist Oliver Sacks’ speculation that brainwave biofeedback might prove useful for migraines after showing promise in treating seizures supports the spectrum concept of related disorders responding to one mode of treatment [30].

Migraine and tension type headache were linked after both types showed a significant response to sumatriptan. A convergence hypothesis was proposed speculating that the entire clinical spectrum of headache may share a common physiological pathway based on one type of medication exerting an effect on two distinctly different types of headache [31,32]. Similarly, an older study shows that neurofeedback was effective for tension type headache [11] and our study finds that several types of biofeedback have an effect on migraines, other types of headache and other comorbidities. Biofeedback used with medications appears to outperform medications alone [5, 33,34]. In our study involving biofeedback with clients using medications, we saw the frequency of usage of the abortive and rescue medications drop along with the frequency of headaches.

Conclusions
Migraine may be progressive disorder with an excellent response to preventive early interventions [33,34]. Yet none of the pharmaceutical options are exceptionally effective or without side effects. The best result that medication has achieved has been only about a 50% reduction in approximately 50% of migraine patients [34]. Our study outperforms this by achieving a 50% or more reduction in 70% of the participants based on follow-up data collected on average, 14 months after patients had completed at least the minimum recommended 20 treatment sessions. The treatment effect sizes we obtained (1.09) are greater than those reported in a recent meta-analysis for either EEG-biofeedback (about .4) or temperature training feedback (about .5) or blood volume pulse feedback (about .7) alone, or temperature feedback plus electromyographic feedback (about .6) [5]. Although we did not have a control group, and thus cannot completely rule out placebo effects in this study, it may be unusual for a placebo effect to last 6 months to two years.

Despite the different types of intervention used in our study (manipulation of the EEG, forehead temperature or hand temperature), the retrospective reports of migraine frequency and the absence of a control group, the statistically and clinically significant improvements observed in this patient population attests to the promise biofeedback based treatment modalities hold for migraine patients. It is our hope that this study will generate an interest in performing larger scale controlled studies in the non-invasive neurotherapies to treat migraine and other chronic and/ or progressive disorders.

Citation:
Material adapted by CFisher from:

Stokes, D., & Lappin, M. (2010). Neurofeedback and biofeedback with 37 migraineurs: A clinical outcome study. Behavioral and Brain Functions, 6(9).

References:
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3.  Lipton R, Bigal M, Diamond M, Freitag F, Reed ML, Stewart WF: Migraine prevalence, disease burden, and the need for preventive therapy.  Neurology 2007,68(5):343-349.
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Here is the original announcement:

Research Support Offer to All ISNR Members

The ISNR Research Foundation will help any ISNR member to conceive, design, and execute a serious, publishable, scientifically sound/valid, statistically powerful, neurotherapy/brain function training clinical trial that will support strong inferences. This offer includes preparing a study proposal that can be put before any granting source proudly.

To support the effort, ISNR-RF will create the database infrastructure needed to accommodate and enable data collection, storage, analysis, client and researcher privacy and protection, and publication within the consortium structure. All aspects of the database will survive even the most rigorous scientific and client protection (Institutional Review Board) reviews.

These clinical trials will establish your reputation as a scientific researcher and the clinical validity of neurotherapy/brain function training in the mainstream scientific community. The proposed clinical trials will not necessarily require large sample sizes and they can be executed by individual neurotherapy/brain function training therapists or small clinics as well as large organizations. Please consider this opportunity to help yourself, your clients, and the neurotherapy/brain function training field.

If you and the ISNR-RF manage to garner grant funding, ISNR would like to receive appropriate grant-supported compensation for time spent on the research effort. ISNR would also like to hold second-level authorship for any published articles resulting from the research.

Charles R. Stark, M.D., BCIA-EEG
Chair, ISNR Clinical Research Consortium

BMED Report encourages all neurofeedback therapists to get involved! Few universities dedicate research manpower or money to neurofeedback clinical trials. This means that non-academic clinicians, businesses, and institutions will need to fill this vital role for evidence-based neurofeedback science to evolve.

Visit the ISNR Research Consortium here.

Enjoy.

CFisher

Ms. Ellison points out that the National Institute of Mental Health (NIMH) will sponsor the first federally funded, peer-reviewed neurofeedback study. She also gives readers a window into her motivation to provide neurofeedback with much attention; she states that “Disclosure: Based on my own experience, I share Gibbons’s enthusiasm. My son and I have both been given diagnoses of ADHD, and I believe that our simultaneous neurofeedback sessions last year helped us survive his middle school.”

The story includes testimonials from other parents who describe their positive experiences with neurotherapy, a basic description of a neurofeedback session and cost, and the need for additional research. Ms. Ellison states that the results of the ongoing NIHM neurofeedback study should be published by next summer. Let us hope so!

Visit The Washington Post original article, “Study may show whether neurofeedback helps people with ADHD and other disorders.”

Enjoy.

CFisher

Most anyone can open up shop as a “neurofeedback technician.” Of course, licensed professionals can quickly get into trouble with state licensing boards if they provide treatments outside their expertise, including biofeedback and neurofeedback; however, state boards cannot regulate those without the proper degree/license. The Washington Post article includes a brief interview with the highly regarded, Corydon Hammond, Ph.D. Dr. Hammond points out that neurofeedback can do harm in untrained hands.

The International Society of Neurofeedback and Research (ISNR) is currently lobbying for this much needed regulation. Practitioners who want to get neurofeedback certification are encouraged to visit the Biofeedback Certification Institute of America.

Visit the Washington Post article “Neurofeedback lacks strong controls”

Enjoy.

CFisher

The Behavioral Medicine Report obtained the publisher’s permission to post Chapter 19 where Newhouse discusses the effectiveness of neurofeedback and cranial electrotherapy stimulation (CES) and the Veterans Administration’s (VA) refusal to support these treatments. This story also includes interviews with Siegfried and Susan Othmer.

Eric Newhouse writes:

Helping The Brain Adjust
Neurotherapy helps reduce the symptoms of PTSD. The VA is not currently allowing the treatment to be used in some government facilities. However, private practitioners are using it with success and hope to convince the VA to change its current position.

As has been mentioned, there are some very interesting treatment options, but not all of them are available to combat vets through the VA, a government agency that can be cautious, stodgy, and bureaucratic. One of them is a new form of neurotherapy, Alpha-Stim, now offered through the Rimrock Foundation of Billings, Montana. Rimrock has been offering neurotherapy to civilians for the past few years after it lost its government contract to provide care to combat vets. Rimrock treated 176 combat vets between 2002 and 2004 before the VA switched its contract to Billings Mental Health. “If we’d had Alpha-Stim [direct electrical stimulation of the brain] when we were doing our vets, every one of them would have been on this,” Mona Sumner, Rimrock’s chief operations officer, told me.

Rimrock is finding that this therapy is working wonders with abused women suffering from PTSD, as well as drug addicts and alcoholics. It said neurotherapy cuts down on the desire to use drugs, as well as reducing stress, anxiety, depression, and insomnia. In a short session, that relief came to Mandy Smith, who suffers from post-traumatic stress disorder and seeks help from the thoughts shooting uncontrollably through her mind. It’s been a day of tears and anger for this 24-year-old abuse victim and former drug addict, who can feel the tension in her forehead and all but see the etched lines that arch up across her forehead from the bridge of her nose. Soft music is playing and the lights are dim as Smith plugs onto each earlobe an electrode attached to a device resembling an iPod. Her session will be 20 minutes.

Developed by Dr. Daniel L. Kirsch, onetime clinical director of the Center for Pain and Stress-Related Disorders at Columbia-Presbyterian Hospital in New York City, the device blows a gentle electrical current through her brain. It has the same frequency as an alpha brainwave, the state that people who meditate seek to achieve. It’s described as being awake but relaxed, the peace you feel on awakening or just before going to sleep. The current is believed to stimulate groups of nerve cells located near the stem of the brain. Those clusters produce neurotransmitters (serotonin and acetylcholine), which modulate brain activity.

“This has been a brutal week for me because of a relationship I was in and because I’m having delusional thoughts of an eating disorder,” said Smith as the treatment begins. “Now that I don’t drink or do drugs anymore, the eating disorder is a way of messing up my head.” After her best friend died in a car wreck at 15, Smith became an alcoholic and then a drug addict. Now she’s in recovery. “I’ve been smoking a lot of cigarettes this week, and I’ve been isolating because I don’t want to be around people,” she said. Therapist Shelly Hocking sits with Smith, watching her face for signs of relaxation. “For the first three or four minutes, my thoughts were just racing,” Smith said. “But now I’m feeling some relief.”

One intrusive thought is often the brutal beating she took outside a Phoenix, Arizona, crack house before dawn one morning a few years ago. “It was just a total act of violence,” she said. “He beat me nearly to death, stabbed me eight times, including one good shot to the arm that went in one side and out the other.”

By now, the treatment is beginning to work. “Before this started, I was thinking about a lot of things, but now I’m just focusing on this conversation,” Smith said. Although she survived the assault, Smith has seen her share of death as she abused LSD, cocaine, and methamphetamines. “I saw one friend die who was drinking and driving,” she said. “He was racing and wrapped his car around a tree. We ran up to pull him out, but he was gargling blood so it was no use.” With about four minutes left in her treatment, the tension lines in Smith’s forehead dissolve and she just looks terribly tired. “I’ve been medicated for years, but this is the best way of dealing with this anxiety,” she said. “You feel a lot better, and you’re not numb.”

For Rimrock’s Mona Sumner, the therapy is simply extraordinary. “Mandy is pretty much a miracle child,” she said. “Her disease (addiction) is so far progressed that our staff says she doesn’t have one more relapse in her. If she relapses again, she’ll be dead.”

Lasting Benefits
After the session, the peace can remain for days. Patients who have been stabilized usually use the machine once or twice a week, Sumner said. “This particular intervention has been one of the most significant therapies that we’ve found. It was a defining moment for the Rimrock Foundation when we began to use it.” It’s particularly helpful for treating depression, anxiety, and insomnia, all of which are symptoms of PTSD, said Jon Gjersing, Rimrock’s director of nursing. Also called cranial electrotherapy stimulation, Alpha-Stim has been approved by the U.S. Food and Drug Administration as a treatment. Stimulators cost $400 to $600, and are available only with a doctor’s prescription.

The Center for Mental Health in Great Falls, which has one of the VA contracts to treat combat vets, doesn’t offer neurotherapy; its medical director, Dr. Michael Mason, said he was unfamiliar with Alpha-Stim. Teresa Bell, spokeswoman for the VA at Fort Harrison, said the agency doesn’t normally use neurotherapy as a treatment. Instead, it relies on cognitive therapy, medications, and a program called Vet-to-Vet in which combat vets help each other with common problems.

But Gjersing said it has proven valuable in treating depression. “Statistics show that 65 percent of all people in treatment suffer from depression,” he said. With PTSD, the brain is hyperactive and can’t slow itself down, he added. “A lot of people go from the sleep mode directly into the anxiety mode. This machine sets up a low-frequency radio wave, and the brain
responds to it by slowing down.” The anxiety will probably return in hours or days, but not as severely as it did before, said Gjersing. It’s also effective on traumatic brain injuries, said Sumner, adding, “It seems to target the damaged part of the brain to work on.” And it can be used to reduce chronic pain, Gjersing said. “It seems to change how the brain processes pain. We do know that depression and anxiety exacerbate pain.”

A study group of 3,200 patients in Texas showed no adverse side effects, said Sumner, although it shouldn’t be used by patients with medical implants. Rimrock is now using Alpha-Stim on most of the young women it’s treating for trauma and drug abuse, Sumner said, “And it’s made a tremendous difference for them.”

Paranoia Becomes Bearable
Anxiety attacks have been severe for Cara, a 26-year-old mother of two sons who asked that her last name not be used because she fears her exhusband, whom she described as a wife-abusing meth dealer. “There’s a restraining order against him,” she said softly, “but that’s only a piece of paper.”

At 13, she said, she was molested by an uncle for several years before she ran away and turned to drugs for relief. When she got pregnant, she stopped doing drugs and got married. Meth tore that marriage apart, she said. “I started using meth again shortly before our divorce, but it didn’t save our marriage,” said Cara. Actually, it made things worse. He beat her badly, and she had to leave their home in Idaho with their children. “But after I filed for divorce, he wouldn’t let it go,” Cara said. “He stalked me and the people he sold meth to stalked me. It was a scary time.”

Cara came to Montana and sought treatment at Rimrock. She lived in constant terror in a group home with an undisclosed location. “I had to have all the blinds at the house pulled down, and I wouldn’t go outside,” Cara said. “I had to peek out the windows all the time, keep track of all the cars coming and going, make notes of all the different license plates. Living in a state of fear all the time made my heart race.” The Alpha-Stim treatment has eased that anxiety a lot, she said. “The first two weeks I was here, I couldn’t sit and watch a movie with my kids,” Cara said. “But now I can sit and relax with them. I know that change is because of the Alpha-Stim because when one of my kids got sick and I missed my treatments for two weeks, I could feel the difference. I was back up at the windows again.” Cara had originally been prescribed Wellbutrin, an antidepressant, but the neurotherapy treatments have been so successful she’s quit taking medications. “I’m grateful for that,” Cara said. “It numbed me, and I didn’t want to be dependent on drugs again.”

Shut Down By The VA
Keli Remus, who runs Chinook Winds Counseling in Great Falls, is a big fan of Alpha-Stim. “I started using it on September 9,” he said. “You know something is working when you can remember the exact day you bought it.” Remus is a counselor who now specializes in PTSD patients under contract to the VA; he started as a sex-abuse counselor. He said that trying to help those victims gave him a secondary case of PTSD. “I was having nightmares four, five, and six times a week,” he said. “And nothing helped. But with Alpha-Stim, they’re almost gone, down by about 95 percent. I only get one or two a month now.”

Based on that personal experience, Remus began using the device on his VA patients and found that it was equally effective. “I was using it on guys who had anxiety and depression. They could calm down and relax so that things registered. Then they began to show a significant change, long-term. I saw that they could think better and function better. One of my guys who struggles with anger was able to remain calm while he sat in a traffic jam.” Unfortunately, when his clients went back down to Fort Harrison for their checkups, they began to talk about how much better they were. “They called me in and ordered me to cease and desist,” said Remus. “So I did. Not only will they not pay for this treatment, but they won’t even let me use it in any session that the VA pays for. But I’m hoping and praying that the VA will change course and allow me to use it.”

Neurofeedback May Help Normalize The Brain
At the EEG Institute in Woodland Hills, California, just north of Los Angeles, counselors use Alpha-Stim to relax patients in the beginning sessions of their treatment, but go far beyond that, clinical director Sue Othmer told me. Their treatment is true neurofeedback. “The essence of neurofeedback is that it’s training our brains, finetuning them,” said Othmer. “We’re teaching the brain how to shift down to a calmer state and relax.”

That involves putting electrodes on a patient and allowing him to play computer games with his emotions. The two calmest brain waves are called alpha and beta, and the patient is working to achieve these calming frequencies. By watching to see what works, the patients learn to control their own brain waves and learn how to quiet their own anxieties. That’s important, Othmer said, because the anxiety tends to block the brain from processing the trauma that injured it. “You can replay minor incidents until you defuse them,” she said. “But in trauma, it’s hard to process anything. The experience sits there unresolved, so it has the weight of an ongoing experience.” Her husband, Siegfried Othmer, said PTSD is basically a physiological memory. “The memory of a traumatic event rivets itself into the body-mind, a physiological memory. The whole body recalls the injury. So the remedy lies in restructuring the memory by allowing the person to benignly experience the memory. And that brings about a separation between the body memory and the mind memory. Then the person can go back and visit that memory safely.”

The first step is to put the person very much at ease, a state where the body has this healing experience. “We put him in a state just short of sleep. Then the brain ruminates about its own self because the external environment is absent. It ruminates about those traumas. They may come up in a veiled fashion, or they may come up rather vividly. But the brain doesn’t go anywhere that a person can’t handle because the vivid memories startle the person out of that state,” said Siegfried Othmer. The trauma has to come out and be processed before the true healing can take place, Sue Othmer said. “In a deep state, you feel safe and calm and relaxed, and your brain can process that trauma. Your brain has wanted to do this work, but it has been blocked by your emotions. So it can be fairly dramatic when those images come forth. I did a session with a Vietnam vet, a medic, who basically saw every bad thing that had happened to him in Vietnam during a 40-minute session. In Vietnam, he was totally devastated, exhausted, covered with sores, and he totally fell apart. After the session, he told me he had developed a totally new image of himself, and that finally allowed him to talk about his experiences.”

She said their work builds on the research done during the 1960s by E.G. Peniston, a VA counselor who found neurofeedback very helpful in dealing with Vietnam vets. Now the EEG Institute offers that help free of charge to combat vets with PTSD. “It was clear that it had a huge influence for veterans,” said Sue Othmer. But her husband can’t figure out why this treatment hasn’t been more popular. “We see a couple of veterans at a time, but we should be flooded with them,” said Siegfried Othmer. “We’ve got occasional vets, all doing well, but we’re not crowded. I don’t understand it. It gets to be enormously frustrating.”

Unfortunately, the vet that the Othmers considered their star patient and recommended for an interview about his success told me he was too stressed out from his dealings with the VA to talk about the treatment.

From the book, “Faces of Combat, PTSD and TBI: One Journalist’s Crusade to Improve Treatment for Our Veterans.”

Eric Newhouse
Pulitzer Prize Winning Journalist

The Gaussian distribution is a fundamental distribution that is used throughout science, for example, the Schrodinger wave equation in Quantum mechanics uses the Gaussian distribution as a basis function without which there would be no microwave ovens or computers, etc. (Robinett, 1997). The application of the EEG to the concept of the Gaussian distribution requires the use of standard mathematical transforms by which all statistical distributions can be transformed to a Gaussian distribution (Box & Cox, 1964). In the case of the EEG, transforms such as the square root, cube root, log10, Box-Cox, etc. are applied to the power spectrum of the digital time series in order to approximate a normal distribution. The choice of the exact transform depends on the accuracy of the approximate match to a Gaussian distribution. The fact that accuracies of 95% to 99% match to a Gaussian are commonly published in the EEG literature encouraged me and colleagues to develop and test the Z score biofeedback program.

Fig. 1 - JTFA normative databases are instantaneous and include within-session variance plus between-subject variance. In contrast, FFT normative data only contains between-subject variance. t = time, s = subjects and SDt = standard deviation within-session and SDs = standard deviation between subjects. Thus FFT Z scores are larger than JTFA Z scores and a ratio of 2:1 is not uncommon. (From Thatcher et al., www.appliedneuroscience.com).

The second design concept is the application of the Gaussian distribution to averaged “instantaneous” time domain spectral measures from groups of normal subjects and then to cross-validate the means and standard deviations for each subject for each instant of time (Thatcher, 1998; 1999; 2000a; 2000b). The cross-validation is directly related to the variance of the distribution. However, in order to achieve a representative Gaussian distribution it is necessary to include two major categories of statistical variance: 1- the moment-to-moment variance or within session variance, and 2- between subject variance across an age group. In the case of the Fast Fourier Transform (FFT) there is a single “integral” of the power spectrum for each subject and each frequency and, therefore, there is only between-subject variance in normative databases that use non-instantaneous analyses such as the FFT. Thus, there is a fundamental and important difference between an instantaneous Z score and an integrated FFT Z score with the former having two sources of variance while the latter has only one source of variance. Figure 1 illustrates the relationship between an FFT based normative database versus an “instantaneous” or Joint Time Frequency Analysis (JTFA) database such as used for the computation of instantaneous Z scores.

The third design concept is simplification and standardization of EEG biofeedback by the application of basic science. Simplification is achieved by the use of a single metric, namely, the metric of the “Z Score” for widely diverse measures such as power, amplitude asymmetry, power ratios, coherence and phase delays. Standardization is also achieved by EEG amplifier matching of the frequency response of the normative database amplifiers to the frequency characteristics of the EEG amplifiers used to acquire a comparison subject’s EEG time series.

A fourth and intertwined clinical concept in the design of Z score biofeedback is “individualized” EEG biofeedback and non-protocol EEG biofeedback. The idea of linking patient symptoms and complaints to functional localization in the brain as evidenced by “de-regulation” of neural populations is fundamental to individualized biofeedback. For example, de-regulation is recognized by significantly elevated or reduced power or network measures such as coherence and phase within regions of the brain that sub-serve particular functions that can be linked to the patient’s symptoms and complaints. The use of Z scores for biofeedback is designed to “re-regulate” or “optimize” the homeostasis, neural excitability and network connectivity in particular regions of the brain. The functional localization and linkage to symptoms is based on modern knowledge of brain function as measured by fMRI, PET, penetrating head wounds, strokes and other neurological evidence acquired over the last two centuries (Heilman & Valenstein, 1993; Braxis et al, 2007; the Human Brain Mapping database of functional localization). Thus, the false concern that Z score biofeedback will make exceptional people dull and an average individual a genius is misplaced. The concept is to link symptoms and complaints and then monitor improvement or symptom reduction during the course of treatment. For peak performance applications, a careful inventory of the client’s personality style, self assessment of weaknesses and strengths and identification of the client’s specific areas that he/she wishes to improve must be obtained before application of Z score biofeedback. Then, the practitioner attempts to link the client’s identification of areas of weakness that he/she wants improved to functional localization as expressed by “de-regulation” of deviant neural activity that may be subject to change.

As mentioned previously, the instantaneous Z scores are much smaller than the FFT Z scores in the NeuroGuide software program which uses the same subjects for the normative database. Smaller Z scores when using the instantaneous Z scores is expected. One should not be surprised by a 50% reduction in JTFA Z scores in comparison to FFT Z scores and this is why it is best to first use 19 channel EEG measures and the highly stable FFT Z scores to link symptoms to functional localization in the brain to the extent possible. Then use the Z Score program inside of NeuroGuide to evaluate the patient’s instantaneous Z scores as a therapy design process before the biofeedback procedure begins (www.appliedneuroscience.com). This will allow one to obtain a unique picture of the EEG instantaneous Z scores of each unique patient prior to beginning Z score biofeedback. The clinician must be trained to select which Z scores best match the patient’s symptoms and complaints. A general rule for the choice of Z scores to use for biofeedback depends on two factors obtained using a full 19 channel EEG analysis: 1- scalp location(s) linked to the patient’s symptoms and complaints and, 2- magnitude of the Z scores. De-regulation by hyperpolarization produces slowing in the EEG and de-regulation due to changes in inhibition produces deviations at higher frequencies. The direction of the Z score is much less important than the location(s) of the deviant Z scores and the linkage to the patient’s symptoms and complaints.

Fig. 2 – Screen capture from NeuroGuideTM in the demo mode from a patient with right parietal and right central injury. Instantaneous Z scores are on the right, EEG traces are on the left. Depress the left mouse button over the traces. Move the mouse to the right border and watch a movie of the dynamic Z scores.

Figure 2 is an example of the instantaneous Z score screen inside of NeuroGuide(TM) while the instantaneous Z scores are being reviewed. A free demo of instantaneous Z scores that are used for real-time Z score biofeedback can be downloaded and evaluated at Applied Neuroscience.

A P4 and C4 theta and delta deviation from normal is evident as well as bilateral occipital delta deviations from normal. There is diminished alpha and theta in the instantaneous Z scores but on the average the dynamic FFT provides a much clearer picture of the right parietal and right central Z scores. For illustration purposes only, a biofeedback protocol would be to reward Z score values less than and greater than 2 standard deviations in the theta frequency band in P4 and C4 and most of the feedback rewards will automatically occur in the delta and theta frequency band. As mentioned previously, the above is an example of an individualized Z score biofeedback procedure after reviewing the patent’s EEG using the same instantaneous Z score program running in BrainMaster, Thought Technology, EEG Spectrum and Deymed.

Robert W. Thatcher, Ph.D.

Members of the International Society for Neurofeedback and Research (ISNR) receive NeuroConnections as a free benefit of membership. Healthcare professionals who specialize in neurofeedback, biofeedback or QEEG are encouraged to join ISNR to receive the full edition (in a full color printed format) of NeuroConnections and other member benefits. The above article was reprinted from NeuroConnections with permission from ISNR.

References:
Box, G. E. P. and Cox, D. R. (1964). An analysis of transformations. Journal of the Royal Statistical Society, 211-243, discussion 244-252.

Brazis et al (2007). Localization in clinical neurology. Williams and Wilkins. Philadelphia, PA.

Heilman, K.M. & Valenstein, E. (1993). Clinical Neuropsychology (3rd ed.). Oxford University Press, New York.

Robinett, R.W. (1997). Quantum mechanics: classical results, modern systems and visualized examples. Oxford University Press, New York.

Thatcher, R.W. (1998) EEG normative databases and EEG biofeedback. Journal of Neurotherapy, 2(4): 8-39.

Thatcher, R.W. (1999). EEG database guided neurotherapy. In: J.R. Evans and A. Abarbanel Editors, Introduction to Quantitative EEG and Neurofeedback. Academic Press. San Diego.

Thatcher, R.W. (2000a). EEG operant conditioning (Biofeedback) and traumatic brain injury. Clinical EEG, 31(1): 38-44.

Thatcher, R.W. (2000b). An EEG Least Action Model of Biofeedback. 8th Annual ISNR conference, St. Paul, MN.

Meta-Analytic Study Design
Published studies from 1970 to 2005 that investigated neurofeedback for epilepsy/seizure using SMR (sensorimotor rhythm) neurofeedback or slow cortical potential (SCP) neurofeedback were candidates for inclusion. The SMR protocol is more popular in the United States, while SCP training is more commonly used in Europe. The researchers focused on individual pre/post treatment seizure rates (seizure frequency) due to a limited number of studies with adequate comparison groups (i.e., assignment of participants with dangerous medical conditions to placebo groups is ethically problematic, though more recent novel neurofeedback studies have worked around this limitation; for example, see here). Few studies reported this information, and unfortunately, this reduced the more than 60 available studies to 10 with a final total of 87 participants.

How Effective?
The group seizure rate was significantly reduced by SMR or SCP neurofeedback. For example, 79% of participants who received SMR neurotherapy decreased seizure frequency. The authors specifically cited one study were the median seizure rate was reduced by 61%, or 13 less seizures per month in 50% of participants. The overall effect size, depending on the reported model, hovered around .20. Qualitatively, this is best described as a “small” effect; however, from a statistical standpoint, this modest effect size comes as no surprise as the relatively small number of participants severely limited the chance of larger effects.

Conclusion
The researchers concluded that,

“Based on these consistent findings, the practical value of neurofeedback should be recognized. Medication, while commonly helpful, generally provides effective control of seizure for only two-thirds of patients. In addition to side effects, long-term use of many anti-seizure drugs has significant health risks [Bohan, Mansuri, & Wilson, 2007; Petty, O'brien, & Wark, 2007]. Neurofeedback offers an attractive alternative to neurosurgery or implantation of vagal nerve stimulators. Antiepileptic drugs are also teratogenic: prenatal exposure to anticonvulsant medication puts children at risk for developing autism” or fetal anticonvulsant syndrome which manifests as major physical birth defects and infant mortality [Pennell, 2002]. Neurofeedback offers women of child-bearing age a possibility of controlling epilepsy without risking the health and well-being of her newborn.”

Summary
This meta-analytic study provides preliminary evidence that neurofeedback may be an effective treatment of epilepsy/seizures and that persons who have failed to respond to front-line medical treatments might benefit from neurofeedback. Keep in mind that though it is difficult to argue that a placebo effect or some unknown confound controlled chronic seizure activity, one can only infer that neurofeedback directly contributed to the reported improvements due to the small number of participants and lack of a comparison group. Hence, specific claims of efficacious treatment cannot be made until larger, more controlled trials are carried out, and this most likely explains why the authors did not provide a formal efficacy rating.

This is a population truly in need of viable alternative treatments, and hopefully many additional neurofeedback for epilepsy studies are on the way.

Enjoy.

CFisher

Reference:
*Tan, G., Thornby, J., Hammond, D.C., Strehl, U., Canady, B., Arnemann, K., & Kaiser, D. (2009). Meta-analysis of EEG biofeedback in treating epilepsy. Clinical EEG and Neuroscience, 40(3), 173-179.

The author gives a basic and fairly accurate description of a typical neurofeedback session that includes the possibility to watch your favorite DVD movies. Lynda Thompson (wife of Michael Thompson, M.D.), a noted psychologist and presenter and the director of a Toronto ADHD center, is briefly interviewed, presumably to give added credibility. The author further explains that questionably designed (at least by medical standards) neurofeedback studies have been heretofore the only evidence that neurofeedback, or EEG biofeedback, is effective for ADHD, but that recent well-designed studies have demonstrated good results. The possibility that neurofeedback might replace or at least compliment psycho-stimulant medication is explored. A German ADHD study is mentioned without a reference; however, this may be Children With ADHD Realize Significant Benefits From Neurofeedback Training In a Randomized Clinical Trial reviewed here back in February. Last, they interview a mother that discusses the positive benefits that her child with ADHD experienced from neurofeedback.

Overall, this is very positive coverage of neurofeedback!

Visit the U.S. News & Word Report article here.

Enjoy.

CFisher

Peniston’s Alpha-Theta Protocol
Peniston & Kulkosky used a multi-modal protocol that called for initial peripheral temperature biofeedback training, autogenic training, and breathing exercises to induce relaxation followed by approximately 30 thirty-minute sessions of EEG biofeedback. Patients learned to increase theta and alpha in occipital regions during eyes closed training to induce a hypnagogic state. Mental imagery scripts based on drug and alcohol rejection scenes, treatment goals, and lifestyle changes developed prior to neurofeedback were read to subjects during the initiation of the alpha-theta training session. The 1989 Peniston and Kulkosky study detailed positive results with this protocol after 15 sessions, and in 1990, Peniston & Kulkosky reported “…fundamental changes in alcoholic personality variables following alpha-theta EEG biofeedback” (p. 37).

Alpha-Theta Neurofeedback Mechanism of Action
The exact mechanism of alpha-theta neurofeedback remains elusive, but there is much speculation and ongoing research (Mark Johnson, personal communication). Peniston, Marrinan, Deming, & Kulkosky (1993) found that a phenomenon known as a crossover (i.e., theta amplitude exceeds alpha amplitude), where participants may experience vivid, healing emotional experiences, contributed heavily to treatment success. Another possibility for these dramatic results advocated by Peniston and Kulkosky (1989; 1990) is that alpha-theta neurofeedback counteracts increased beta-endorphin levels related to the stress of abstinence. However, at the present time, the precise mechanism(s) of action in the Peniston Protocol remain unknown (Gruzelier & Egner, 2005).

How Effective Is Alpha-Theta Neurofeedback?
The Peniston Protocol and the Scott and Kaiser Modifications of the Peniston Protocol (discussed below) are effective treatments when defined as long term abstinence. Reports of approximately 50% – 80% success inpatient (Burkett, Cummins, Dickson, & Skolnick, 2005; Scott & Kaiser, 1998; Scott, Kaiser, Othmer, & Sideroff, 2005) and 70% success outpatient (Callaway & Bodenhamer-Davis, in press) using various definitions of “treatment success,” “abstinence,” and “relapse.” Participants that complete a Peniston Protocol program can experience the “Peniston Flu,” an effect in which nearly 50% of subjects experience an allergic reaction to their abused substance (Demos, 2005). This attests to the powerful effects that are possible with alpha-theta neurofeedback.

Scott and Kaiser Modifications of the Peniston Protocol
Researchers hoped that the Peniston Protocol could produce similar successful outcomes with other substance abuse disorders. However, only limited success in patients with other drug addictions, such as cannabis dependence and stimulant dependence, would be realized using the Peniston Protocol (Sokhadze, Cannon, & Trudeau, 2008). Scott and Kaiser (1998) eventually discovered that patients with polysubstance (i.e., cocaine and methamphetamine) abuse in an in-patient setting demonstrated marked improvement with the addition of SMR-beta enhancement to the protocol prior to alpha/theta training. Patients completed 10 to 20 SMR-beta neurofeedback sessions over the first 10 days of treatment followed by 30 alpha/theta sessions. Scott and Kaiser believed that an SMR-beta protocol increased treatment stay over and above the effects of alpha/theta neurofeedback when compared to control subjects. Patients that completed this program had significantly decreased scores on multiple mood and personality scales on the Minnesota Multiphasic Personality Inventory II (MMPI-2), increased attention, and greater likelihood of permanent abstinence. Their modified alpha-theta protocol became known as the Scott and Kaiser Modifications of the Peniston Protocol.

A more recent investigation into polysubstance abuse using the Scott and Kaiser Modifications of the Peniston Protocol was completed (Scott, Kaiser, Othermer, & Sideroff, 2005). Again, significant improvements on multiple measures were realized, including increased attention and concentration scores on the TOVA, reduced psychopathology as measured by the MMPI-2, improved treatment completion rates, and 77% abstinence after 1 year. Burkett, Cummins, Dickson, and Skolnick (2005) integrated the Scott and Kaiser Modifications of the Peniston Protocol into a faith-based inpatient treatment facility for homeless crack cocaine dependent persons. The researchers reported 49% complete abstinence from crack cocaine and 40% partial relapse (crack cocaine used 1 – 9 times) with only 10% full relapse after one year. Additionally, they found significant improvements in treatment retention rates, establishment and maintenance of a regular residence, and holding a steady job or attending school, as well as decreased depression and anxiety, and reduced rearrest rates.

Summary
The research discussed herein suggests that Alpha-theta neurofeedback may be an effective treatment for notoriously difficult-to-treat substance abuse populations known for high relapse rates. It is important to note that these studies have their limitations, some significant, especially for those who place importance on randomized double blind designs. The complexities of alpha-theta neurofeedback unfortunately do not easily lend itself to blinded designs. Nonetheless, ingenious neurofeedback research designs have been published of late; for example, read “Neurofeedback Significantly Improves Sleep In A Small Group Of Insomniacs.” Perhaps researchers will eventually create a novel way to isolate the effects of alpha-theta neurofeedback while controlling for extraneous variables. Until then, I believe that the published research so far justifies alpha-theta neurofeedback as a viable treatment option for persons who abuse substances, particularly for those who have not responded to other treatments.

Enjoy.

CFisher

References:

Budzynski, T. (1999). From EEG to neurofeedback. In J. Evans & A. Abarbanel (Eds.), Introduction to Quantitative EEG and Neurofeedback. San Diego: Academic Press.

Burkett, V., Cummins, J., Dickson, R., & Skolnick, M. (2005). An open clinical trial utilizing real-time EEG operant conditioning as an adjunctive therapy in the treatment of cocaine dependence. Journal of Neurotherapy, 9(2), 27-47.

Callaway, T., & Bodenhamer-Davis, E. (in press). Extended follow-up of Peniston protocol results with chemical dependency. Journal of Neurotherapy.

Demos, J. (2005). Getting Started with Neurofeedback. New York: W. W. Norton & Company.

Gruzelier, J., & Egner, T. (2005). Critical validation studies of neurofeedback. Child and Adolescent Psychiatric Clinics of North America, 14, 83-104.

Peniston, E., Marrinan, D., Deming, W., & Kulkosky, P. (1993). EEG alpha-theta brainwave synchronization in Vietnam theatre veterans with combat-related post-traumatic stress disorder and alcohol abuse. Advances in medical psychotherapy, 6, 37-49.

Peniston, E., & Kulkosky, P. (1989). Alpha-Theta brainwave training and beta-endorphin levels in alcoholics. Alcoholism: Clinical and Experimental Research, 13(2), 271-279.

Peniston, E., & Kulkosky, P. (1990). Alcoholic personality and alpha-theta brainwave training. Medical Psychotherapy, 3, 37-55.

Scott, W., Kaiser, D., Othmer, S., & Sideroff, S. (2005). Effects of an EEG biofeedback protocol on a mixed substance abusing population. The American Journal of Drug and Alcohol Abuse, 31, 455-469.

Scott, W., & Kaiser, D. (1998). Augmenting chemical dependency treatment with neurofeedback training. Journal of Neurotherapy, 3(1), 66.

Sokhadze, T., Cannon, R., & Trudeau, D. (2008). EEG biofeedback as a treatment for substance use disorders: Review, rating of efficacy, and recommendations for further research. Applied Psychophysiology and Biofeedback, 33, 1-28.

Participants (n=27) received random assignment to a neurofeedback (n=16) or wait-list control group (n=11). Individualized neurotherapy protocols (i.e., based on the QEEG) were utilized for the 30-40 half-hour EEG biofeedback sessions received by those in the treatment group. Typically, participants were rewarded when they decreased 0-8Hz (slow wave activity) and 22-35Hz (fast activity associated with anxiety and rumination) and increased 10-18Hz (Alpha and cognitive Beta).

A wide variety of psychological and neuropsychological assessments were administered pre/post-treatment to determine changes in executive functioning, memory, and EEG. The researchers did not specify the exact components of executive functioning they sought to assess though their choice of tests gave some indication.The specific assessment measures were:

1. QEEG
2. Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A; self and informant report)
3. Symptom Checklist 90-R
4. Williams’ Memory Assessment Scale
5. Rey-Osterreith Complex Figure Task
6. Wisconsin Card Sort Test
7. Integrated Visual and Auditory Continuous Performance Test (IVA)
8. Delis-Kaplan Executive Function Battery (omitted Proverbs, second Card Sort set, and Tower test)
9. Mini Mental Status Exam

(click to enlarge) Figure 5. Compared to controls, improvement in treated subjects showed a significantly greater correlation with reduction in slow wave activity.

Participants in the QEEG-guided neurofeedback group realized statistically significant improvements in verbal memory, verbal fluency, visual memory, executive function, and behavioral inhibition at post-testing. The researchers noted “trends” toward improvement on the Mini-Mental Status Exam (p=.072) and Symptom Checklist 90-R (p= .085). No changes were found on the IVA Attention, Wisconsin Card Sort, and Delis-Kaplan Executive Function System. Statistically meaningful changes in the QEEG for persons in the treatment group included greater power in all frequencies higher than 10 Hz, as well as reduced 1-4 Hz amplitudes during eyes-closed assessment at F4 and C4. See Figure 5 for an example of changes in the QEEG. For comparison, 10 of 12 persons in the control group remained the same or declined in their overall functioning.

The researchers noted that despite the positive findings for the neurofeedback group as a whole, 6 of 16 participants with dementia evidenced little change or even declined. They then set out to identify the best candidates for neurofeedback and their initial assessment revealed that the Williams’ Memory Assessment Scale Global Memory Index pretest score significantly correlated (r= .71, p< .01) with the standardized mean treatment effect on variables that improved (p< .10) in the neurofeedback group and not in the control group. This suggested that those who entered the study with better memory functioning benefited most from neurotherapy.

The researchers concluded that:

“This study showed that neurofeedback training resulted in significant improvement in memory and some aspects of executive function, compared to a waiting list control, suggesting that neurofeedback is a “possibly efficacious” [Level 3] treatment for dementia. The finding that the efficacy of neurofeedback is greater in persons with more intact memory function suggests that this intervention is more strongly indicated for earlier stage cases. It also suggests that learning and memory are involved in neurofeedback’s mechanism of action.”

Please review the BMED Report article, “Evidenced-Based Biofeedback/Neurofeedback” for a quick overview of the 5 levels of efficacy accepted by ISNR and AAPB.

Keep in mind that small sample sizes typically limit or nullify research findings due to poor statistical power; however, in the present study, neurofeedback proved to be effective despite a small number of participants. Obviously, a much larger sample size is required to better estimate the efficacy of neurofeedback for dementia, to determine its side effects, if any, to refine criteria for ideal candidates for EEG biofeedback, and to identify the most effective protocols.

Important Note: The researchers are actively recruiting additional participants. Please contact Marvin H. Berman, Ph.D., Principal Investigator for additional information at (610) 940-0488 or online.

Download a poster presentation of “Efficacy of neurofeedback for executive and memory function in dementia” here.

Reference:
*Berman, M., & Frederick, J. (unpublished manuscript). Efficacy of neurofeedback for executive and memory function in dementia.

Editorial Note: While The Behavioral Medicine Report believes that Marvin H. Berman, Ph.D. will conduct safe and quality research, we cannot guarantee your safety or satisfaction with the results. We encourage all participants to discuss the research with the primary investigator and to review the informed consent documents before deciding to participate.

In order to look forward, it is instructive to look back, and to view our work in the context of our historical and anthropological development. Suppose an anthropologist visits earth from another planet, and is assigned the task of making a brief summary of human technical and cultural development, up to the current time. Something like the following graph might result.

Figure 1. (click to enlarge) Technical/Cultural Revolution

Approximately 100,000 years ago, humans were hunters and gatherers. Skills involved traveling, searching, trapping, killing, transporting, and using simple weapons and tools. Basic teamwork became essential to survival. Successful hunters were hyper-vigilant, being occupied with both finding dinner, and making sure they did not become something else’s dinner. It was essential to constantly be on the lookout, finding game, chasing it down, and catching it. Those who survived in this environment had many of the qualities we now associate with “attention deficit disorder” and “hyperactivity.” But these are useful skills, in the right context.

About 10,000 years ago, agriculture was discovered. People learned to stay in one place, watching the stars, clouds, moon, and weather. It was necessary to carefully study plants and their environment, recognize good things to eat, and recognize things that were not good to eat. It was necessary to cultivate, remove weeds, and know when planted foods were ready. Preparation of food by grinding, cooking, and preserving became important. Calendars and timekeeping, hence mathematics, now had survival value. The mind-set associated with these activities were in strong contrast to the previous 90,000 years. This mind-set now predominates in education. We are expected to sit still, study, concentrate, and be quite happy without stimulation, excitement, or adventure. If we are not happy with this, there are drugs we can take to stifle our need for novelty and exploration. We classify our more restless individuals as sick, disabled, and suffering from a disease.

We see further that there was an industrial revolution characterized by wheels, machines, factories, and cities. Following that, an information revolution was brought about through communications, computers, and automation. Many of us have seen the information revolution firsthand. From room-sized computers that could barely handle a few thousand calculations per second, we now have powerful processors in our handheld personal computers, wireless telephones, televisions, and music players. Within 5 years, these appliances will merge into one. After that, something wearable or even implantable will appear, that plays directly into the ears and eyes of the user. We will be able to communicate, do business, be entertained, and study using an implanted device that might respond to subtle muscle activity, subliminal vocalizations, direct nerve signaling, brainwaves, or other inputs.

We are all hunter/farmers, making our way in a new world that we have created, and are continuously recreating. We have within us all of these qualities, and any given individual may adopt a hunter mentality, or a farmer mentality, at any given time. Our very genes contain the seeds of both of these modes, and we can express either of them whether we know it or not. We are flexible in this regard, though some may lack certain task-switching skills. It is an insult to take those with a strong hunter inclination, and marginalize and medicate them. We are drugging our Alexanders, our Henry Fords, and our Thomas Edisons, into submission. Rather than “solving” the “problem,” we should be teaching the flexibility and appropriateness needed for specific tasks, and inculcating an adaptive style that serves a broad base of needs, not just the classroom setting.

So these hunter/farmers, who learned to make machines and then built themselves an information-based world, are now engaged in a self-created consciousness revolution. In the 1960’s and 1970’s it became common to question and look into the mental realm using a variety of techniques and agents; it became acceptable to look into new religions, belief systems, and other mentally focused pursuits. The U.S. Congress declared the 1990’s the “Decade of the Brain”, awakening interest in the brain. We have seen increased interest in meditation, spirituality, mental development, and similarly empowering pursuits. We see the widespread practice of reading, going to counselors or workshops, training classes and seminars, group processes, personal experiences (Outward Bound, survival experiences, religious retreats). An increasing number of people are aware of and accept the importance of “the inner”, as being as important, or more important, than “the outer”. We are seeing record amounts of psychoactive medications being used, as the chemical treatment of depression, anxiety, and attention problems alone represent a multi-billion dollar industry, motivated by some of the strongest advertising and lobbying forces in history.

So where are we headed? Where will today’s brain science, individual and collective consciousness, and the roots of neurofeedback, lead us during this century? What is neurofeedback? In the broadest sense, it is a means to precisely navigate inner space. What the compass, sextant, and gyroscope did for navigation and exploration of the outer world, neurofeedback can do for the inner world. Imagine systematically exploring and discovering inner lands, worlds, and dimensions that are now only fleetingly glimpsed by a select few. That flash of insight that today characterizes the occasional mental breakthrough can become something that is reached over and over, transforming individual and collective consciousness.

Let us look at some of the things we now take for granted, that would have been unthinkable only 100 years ago. Men have walked on the moon. It is routine to travel across the country, even around the world, in a single day. We have decoded the entire human genome. We know the mass of the electron to 13 decimal places. We can see and interpret events that happened 13 billion years ago. We can replace an entire human heart with a manmade device.

With this point of view, we can look forward 100 years, and envision things that are today unthinkable. Imagine that the study of consciousness enters the world of physics, and we have a true science built around the phenomena of mind. Imagine equations similar to Einstein’s field equations, but which include consciousness as a physical field. It is likely that these fields will involve other dimensions, giving rise to a sound physical basis for “other-worldly” phenomena. We may come to look upon intention as a force, similar to physical forces. We may come to understand the physical phenomena that give rise to consciousness, and may even learn to create artificial consciousness. We will understand the physical underpinnings of subjective experience, an area that is entirely mysterious to us now. 100 years ago, no one had even heard of a radio or a computer. Today, even schoolchildren can be “computer wizards” who can run circles around their parents in installing, using, even creating computer programs. So what will the “brain wizards” of the future look like?

Imagine a scientific basis for direct mind-to-mind communication. Imagine that it is possible to systematically teach clairvoyance. Imagine that we learn how to train psychokinetic ability. Imagine that we learn to develop the mind with the same zeal and specificity with which we currently develop the body. Look at a professional body builder, and ask yourself what might happen if an individual could apply the same level of determination and knowledge to the development of the brain and mind. What would a 21st century brain-builder be like? Might psychokinesis someday become as systematic and well-understood as physical exercise is today?

Imagine a world in which the cell phone is an artifact of the past. Direct mental communication is possible, for those who want to develop the ability. Instead of going to the store to pick up a cell phone, you go to a neurofeedback trainer who specializes in providing this ability. There may be some physical aspects such as implants, chemical treatments, special dietary supplements, and so on. But the individual will be trained to develop and employ abilities that today lie latent in all of us.

Imagine a system in which you put on an EEG hat (or not), and the system immediately takes over from there. It scans your brainwaves, makes analyses and comparisons, figures out what you “need”, and proceeds to configure and control the training. The feedback is based upon a complex, adaptive analysis of your brain, and does whatever is needed to move you wherever you want to go. Training involves the entire head, with global or localized training being done automatically. No more separate QEEGs, no waiting, no using separate protocols, no setting up the system, choosing settings, making changes. The system sees your response to the feedback, and adapts instantly. In a single session you might experience 2, 3, or 100 different training protocols, depending on how you respond. The displays include virtual reality, sensory immersion, abstract sights and sounds, whole head maps, real-time tomographic analyses, and statistical results, all in a comprehensive and easy to understand format.

Imagine a world in which eating medicine for psychological problems is considered obsolete. Our great grandchildren will laugh when they say “Grandma told me people used to eat serotonin uptake inhibitors to feel better.” In the future, people will be empowered to self-regulate their own mental health and stability, and it will no longer be necessary to tolerate side effects in order to deal with depression, anxiety, attention disorders, or other mental challenges.

Imagine a world in which a significant journey can be taken without physical transport, but by working with neurofeedback-guided transformation. You go into a full sensory immersion world, in which your internal state is reflected in your external world. You are free to explore, work, create, and relax in your personal reality. Feedback includes sound, sights, tactile sensations, even smells. The feedback can give rise to genuine out-of-body experiences, remote viewing, and direct mind-to-mind communication, which spring from the neurofeedback world as new dimensions in consciousness and experience. Shared experiences are even possible, giving rise to entirely new ways of being with others, transforming relationships and entire social structures.

We can envision a future in which a brainwave elite emerges. These are the individuals who have the aptitude and interest to develop mental powers well beyond those we know today. They may be called “heads,” “brainmasters,” “electric gurus,” or “cybernauts,” in reference to the emphasis they put on the use and development of the brain and mind. Not everyone will have the time, ability, or inclination to develop these skills. Building the mind in this way is sure to become controversial. New political, social, legal, and medical issues will arise. Perhaps those who are not part of this elite will continue to be relegated to eating medications, experiencing mental strife, and pursuing “old fashioned” therapies to address their mental woes.

Imagine a world in which millions, perhaps billions, of brains, are in a state of continual connectedness. A new form of consciousness emerges, in which individual brains take on the role of individual neurons, in a global brain. The next major revolution may indeed by one of “hyperconsciousness” brought on by these changes. We may find ourselves exploring other dimensions through the power of the mind, thus circumventing the anticipated challenges of space travel, supplanting it with direct travel at the level of consciousness, not merely at the level of space, time, and matter.

Scientists believe that the sun will explode billions of years in the future, and that our entire solar system will be vaporized. How will humanity persist after this cataclysm? What will happen even further into the future, when the universe meets it fate, be it eventual expansion into a black void, or compression into a “big crunch”? Will consciousness itself have the ability to persist beyond the physical reality we cling to? It is possible that, through advanced development of the mind, we will find ourselves living in an entirely different realm, one that looks back on our entire 3-dimensional universe as a distant relic of the past, much as we now look back to the Olduvai Gorge and the Mesopotamian watershed, the birthplaces of our earthbound experience.

We can now see that to consider neurofeedback solely as a means to relieve specific maladies, or to do a brain tune-up, is to ignore its true power and potential. In that view, the best that can be hoped is that some people suffer less from specific distresses, but that humanity becomes no different in the whole than it is today. To view neurofeedback strictly as a “fixer” is to say that our consciousness status quo is just fine, and all that we need to do is stamp out the aberrations. That would be like seeing the value of the automobile in running local errands, and saving a few minutes here and there. But in much the way the automobile gave rise to roads, suburbs, shipping and industry, thus transforming our world, neurofeedback will be no less a transforming agent. When neurofeedback reaches its full potential, the meaning of the human mind will have changed, and the most significant phase in human evolution will have taken place.

Hopefully, “The Decade of the Brain” will be looked upon in future years as the seed from which emerged brain mastery, consciousness exploration, and precise mental navigation. We will have learned to use that “90%” of the brain we are supposed to be ignoring, and we will use it well. These developments will have lead to a global hyperconsciousness that will be a first step toward a true supercivilization. We will reach beyond the stars into other dimensions, and beyond. We are truly poised to change the universe – one brain at a time.

Thomas F. Collura, Ph.D., P.E.

Members of the International Society for Neurofeedback and Research (ISNR) receive NeuroConnections as a free benefit of membership. All professionals who specialize in neurofeedback, biofeedback or QEEG are encouraged to join ISNR to receive the full edition (in a full color printed format) of NeuroConnections and other member benefits. The above article was reprinted from NeuroConnections with permission from ISNR.

Background
Research continues to provide empirical support for NFT efficacy and effectiveness. A recent meta-analysis demonstrated large effect sizes for NFT on impulsivity and inattention and a medium effect size for hyperactivity symptoms of ADHD; utilizing AAPB and ISNR clinical efficacy guidelines, the authors classified NFT as a “Level 5 Efficacious and Specific” treatment for ADHD (Arns, et al., 2009). The National Institute of Mental Health funded a randomized control study of NFT for ADHD. Hammond (2007) compiled an extensive bibliography of neurofeedback research, and Yucha and Gilbert (2008) published Evidence-Based Practice in Biofeedback and Neurofeedback. The September 2009 ISNR conference will be offering an extensive number of presentations of current research findings.

Despite advances in the quantity and quality of NFT research, a comprehensive literature review only found a handful of experimental investigations into practitioner variables that influence NFT process and outcome variables. Rubi (2006) investigated the utilization of NFT around the world and reported on practitioner demographic variables. Additional findings of our literature review included one article that emphasized the importance of establishing formal NFT practice standards (Hammond & Kirk, 2008) and another that discussed a staff training program that highlighted age as a potential practitioner variable for specific client types ( Thompson and Thompson, 2008).

Current Investigation
Limited investigation into practitioner variables that influence NFT process and outcomes triggered our team to explore this topic. We started with the following questions: Are there practitioner characteristics specific to NFT? If so, what are the characteristics? Do the characteristics influence process and outcome variables? To explore our questions, we developed a mixed-method three phase study. Phase one focuses on uncovering NFT perspectives through qualitative methodology. Phase two proposes to develop and test a NFT practitioner characteristic (NFPC) measurement tool through a confirmatory factor analysis. Phase three investigates practitioner variables (measured by the NFPC) that influence process and outcome variables.

Take The 10-Minute Online Survey
Visit Survey Monkey here.
The researchers will donate $2.00 to the ISNR Research Fund for each completed survey (subject to maximum allocated research funds).

Thanks in advance for your participation,
Jonathon Larson
Illinois Institute of Technology, Chicago

References:
Arns, M., de Ridder, S., Strehl, U., Breteler, M., and Coenen, A. (2009). Efficacy of neurofeedback treatment in ADHD: The effects on inattention, impulsivity, and hyperactivity: A meta-analysis. Clinical EEG and Neuroscience, 40, 180-189.

Hammond, D.C. (2007). Comprehensive Neurofeedback Bibliography. Journal of Neurotherapy, 11, 45-60.

Hammond, D.C., and Kirk, L. (2008). First, do no harm: Adverse effects and the need for practice standards in neurofeedback. Journal of Neurotherapy, 12, 79-88.

Rubi, M.C.M., (2006). Neurofeedback around the world. Journal of Neurotherapy, 10, 63-73.

Thompson, M., and Thompson, L. (2008). Achieving excellence with your staff: A consultant staff training program in Selected Abstracts of Conference Presentation at the 2007 International Society for Neurofeedback Research (ISNR) 15th Annual Conference, San Diego, California. Journal of Neurotherapy, 12, 75.

Yucha, C., and Montgomery, D. (2008). Evidence-Based Practice in Biofeedback and Neurofeedback. Wheat Ridge, CO: AAPB.

Dr. Sterman and Dr. Lisaby explicate a number of different brain related treatments that include neurofeedback and transcranial magnetic stimulation (TMS), and neuroimaging techniques, such as quantitative electroencephalography (qEEG). Other general topics include a basic description of the human EEG, the role of the thalamus in brain circuits, EEG activation and mood, operant conditioning and the Law of Effect, and long-term potentiation (LTP). They also accept questions from radio listeners who ask about the treatment of migraine headaches, Autism, peripheral neuropathy, and major depression.

I am very pleased that Dr. Sterman was selected for this interview as he is a “polished” and expert speaker on the topic of human physiology and neurofeedback. In fact, The Behavioral Medicine Report republished one his articles that you can read here.

Visit the Barry Sterman interview at WNYC.org.

Enjoy.

CFisher

Eugene Arnold, professor emeritus of psychiatry at Ohio State University, provides a relatively cautious, but positive, overview of the benefits of neurofeedback for ADHD. What are the other 8 treatments you ask? They are positive parenting, various parent and child behavioral programs, interactive metronome training, meditation, a natural environment, more sleep, a healthier diet, and exercise.

Visit 9 Drug-Free Approaches to Managing ADHD here.

Enjoy.

CFisher

Participants in the neurofeedback group (3 women and 6 men; mean age = 41) and biofeedback group (3 women and 5 men; mean age = 43) received approximately 20 sessions of training and all participants were medication free 4 weeks prior and throughout the study. The biofeedback protocol called for relaxation training via reduction of EMG at Fpz. Neurotherapy utilized the now classic Cz/SMR training protocol, which enhances 12-15Hz (SMR) and inhibits 4-8Hz (theta) and 20-30Hz (high beta). As you may recall, we previously reported on the successful application of SMR to sleep. Participants completed a wide variety of pre/post objective and subjective assessments, such as bedtime dairies, sleep logs, EEGs (polysomnography), Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Athens Insomnia Scale, State Trait Anxiety Index, Beck Depression Inventory, Presleep Arousal Scale with a somatic and a cognitive subscale, and the Mini International Neuropsychiatric Interview. Outcome measures included total sleep time, sleep latency, wake after sleep onset, sleep efficiency, and time in bed.

Participants in the neurofeedback group experienced statistically significant reductions in sleep latency (39%) and waking after sleep onset (53%) in a within group pre-post analysis. While participants in the biofeedback condition also reported decreases in sleep latency (44%) and waking after sleep onset (13%), only participants in the neurofeedback group realized significant improvements in rapid eye movement (REM) sleep, total sleep time, and time in bed. Effect sizes ranged from small to medium; however, there is no surprise here given the small sample. I suspect larger effect sizes could be realized with a bigger sample size.

The researchers hypothesized that:

“Applying a NFB protocol intervening on the level of cognitive processing, may thus have had an influence on cortical arousal and information processing during sleep, resulting in an increase of TST [total sleep time]. On a more concrete level, by inhibiting high beta (20-30Hz) during NFB [neurofeedback] training we tried to intervene directly on the reactivity to stress and arousal. Furthermore, Sterman et al. [1970] showed that the increase of SMR resulted in a facilitation of sleep spindle bursts and quiet sleep. This in turn might have had an influence on the consolidation of sleep in our subjects and might explain the positive impact on sleep duration that we observed” (pg. 18-19).

This study further provides initial evidence that home-based neurofeedback can be a viable therapy alternative despite the many concerns that I have with this treatment approach. Additionally, the researchers point out that neurofeedback / biofeedback over the internet may have controlled for the nearly always confounding therapist-patient interaction in exchange for control of the environment (i.e., each participant trained in a unique situation). Another finding of interest was that cognitive arousal, as opposed to somatic factors, clearly accounted for sleep problems for participants in both groups. This suggests that neurofeedback and Cognitive Behavioral Therapy (CBT) may have the potential to be complementary treatments in a multi-modal treatment plan for chronic sleep related difficulties. This represents an area for future research. Last, research is slowly accumulating to show that neurofeedback for insomnia may be an efficacious treatment alternative to pharmaceutical ones.

Enjoy.

CFisher

Reference:
*Aisha Cortoos, Elke de Valck, Martijn Arns, Marinus Breteler, & Raymond Cluydts (in press). An exploratory study on the effects of tele-neurofeedback and tele-biofeedback on objective and subjective sleep in primary insomnia patients. Applied Psychophysiology and Biofeedback.

Editorial Note: My thanks to Martijn Arns at Brainclinics Diagnostics B.V. for his help in the acquisition of this pre-published study, and for Aisha Cortoos for providing the PDF copy.

In the current study, the primary outcome variables were (1) hyperactivity, (2) inattention, and (3) impulsivity. Fifteen studies with a total of 1194 subjects (prospective controlled = 476; pre/post-test design = 718) were located for the meta-analysis. A majority (88%) of participants were medication free at the time of neurotherapy. Four studies used randomized assignment and 3 compared neurofeedback to stimulant medication (thought to be the “gold standard” in the medical community).

The end result was that neurofeedback for childhood ADHD achieved a “Level 5 – Efficacious and Specific” rating. Specifically, researchers found that neurofeedback generated “large” effect sizes (significant improvements) for pediatric inattention and impulsivity and a “medium” effect size for pediatric hyperactivity symptoms. Another important finding was that neurofeedback was no worse than (nor better than) methylphenidates (a class of ADHD stimulant medications). Thus, parents may want to give neurofeedback serious consideration a front line treatment for their child’s attention and behavior difficulties in light the ongoing concerns of stimulant medication side effects. The validation of neurofeedback as an efficacious treatment, at least for pediatric ADHD, represents an important development for the field of neurofeedback, clinicians, and their patients and may be the first step toward insurance coverage of EEG biofeedback.

Last, this a dense meta-analytic study with much data to mull over. I plan to post several additional, more detailed reviews of this study, including specific statistics, as well as its implications for neurotherapy once I have completely sorted through this manuscript.

References:
*Arns, M., Ridder, S.D., Strehl, U., Breteler, M., & Coenen, A. (unpublished manuscript). Efficacy of neurofeedback treatment in ADHD: The effects on inattention, impulsivity and hyperactivity: A meta-analysis. Clinical EEG and Neuroscience.

Brain Clinics Press Release is here.

Below are the 3 sample brochures.

For Professionals:

(Click To Enlarge)

(Click To Enlarge)

For Patients:

(Click To Enlarge)

Enjoy.

CFisher

I am very pleased to see the good folks at ISNR advocating (and funding through donations) quality QEEG/neurofeedback research. Several excellent randomized, double-blind studies will work wonders for the field of neurofeedback in terms of public acceptance and potential insurance coverage.

View the ISNR Research Foundation RFP document here.

Enjoy.

CFisher

What is DC-EEG?
DC-EEG is a bit of a misnomer, as DC, or direct current, refers to a signal value that is not changing. It is commonly understood to be the baseline about which the oscillating EEG activity varies. Technically, the DC component is the average of the signal, and it happens to turn up as the first term of the Fourier series, or the first value in the frequency domain obtained using the fast Fourier transform (FFT). OK, enough math for now, all this means is that when a very slowly changing EEG signal is described, the term DC is adopted when referring to the signal as DC-EEG.

Most often, the term DC applied to the EEG signal is borrowed from the term DC used to characterize the amplifier being used in the recording. A true DC amplifier does not omit any low frequencies and the DC component of the signal is captured along with all the rest. In most applications, the DC component is selectively omitted from the signal acquisition (the motivations for this will be explained later), and the baseline of the recorded EEG is zero, i.e. the EEG signal oscillates about the zero line. In addition to the DC component, very low frequencies are also omitted, as the truncation can never be instantaneous. What is actually left out of the recording is a range of low frequencies starting at the DC point (0 Hz) and ending at the low cutoff frequency of the system (often around 1-2 Hz).

This brings only benefits as long as the signal of interest is within the frequency range that remains above the cutoff point. When this signal lives below the cutoff frequency, removal of the DC component and the range of frequencies slightly above it will also remove the required signal. This signal of interest, as it applies to the research discussed in this article, refers to EEG activity below 1 Hz, below 0.1 Hz, even below 0.01 Hz – in other words very slowly oscillating neurocortical activity.

Terminology tends to get tangled, but if semantics are respected and time and frequency are considered to be intimately related, it becomes clear that DC-EEG, low frequency EEG and slow cortical potentials (SCP) in fact all refer to the same thing. (Consider: a DC amplifier passes low frequencies, which can be described as slow activity, and cortical potentials are the source of surface EEG). In the field of neurofeedback to date, the different terms tend to describe the particular methodology, as low frequency training and self-regulation of slow cortical potentials may imply different training strategies applied to the same EEG signal.

In the text that follows, when referring to the concept of recording EEG with a DC amplifier, the broad term DC-EEG will be used.  When referring to the EEG itself, the terms low frequency EEG and slow cortical potentials will be used according to the context.

Why DC-EEG?
DC-EEG is considered to reflect the general state of neurons and to contribute to the explanation of the mechanisms of surface EEG (Speckmann and Elger, 2005). The origin is reported to be linked to several phenomena, at the same time neuronal, glial and non-neuronal in nature. The SCP is an indicator of relative whole brain state, as slow shifts tend to reflect general activation and inhibition.

Negative shifts of SCPs reflect widespread depolarization of apical dendrites of pyramidal neurons (Birbaumer et al., 1990) and decrease of thresholds for paroxysmal activity. Positive shifts of SCPs are thought to result from inhibitory sources.  Dr. Ute Strehl states it this way:  “Negative SCPs increase firing probabilities, whereas positive SCPs [inhibit] the respective cell assembly.  These neurophysiological considerations suggest an important role for SCPs in the modulation of excitation thresholds of cortical pyramidal cells [the source of surface EEG]” (Langley, 2001).  Hinterberger (2004) summarizes as follows: ”negativity represents the mobilization or readiness, positivity represents ongoing cognitive and neural performance or inhibition of neuronal activity.”

Figure 1. Average EEG waves during voluntary production of cortical negativity (red) and positivity (blue), with passive viewing (no SCP shift) shown in green. Taken from Birbaumer et al., 2003

The early work by Niels Birbaumer and his group at the University of Tubingen, in Tubingen, Germany, showed that control of these SCP shifts can be learned (Kubler et al., 1999; Birbaumer et al., 2000; Kubler et al., 2001, Wolpaw et al., 2002) (Figure 1). This was recently correlated to changes in fMRI data to further validate the previous findings (Birbaumer et al., 2003).   Using biofeedback, patients were taught to control their SCPs to produce the positive and negative shifts required to select letters or words in a computer program.  This was quite an inspiring undertaking with touching results, as one of the first successful messages typed using the device was a heartfelt thanks to Dr. Birbaumer and his team (Geary, 2002).

Applied to epilepsy, it is believed that suppressing negative SCP shifts can help to limit the electrocortical activation of the brain and control the incidence of seizures (Kotchoubey et al., 2001; Rockstroh et al., 1993).

Contrarily, when applied to ADHD, negative shifts are encouraged in the hopes that the subjects can retain the skills required to reproduce the general activation and apply it when concentration is required (Strehl et al., 2006; Drechsler et al., 2007).  Innovative ways to have children apply the method to their everyday life have been proposed as well.  For example, they are given a card on which is displayed an image of the feedback they received while training, and are instructed to try to replicate the self-regulation while looking at the card.  Results have been encouraging, and there is more significant validation work currently underway (Riss, 2008).

Figure 2. Average CNV during assessment of migraine disorder. Migraine patients appear to produce increased negative amplitudes in the pain-free interval (thick line) compared with healthy controls (thin line). Protocol and method of analysis are similar to the Tubingen approach shown in Figure 1. Taken from Kropp et al, 2002. Note: scale is positive DOWN.

Several other applications exist, including depression (Schneider et al., 2005a), substance abuse (Schneider et al., 2005c) and schizophrenia (Gruzelier et al., 1999; Schneider et al, 2005b), to name a few.  A large list of abstracts has been compiled to serve as a recent review of literature regarding self-regulation of SCP (Langley, 2001). Researchers at the University of Kiel have applied this same technique to the assessment and treatment of migraine (Siniatchkin et al., 2000a; Siniatchkin et al., 2000b; Kropp et al., 2002) (Figure 2).  As seen in Figure 3, migraine sufferers exhibit increased amplitudes as well as reduced habituation of the Contingent Negative Variation, or CNV – a negative SCP shift in response to preparation (Andrasik and Rime, 2007). During training, subjects are taught to suppress negative SCP shifts to reduce frequency and intensity of migraine attacks.  An adaptation of the Tubingen protocol is suggested as a standard for assessment and training of SCP applied specifically to migraine (Kropp, 2000).

Why is it not so straight forward?
As previously mentioned, the DC and low frequency range of the EEG signal are often selectively omitted from recordings simply because of the complexity involved with their inclusion.  Several effects – physiological, mechanical, electrical, and chemical – exist to make the recording of EEG with a DC amplifier somewhat of a challenge.  Historically, the best way to deal with this has been to filter out the low frequencies.  To properly acquire and analyze DC-EEG, the issues involved must be well understood and carefully accounted for, as they have been in almost all of the literature on the topic, at least as experienced by the author of this article.  That is not to say that a DC amplifier is not a wonderful tool, only that it comes with great responsibility.  Or, more simply put: there is no free lunch!

Figure 3. Average CNV in migraine patients, with focus on early and late CNV components. Traces A and B in top pane were recorded the day before an attack, traces C and D were recorded 2 days following. Traces A and C were measured during stress, traces B and D during rest. Trace B during stress and before an attack, a clear increased negative CNV can be seen. Taken from Andrasik and Rime, 2007. Note: scale is positive DOWN.

DC drift
First things first, the DC value of the EEG, or the baseline about which the signal oscillates, actually changes over time.  This effect is called DC drift.  The rate of this drift is influenced by several factors, the most significant of which is electrode polarization.  Electrode polarization is the electro-chemical effect that exists when a metallic electrode is placed in contact with an electrolyte (the conductive gel in this case) and the scalp.  A chemical reaction begins during which ions are attracted to the surface of the electrode and charge begins to accumulate.  This occurs at each electrode site in different quantities and at different rates, and this discrepancy in charge accumulation creates a voltage that is measured by the system (a.k.a. the battery effect).  To make a long story short, the system ends up measuring this additional voltage in parallel with the EEG.

Figure 4. Raw, unfiltered DC-EEG captured with sintered silver/silver/chloride electrodes, shortly after placement. Note the floating baseline (downward in this case) and the very high drift rate of almost 1000 uV in 4 mins (approx. 250 uV / minute). While this drift does decline after some time has elapsed and electrode polarization has reached equilibrium, it is always present in DC-EEG.

The only way to completely remove this effect is to completely remove the low frequencies.  When this is not an option, efforts to minimize the effect of DC drift should be made.  Also, more important than equipment specifications or technical features, the experimental or clinical paradigm should be such that the effect of DC drift, and all other low frequency artifacts, is inherently ignored by the design of the protocol (more on this later).

To minimize the effect of DC drift, specific amplifier characteristics are required and special electrodes must be used.  The amplifier requirements are not so stringent, and are met by most modern commercial DC systems.  The special electrodes are made of sintered silver-silver chloride.  The term sintered implies a specific manufacturing process, by which the chloride is added to the silver throughout the material and becomes part of the entire electrode, as opposed to comprising a thin sheet on the surface as with regular silver-silver chloride electrodes.  A nice comparison of the low frequency performance of most commercially available electrodes was performed by Talgren et al. (2005a), and the results are straight forward: only this type of electrode will do for low frequency recordings.  It offers the lowest electrode polarization (and hence contribution to DC drift), the least low frequency noise and the best long-term stability. Several chloride-based conductive pastes are recommended as well (among these are name brands EC2, Ten20, and Electro-Gel).

The sintered Ag/AgCl electrodes themselves are somewhat delicate.  They are absorbent and should not be left in contact with any substance for very long, lest they absorb foreign ions and then performance becomes degraded.  They should be cleaned immediately after use and never left with any paste affixed that can dry and harden.  Ideally they should be rinsed with distilled water and should be left to hang dry.  It is also sometimes recommended that before use, soaking them in a saline solution for up to an hour can help reduce polarization and decrease settling time once they are actually applied.

In addition to using these electrodes and pastes, careful preparation and placement techniques should be employed to ensure reliability, lower electrode impedance, and avoid artifacts related to the skin-electrode interface as much as possible.

Skin-electrode interface
Two important requirements for DC-EEG were described in context of DC drift (a stable system with good amplifier specifications, and high quality non-polarizing electrodes with a chloride-based conductive paste).  The third important requirement for DC-EEG involves the skin-electrode interface, which is determined by how well the skin is prepared and the electrodes are applied.

Integrity of the skin-electrode interface is crucial to minimizing artifacts due to electrode movement and transdermal potentials (specifically galvanic skin response, or GSR).  Tallgren (2005b, 2006) warns that the only way to avoid electrode movement artifacts is to fix the electrode with collodion (a pyroxilin-based surgical adhesive often used to fix surface EEG electrodes for long term recording) or other method (proprietary methods are described) and to ensure a constant amount of paste is always used.  Bauer et al. (1989) recommend that the electrode gel be properly evacuated using a vacuum pump to avoid air bubbles in the gel.

Tallgren (2005b, 2006) also warns that the only way to avoid GSR artifact, and to reliably record slow cortical potentials with a DC amplifier is to short circuit the skin, meaning it must be punctured.  While this would seem extreme, it is repeatedly mentioned as a critical requirement in DC-EEG.  Recent studies by Hennighausen et al. (1993), Bauer et al. (1989), Voipio et al. (2003) and Tallgren (2005b) confirm previous studies by Picton and Hillyard (1972) and Cowen (1974) in which continuous, unpredictable DC drifts and often a profound contamination by GSR were measured when skin was left intact.

Other important effects
Eye movement is another significant source of artifact in DC-EEG recordings.  Sometimes confused as ocular EMG, the signal produced by the eye is in fact due to the electrical properties of the eye itself. The eye acts as an electrical dipole and produces a signal that is captured by the EEG amplifier. Eye blinks are well-known contaminants in neurofeedback, but eye movement and even eye position are important in DC-EEG as they contain considerable low frequency content. Eye position is in fact a DC signal itself, and it influences the baseline of the EEG signal; upward gazes will shift the baseline upwards, and downward gazes downwards. In addition to acting as an artifact, in SCP protocols eye movements can actually influence the feedback by mimicking the required positive and negative shifts in the SCP (voluntarily or otherwise).

Respiration causes another, lesser-known physiological artifact in DC-EEG. Voipio et al. (2003) make a strong case for a non-neuronal generator of DC shifts, manifested as negative shifts linked to hyperventilation and positive shifts linked to hypoventilation, both directly caused by changes in partial pressure of carbon dioxide (PCO₂) in the brain.  Speckmann and Elger (2005) also present a clear positive shift during hypercapnia (increased CO₂).

Finally, the influence of inter-subject variability which always helps to keep things interesting.  According to Kotchoubey et al (2000), “subjects differ greatly in their ability to learn” and “independently of this, humans differ substantially in their overall tendency to produce positive or negative shifts, regardless of the task.” That said, a quote from Hinterberger et al. (2003) is interesting:

Success in self-regulation training depends not only on the correct selection of technical parameters, but also on the patient’s psychological and physical state, motivation, social context, and the trainer-patient-relationship. Recent data demonstrated that self-regulation and communication skills of severely paralyzed patients could be predicted from the results of the initial training period: Patients who later acquired the self-regulation skill well enough to communicate (i.e., > 75% correct responses), had already showed a high performance (>80%) in the first 30 training sessions (about three training days [at 7-10 sessions per day, 4-8 minutes per session]) (Neumann and Birbaumer, 2003). Attentional capacities and motivational factors might be responsible for these performance differences between patients.

Siniatchkin et al. (2000b) also confirm previous reports that children and adults can successfully learn self-regulation of SCP within 2 sessions.

What has been done?
It would appear nearly impossible to work with DC-EEG with all these sources of artifact and ambiguity.  An obvious question arises: How has self-regulation training of SCP been achieved if simply measuring the signal is so complicated?  Thankfully there has been significant innovative work that has shown solid results through practical methodology, with the a priori intention of influencing clinical practice to follow suit.

AC vs. DC
The suggestion has been made that DC-EEG is the only way to record slow potentials (Voipio et al., 2003; Tallgren, 2006).  Even more benefits are appreciated when no filters whatsoever are applied, and the more apt term full-band EEG, or fbEEG, is adopted (Vanhatalo et al., 2005).  These are certainly valid arguments, and the authors make a strong theoretical case as applied to several areas of EEG analysis.  For real-time neurofeedback however, DC-EEG is simply too impractical for use in a clinical setting.  The authors agree, as mentioned above, that an absolute requirement, at the very least, is to puncture the skin.  Co-author Pekka Tallgren, in his own comprehensive treatise on clinical DC-EEG (Tallgren, 2006), concludes after having tested several different methods to short circuit the skin, that there is no simple, quick, practical solution and that this remains a significant problem in the use of DC-EEG for clinical work.

In fact, most often DC amplifiers have not been used in the research of low frequency EEG because the complexity simply outweighs the benefits.  All of the research quoted in this article, as well as that of many other studies, was mostly carried out using low frequency AC amplifiers (amplifiers that omit the DC component).  Birbaumer’s original Thought Translation Device (Birbaumer et al, 2003) and much of the work at Tubingen was implemented with a PSYLAB EEG8 amplifier from Contact Precision Instruments, which not surprisingly has a low frequency cutoff of 0.01 Hz.

That said, a DC amplifier can certainly be used, and would indeed record a theoretically pure SCP, but until more research is done and new discoveries are made, the DC-EEG issues outlined above cannot be ignored.  The cost involved with using an AC amplifier is that a small portion of the SCP signal is lost.  Also, the dynamics of the AC amplifier are such that recovery from movement artifacts require quite a long time.  Thus, failing to identify these artifacts renders the recording useless, and avoiding or removing them becomes mandatory.

The benefit is a significant reduction in DC drift, although several of the same exogenous artifacts still exert influence albeit to a lesser degree.  In essence, the extent of the trade-off depends on the cutoff of the AC amplifier.  The lower it is, the more DC effects are included; the higher it is, the less pure SCP is recorded.  The usual operating point is such that some low frequency effects are tolerated and an acceptable (although unknown) amount of SCP is filtered.

Standard Protocols based on the Tubingen Research
Electrode placement is at the vertex (‘Cz’ in the International 10-20 system) referenced to linked mastoids.  To differentiate the SCP from DC drift and other low frequency artifacts, the mean SCP amplitude is computed relative to a trailing baseline and the clinical protocols are designed to isolate the positive and negative shifts from the background EEG. The general idea is that self-regulation via visual or auditory information is coordinated with an “effector,” either motor (push button response) or non-motor (imagery and thinking) that explicitly elicits SCP output (Kotchoubey et al., 2000).

This is achieved using oddball paradigms and multi-trial averaging, such that repeated efforts to move the SCP in one direction or another are averaged separately.  This ensures that what is trained and measured is in fact the self-induced shifts that are required as immediate responses to the stimuli pairs (target and non-target, for example; or positive and passive, negative and passive, or positive and negative).  It also allows measurement of the respective SCPs, and hence the ability to quantify the progress of the self-regulation training by reporting an actual amplitude reading for a given session.

Figure 5. DC-EEG shown with timeline of stimuli event triggers (indicating when the stimuli were presented). The pre-stim baseline is defined as directly before the stimulus, and the response SCP is immediately after. Before averaging, the baseline is removed from the SCP response such that what is captured is the explicit change in slow EEG output in response to the self-regulation cue, as mentioned in Kotchoubey et al., 2000.

To maximize learning, positive and negative shifts are randomly distributed.  Trials also exist both with and without feedback.  Feedback is given when the individual SCP shift produced is large enough to reach a threshold.  The trials without feedback are called transfer trials as they are designed to transfer the ability to produce shifts in real life situations, when no feedback exists.

The number of sessions varies, but in general the strategy includes groups of sessions separated by periods of non-training.   For example, one of Dr. Strehl’s ADHD protocols includes thirty 1-hour sessions, in three groups of ten, with each group lasting two weeks (five days per week) and separated by a 4-6 week break (Strehl et al., 2006).

To eliminate the influence of EOG and the CO₂ effect
Eye movements should be discouraged as much as possible.  The gaze of the subject should be fixed and the subject should be instructed only to blink between trials (to avoid eye blinks being included in the trial averages).

In a slightly more advanced approach, EOG can be measured simultaneously and each or any combination of the following can be done:  feedback can be interrupted when EOG activity exists, the EEG recording can be marked to indicate presence of EOG, and the EOG can be removed offline.

The Birbaumer group in most cases performs the subtraction online to ensure that feedback is not given for eye movements.  This is implemented using a direction-independent method such that eye movement interrupts feedback but does contribute to it (by moving in the opposite direction, for example) (see Kotchoubey et al., 2000).  Offline correction is also performed before analysis of the averages.  This is a very useful technique that would seem to apply very well to general artifact removal in any type of biofeedback protocol.  The online method does not necessarily have to be perfect, as long as processing times are fast and feedback is not influenced, and the associated offline method can require more processing power to remove artifacts accurately for the analysis of the data.

Respiration can also be measured to ensure that breathing remains calm and rhythmic (e.g. 4-6 breaths per minute).  At the very least, breathing can be monitored visually without necessarily recording respiration, and the practicing clinician can respond to irregular breathing appropriately.

Conclusion
All of the technical and scientific challenges presented in this article are by no means meant to frighten or deter the reader from further exploring DC-EEG and self-regulation of SCPs.  On the contrary; they are presented to inform so that as the new techniques are adopted, the likelihood of positive clinical outcomes is maximized. An analogous discussion could be about driving a car, in which the concepts of a gas pedal and brakes, a clutch and stick shift, a steering wheel, road conditions, traffic signs, pedestrians and speeding tickets may seem frightening and may even be strong deterrents.  Most of us drive a car every day without considering these things to be overwhelming challenges, yet we are intimately aware of each and every one of them every time we get behind the wheel.

Clearly all the successful researchers who obtained results both experimentally and clinically with SCPs were well aware of these DC-EEG issues, and they managed, through this knowledge and with much creativity and determination, to achieve applicable results.  As a clinician, thankfully you need not reinvent the wheel.  That is the point of relying on research: you stand, so to speak, on the shoulders of giants.   At the same time, clinical work is the loop that closes the circle, and research cannot truly progress without a venue for the applications it suggests.  True progress is gained through collaboration, and only a consistent effort can continue to drive the field.

Figure 6. BioGraph Infiniti screen showing voluntary SCP production of positivity (red) and negativity (blue). Also displayed are mean values for early and late SCP components. Mean total SCP values are shown along the right. Reaction time statistics are also displayed here, and are optionally available in parallel with SCP measurements as they reflect attention and focus (low errors) and motor readiness (low mean reaction times). Note: scale is positive UP.

If you would like to know more about DC-EEG, SCP and assessment and training techniques using Thought Technology’s new line of SCP equipment for the Infiniti platform (Figure 6.), please contact Marc Saab at Thought Technology.

Mark Saab
Thought Technology

Editorial Comment From CFisher:
Those who are not familiar with NeuroConnections can now better understand of the quality of their articles. NeuroConnections is a free benefit of membership from the International Society for Neurofeedback and Research (ISNR) and available only in printed format. I encourage all professionals who specialize in neurofeedback, biofeedback or QEEG to join ISNR to receive NeuroConnections and other member benefits. The above article was reprinted from NeuroConnections (January, 2009) with permission from ISNR.

References:
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Bauer H, Korunka C, Leodolter M.  Technical requirements for high-quality scalp DC recordings.  Electroencephalography and Clinical Neurophysiology; 72: 545-547, 1989.

Birbaumer N, Elbert T, Canavan GM, Rockstroh B.  Slow potentials of the cerebral cortex and behaviour.  Physiol. Rev.; 70: 1-41, 1990.

Birbaumer N, Kübler A, Ghanayim N, Hinterberger T, Perelmouter J, Kaiser J, Iversen I, Kotchoubey B, Neumann N, Flor H.  The thought translation device (TTD) for completely paralyzed patients.  IEEE Trans. Rehab. Eng.; 8: 190-193, 2000.

Birbaumer N, Hinterberger T, Kübler A, Neumann N.  The Thought-Translation Device (TTD): Neurobehavioral Mechanisms and Clinical Outcome.  IEEE Trans. on Neural Sys. and Rehab Eng.; 11(2), 2003.

Cowen MA. The brain as generator of transcephalically measured direct current potentials. Psychophysiol.; 11:321-35.  1974

Drechsler R, Straub M, Doenhart M, Heinrich H, Steinhausen HC, Brandeis D.  Controlled evaluation of a neurofeedback training of slow cortical potentials in children with ADHD.  Behavioral and Brain Functions; 3(35), 2007

Geary J.  The Body Electric: An anatomy of the new bionic senses.  Rutgers University Press.  Piscataway, NJ.  2002.

Gruzelier JH, Hardman E, Wild J,  Zaman R. Learned control of slow potential interhemispheric asymmetry in schizophrenia. International Journal of Psychophysiology; 34: 341-348, 1999.

Hennighausen E, Heil M, Rosler F.  A correction method for DC drift artifacts.  Electroencephalography and Clinical Neurophysiology; 86: 199-204, 1993.

Hinterberger T, Houtkooper JM, Kotchoubey B. Effects of feedback control on slow cortical potentials and random events.  The Parapsychological Association Convention; Vienna, Austria. 2004

Hinterberger T, Schmidt S, Neumann N, Mellinger J, Blankertz B, Curio G, Birbaumer N.  Brain-computer communication and slow cortical potentials.  TBME-00279-2003, 2003.

Kotchoubey B, Haisst S, Daum I, Schugens M, Birbaumer N.  Learning and self-regulation of SCP in older adults.  Experimental Aging Research; 26: 15-35, 2000.

Kotchoubey B, Strehl U, Uhlmann C, Holzapfel S, König M, Fröscher W, et al. Modification of slow cortical potentials in patients with refractory epilepsy: A controlled outcome study. Epilepsia; 42: 406-416, 2001.

Kropp P, Kiewitt A, Göbel H, Vetter P, Gerber Wd.  Reliability and stability of contingent negative variation.  Applied Psychophysiology and Biofeedback;  25 (1): 13-32, 2000.

Kropp P, Siniatchkin M, Gerber WD.  On the pathophysiology of migraine – links for “empirically based treatment” with neurofeedback.  Applied Psychophysiology and Biofeedback; 27 (3): 203-213, 2002.

Kübler A, Kotchoubey B, Hinterberger T, Ghanayim N, Perelmouter J, Schauer M, Fritsch C, Taub E, Birbaumer N.  The thought translation device: a neurophysiological approach to communication in total motor paralysis. Exp. Brain Res.; 124: 223-232, 1999.

Kübler A, Kotchoubey B, Kaiser J, Wolpaw J, Birbaumer N. Brain-computer communication: unlocking the locked-in.  Psych. Bull.; 127(3): 358-375, 2001.

Langley Z.  Slow cortical potentials: neurobehavioral management of epileptic seizures – An interview with Dr Ute Strehl.   2001.  Personal website of Professor Zoe L. Langley, Indiana University.  Last accessed Dec 2008:  http://www.indiana.edu/~pietsch/zoestrehl.html

Langley Z.  Slow cortical potentials: A survey of the recent literature.  2008.   Personal website of Professor Zoe L. Langley, Indiana University.  Last accessed Dec 2008: http://www.indiana.edu/~pietsch/scp.html

Neumann N, Birbaumer N. Predictors of successful self-control during brain-computer communication.  Journal of Neurology, Neurosurgery, & Psychiatry; 74(8): 1117-1121, 2003.

Picton TW, Hillyard SA. Cephalic skin potentials in electroencephalography. Electroencephalography and Clinical Neurophysiology; 33(4): 419-424, 1972.

Riss R, Strehl U.  Slow Cortical Potentials in the Treatment of ADHD – An interview with Ute Strehl.  NeuroConnctions newsletter.  ISNR and AAPB, October 2008.

Rockstroh B, Elbert T, Birbaumer N, Wolf P, Düchting-Röth A, Reker M, et al.. Cortical self-regulation in patients with epilepsies. Epilepsy Research; 14: 63-72, 1993.

Schneider F, Heimann H, Mattes R, Lutzenberger W, Birbaumer N.  Self-regulation of slow cortical potentials in psychiatric patients: depression.  Applied Psychophysiology and Biofeedback; 17 (3): 203-214, 2005.

Schneider F, Rockstroh B, Heimann H, Lutzenberger W, Mattes R, Elbert T, Birbaumer N, Bartels M.  Self-regulation of slow cortical potentials in psychiatric patients: schizophrenia.  Applied Psychophysiology and Biofeedback; 17 (4): 277-292, 2005.

Schneider F, Elbert T, Heimann H, Welker A, Stetter F, Mattes R, Birbaumer N, Mann K.  Self-regulation of slow cortical potentials in psychiatric patients: alcohol dependency.  Applied Psychophysiology and Biofeedback; 18 (1): 23-32, 2005.

Siniatchkin M, Hierundar A, Kropp P, Kuhnert R, Gerber WD, Stephani U.  Self-regulation of slow cortical potentials in children with Migraine: an exploratory study.  Applied Psychophysiology and Biofeedback; 25 (1): 13-32, 2000.

Siniatchkin M, Kropp P, Gerber WD.  Neurofeedback – The significance of reinforcement and the search for an appropriate strategy for the success of self-regulation.  Applied Psychophysiology and Biofeedback; 25 (3): 167-175.  2000.

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Strehl U, Leins U, Goth G, Klinger C, Hinterberger T, Birbaumer N. Self-regulation of Slow Cortical Potentials: A New Treatment for Children With Attention-Deficit/Hyperactivity Disorder. Pediatrics; 118: 1530-1540, 2006.

Talgren P, Vanhatalo S, Kaila K, Voipio J.  Evaluation of commercially available electrodes and gels for recording of slow EEG potentials.   Clinical Neurophysiology; 116: 799-806, 2005.

Tallgren P. DC-stable electrode-skin interface for human EEG recordings. Helsinki University of Technology, Applied Electronics Laboratory, Series E: Electronic Publications, E5: 3-12, 2005.

Talgren P.  DC-EEG for routine clinical use: methods and clinical impact.  Doctoral dissertation  – Applied Electronics Lab., Helsinki University of Technology  – Helsinki. ISBN 951-22-6955-4. 2006.

Vanhatalo S, Voipio J, Kaila K.  Full-band EEG (FbEEG): an emerging standard in electroencephalography. Clinical Neurophysiology; 116: 1-8, 2005.

Voipio J, Tallgren P, Heinonen E, Vanhatalo S, Kaila K.  Millivolt-Scale DC Shifts in the Human Scalp EEG: Evidence for a Nonneuronal Generator.  Journal of Neurophysiology; 89: 2208-2214, 2003.

Wolpaw JR, Birbaumer N, McFarland DJ, Pfurtscheller G, Vaughan TM. Brain-computer interfaces for communication and control. Clin. Neurophysiol.; 113(6): 767-791, 2002.

The current study used a match control design to record the QEEG of unmedicated patients (n=22) with OCD (free of medication and depression) and healthy controls (n=20) in resting and hyperventilation conditions. QEEG consisted of 30 minutes of eyes closed recordings referenced to Cz. Frequency bands were defined as follows: delta (.5-3.0Hz), theta (3.5-8.0Hz) alpha (8.5-12Hz), beta (12.5-30 Hz). Hemispheric asymmetry and regional differences (frontal F3, F4, F7, F8; temporal T3, T4, T5, T6; parietal P3, P4) were assessed.

Participants in the OCD group were predominately female (n=17) with an average age of 28 (SD=7; range 14 to 47), while those in the control group were also mostly female (n=14) with mean age of 30 (SD=2; range 18 to 39). Subjects were further assess with the Hamilton Depression Rating Scale (HDRS) and Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Patients with OCD then received pharmacotherapy (11=fluvoxamine; 4=fluoxetine; and 5=sertraline) after the initial QEEG assessment.

QEEG analysis of relative power revealed that those with OCD had a significant increase in 2-4Hz (delta) and 5-7Hz (theta) activity in the frontotemporal areas and a decrease in 8-12Hz (alpha) activity in the left frontal region in resting states, as well as significantly deficit beta activity in left frontal recordings during hyperventilation. Excessive delta in the left hemisphere appeared to be the most prominent overall finding. Researchers further found that heightened left temporal theta activity in resting state conditions correlated with increased illness duration, that left frontotemporal dysfunction best characterized females with OCD and those who responded to pharmacotherapy, and that the severity of left frontotemporal dysfunction was positively associated with OCD severity.

The obvious implications for neurofeedback include inhibiting the excessive slow wave activity found in the fronto-temporal areas based on the patient’s QEEG. Enhancing deficient alpha represent an additional protocol; however, I often utilize inhibit protocols first and only enhance when needed. I am also uneasy about increasing alpha in the temporal lobes.

Of course, the above neurotherapy protocols are speculative and need further research to support their use. Responsible neurotherapy should only be conducted based on the patient’s presenting symptoms and personal EEG, not generic protocols found on a website.

A few comments about this study. The data was somewhat difficult to interpret, although I believe the summary above is accurate. I would like know more about the mens’ brain maps. One potential confound I recognized in this study was that participants underwent 30 minutes of eyes closed recordings. This is a fairly long recording that likely introduced some drowsiness, and I am interested to know if the above findings persist if only the first few minutes of the EEG recording were used.

Enjoy.

CFisher

Reference:
*Tot, S., Ozege, A., Comelekoglu, U., Yazici, K., & Bal, N. (2002). Association of QEEG Findings With Clinical Characteristics of OCD: Evidence of Left Frontotemporal Dysfunction. Canadian Journal of Psychiatry, 47(6), August, 538-545.

In this cross-sectional case control study, children aged 3-12 years received a QEEG using the International 10–20 system during rest and hyperventilation states. Frequency band were defined as: delta (0.5–3 Hz), theta (3.5–8 Hz), alpha (8.5–12 Hz), and beta (12.5–30 Hz). No subjects in experimental group (male = 20, average age = 6.9; age range 3-12) or control group (male = 14, average age = 8.8; age range 4-11) exhibited epileptiform activity.

Visual examination of the raw EEG found increased parieto-occipital slow waves in 4 participants with stuttering and 1 in the control group. One child with stuttering had obvious fronto-central asynchronic slow waves.

An overall summary of the QEEG analysis, irrespective of montage, was that children who stuttered exhibited significantly increased delta and theta and reduced alpha and beta when compared to controls. These differences were apparent during resting background activity and at hyperventilation, except that theta increased only during hyperventilation. QEEG analysis of hemispheric asymmetry at rest found significantly more delta in the right frontal regions (56.6 ± 16.2%) than in the left (49.8 ± 16.7%) for those who stutter. Compared to the control group, children who stutter exhibited increased delta in the right front regions (56.6 ± 16.2% versus 41.8 ± 17.7%, p = 0.004) and parietal regions (47.9 ± 25.5% versus 27.9 ± 15.7%, p = 0.003) at rest, and increased delta (45.3 ± 21.2% versus 34.3 ± 10.5%) in the right parietal region during hyperventilation. Children who stutter also had significantly lower alpha in the left and right frontal regions at rest and in the right frontal region during hyperventilation, as well as significantly lower beta in the left region during rest and in the bi-lateral temporal regions during hyperventilation.

The researchers summarized these results as:

“The results of QEEG analysis revealed increased slow wave, especially delta, activity both of the recordings from resting state and hyperventilation in the children with stuttering compared to the controls. These observations were supported by decreased alpha and beta activity all of the brain recordings, especially from right frontal and bi-temporal regions. Our results suggested a possible role of right frontal….dysfunction during resting state and bi-frontal neuronal dysfunction during hyperventilation.” (pg. 278).

Although the authors did not discuss the treatment implications for neurofeedback, there is a wealth of data here that suggests that stuttering may be amenable to neurotherapy. It appears that neurotherapists could target the overall excessive delta/theta with appropriate inhibit protocols and deficient alpha/beta with relevant enhance protocols. I tend to use inhibit protocols first and only enhance as needed. Restoration of the significantly deviant delta asymmetries may represent an additional neurofeedback protocol. I am cautious to enhance delta so I might inhibit the right hemisphere before I would enhance on the left. Excessive delta in the right hemisphere (frontal/parietal regions) suggest a possible “disconnect” from the left brain and overall slow information processing. Additionally, deficient beta in the left hemisphere could be a particularly important target since this side the brain handles language for most persons.

Of course, the above neurotherapy protocols are speculative and need further research to support their use. Responsible neurotherapy should only be conducted based on the patient’s presenting symptoms and personal EEG, not generic protocols found on the internet.

Reference:
*Ozege, A., Toros, F., & Comelekoglu, U. (2004). The Role of Hemispheral Asymmetry and Regional Activity of Quantitative EEG in Children with Stuttering. Child Psychiatry and Human Development, Vol. 34(4), Summer, 269-280.

As you can imagine, many biofeedback/neurofeedback practitioners expressed their unhappiness with this decision and cited various reasons why they disagree with Blue Cross/Blue Shield, including their failure to incorporate important studies in their review. They further called on their colleagues and professional organizations to petition these findings. Additionally, if I read the Blue Cross/Blue Shield Position Statement right, they state that biofeedback for migraine is an acceptable treatment. This would be a welcome finding if true.

Here is the Blue Cross/Blue Shield Position Statement in its entirety:

Subject: Biofeedback Therapy and Neurofeedback
Policy #: MED.00023 Current Effective Date: 04/22/2009
Status: Revised Last Review Date: 02/26/2009

Description/Scope

Neurofeedback is a specific technique where the electroencephalogram (EEG) is used as the source of feedback information in order to modify brain activity.

Position Statement

Investigational and Not Medically Necessary:

Electroencephalogram (EEG) biofeedback, also known as neurofeedback, is considered investigational and not medically necessary for all conditions.

The use of unsupervised home biofeedback devices is considered investigational and not medically necessary for all conditions.

Rationale

Results of randomized controlled trials of individuals with migraine or tension headaches have shown that biofeedback is associated with a decrease in the headache pain and use of less migraine medication compared to individuals treated with self-relaxation therapy alone (Nestoriuc and Martin, 2007; Nestoriuc, 2008).

The American Academy of Family Physicians (AAFP) 2000 guidelines on preventive therapy for migraines, based on evidence review by the U.S. Headache Consortium, recommend that “relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback and cognitive-behavioral therapy may be considered as treatment options for prevention of migraine (Grade A recommendation).” (Campbell, 2000; Morey, 2000)

The National Institute of Neurologic Disorders and Stroke (NINDS) states that “when headaches occur three or more times a month, preventive treatment is usually recommended. Drug therapy, biofeedback training, stress reduction, and elimination of certain foods from the diet are the most common methods of preventing and controlling migraine and other vascular headaches. Drug therapy for migraine is often combined with biofeedback and relaxation training.” (NINDS, 2008)

At this time there is insufficient or conflicting evidence in the peer-reviewed literature comparing biofeedback to established treatment modalities (e.g. pharmacotherapy or behavior therapy), to conclude that biofeedback therapies or neurofeedback (i.e. EEG biofeedback) are effective treatments for other conditions, including, but not limited to, anxiety disorders, asthma, attention deficit disorder (ADD), attention deficit hyperactivity disorder (ADHD) (Drechsler, 2007; Leins, 2007), cardiovascular disease, constipation, endometriosis-associated pain, hypertension (Nakao, 2003; Rainforth, 2007), insomnia, learning disabilities, menopausal hot flashes, movement disorders, Raynaud’s syndrome (Middaugh, 2001), seizure disorders, or substance abuse-related disorders.

Biofeedback medical devices are classified by the U.S. Food and Drug Administration (FDA) as Class II, special controls, medical devices, subject to certain limitations and exempt from 510(k) pre-market notification. Despite the availability of numerous biofeedback devices for home use, biofeedback has not been adequately studied in unsupervised home settings.

Background/Overview

Neurofeedback (i.e. EEG biofeedback) describes the feedback of neural information and has been investigated as a treatment of a variety of disorders including ADHD, anxiety and panic disorders, depression, learning disabilities, menopausal hot flashes, seizure disorders, sleep disorders, stress management, substance abuse and related disorders, or traumatic brain injury. Although related in concept to biofeedback, neurofeedback differs in that the information fed back to the individual (i.e. EEG tracings) is a direct measure of global neuronal activity, while other biofeedback technique provide feedback on specific physiological processes such as tension of specified muscle groups or skin temperature. The individual may be trained to either increase or decrease the prevalence, amplitude or frequency of specified EEG waveforms (e.g., alpha, beta, theta waves), depending on the changes in brain function associated with the particular disorder.

90901 Biofeedback training by any modality

When services are Investigational and Not Medically Necessary:
For the procedure codes listed above, for all other diagnoses not listed, or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

When services are also Investigational and Not Medically Necessary:
CPT 90911 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry
No specific code for EEG biofeedback (neurofeedback)

HCPCS
E0746 Electromyography (EMG), biofeedback device
No specific code for EEG biofeedback (neurofeedback) device

ICD-9 Diagnosis
All diagnoses

References

Peer Reviewed Publications:

1.. Angelakis E, Stathopoulou S, Frymiare JL, et al. EEG neurofeedback: a brief overview and an example of peak alpha frequency training for cognitive enhancement in the elderly. Clin Neuropsychol. 2007; 21(1):110-129.
2.. Benner-Davis S, Heaton PC. Attention deficit and hyperactivity disorder: controversies of diagnosis and safety of pharmacological and nonpharmacological treatment. Curr Drug Saf. 2007; 2(1):33-42.
3.. Drechsler R, Straub M, Doehnert M, et al. Controlled evaluation of a neurofeedback training of slow cortical potentials in children with attention deficit/hyperactivity disorder (ADHD). Behav Brain Funct. 2007; 26:33-35.
4.. Egner, T, Gruzelier, J.H. EEG biofeedback of low beta band components: frequency-specific effects on variables of attention and event-related brain potentials. Clinical Neurophysiology. 2004; 115:131-139.
5.. Gardea M, Gatchel R, Mishra K. Long-term efficacy of biobehavioral treatment of temporomandibular disorders. 2001; 24(4):341-359.
6.. Grego D. Management of adolescent chronic pelvic pain for endometriosis: a pain center perspective. Journal Pediatric Adolescent Gynecology. 2003; 16:217-219.
7.. Hammond DC. Neurofeedback with anxiety and affective disorders. Child Adolesc Psychiatric Clin N Am. 2005; 14:105-123.
8.. Holtmann M, Stadler C. Electroencephalographic biofeedback for the treatment of attention-deficit hyperactivity disorder in childhood and adolescence. Expert Rev Neurother. 2006; 6(4):533-540.
9.. Lake EA. Behavioral and nonpharmacological treatments of headache. Headache. 2001; 85(4):1055-1075.
10.. Leins U, Goth G, Hinterberger T, et al. Neurofeedback for children with ADHD: a comparison of SCP and Theta/Beta protocols. Appl Psychophysiol Biofeedback. 2007; 32(2):73-88.
11.. Levesque J, Beauregard M, Mensour B. Effect of neurofeedback training on the neural substrates of selective attention in children with attention-deficit/hyperactivity disorder: a functional magnetic resonance imaging study. Neurosci Lett. 2006; 394(3):216-221.
12.. Meuret A, Wilhelm F, Roth W. Respiratory feedback for treating panic disorder. J Clinical Psychol. 2004; 60 (2):197-207.
13.. Michael AJ, Krishnaswamy S, Mohamed J. An open label study of the use of EEG biofeedback using beta training to reduce anxiety for patients with cardiac events. Neuropsychiatr Dis Treat. 2005; 1(4):357-363.
14.. Middaugh SJ, Haythornthwaite JA, Thompson B, et al. The Raynaud’s Treatment Study: biofeedback protocols and acquisition of temperature biofeedback skills. Appl Psychophysiol Biofeedback. 2001; 26(4):251-278.
15.. Monastra VJ. Quantitative electroencephalography and attention-deficit/hyperactivity disorder: implications for clinical practice. Curr Psychiatry Rep. 2008; 10(5):432-438.
16.. Nakao M, Yano E, Nomura S, Kuboki T. Blood pressure-lowering effects of biofeedback treatment in hypertension: a meta-analysis of randomized controlled trials. Hypertens Res. 2003; 26(1):37-46.
17.. Nestoriuc Y, Martin A. Efficacy of biofeedback for migraine: a meta-analysis. Pain. 2007; 128(1-2):111-127.
18.. Nestoriuc Y, Rief W, Martin A. Meta-analysis of biofeedback for tension-type headache: efficacy, specificity, and treatment moderators. J Consult Clin Psychol. 2008; 76(3):379-396.
19.. Proctor ML, Murphy PA, Pattison HM, et al. Behavioural interventions for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2007; (3):CD002248.
20.. Rainforth MV, Schneider RH, Nidich SI, et al. Stress reduction programs in patients with elevated blood pressure: a systematic review and meta-analysis. Curr Hypertens Rep. 2007; 9(6):520-528.
21.. Scharff L, Marcus DA, Masek BJ. A controlled study of minimal-contact thermal biofeedback treatment in children with migraine. J Pediatr Psychol. 2002; 27(2):109-119.
22.. Scott Morey, S. Practice guidelines of the American Academy of Family Physicians. Guidelines on migraine: part 4. General principles of preventive therapy. Am Fam Physician. 2004; 62(1):2359-2360, 2363.
23.. Siepmann M, Aykac V, Unterdörfer J, et al. A pilot study on the effects of heart rate variability biofeedback in patients with depression and in healthy subjects. Appl Psychophysiol Biofeedback. 2008; 33(4):195-201
24.. Sierpina V, Astin J, Giordano J. Mind-body therapies for headache. Am Fam Physician. 2007; 76(10):1518-1522.
25.. Silver N. Headache (chronic tension-type). Am Fam Physician. 2007; 76(1):114-116.
26.. Trautmann E, Lackschewitz H, Kröner-Herwig B. Psychological treatment of recurrent headache in children and adolescents-a meta-analysis. Cephalalgia. 2006; 26:1411-1426.
27.. Vasudeva S, Claggett AL, Tietjen GE, McGrady AV. Biofeedback-assisted relaxation in migraine headache: relationship to cerebral blood flow velocity in the middle cerebral artery. Headache. 2003; 43(3):245-250.
Government Agency, Medical Society, and Other Authoritative Publications:

1.. Applied Psychology and Biofeedback. Disorders that are amenable to intervention by biofeedback and neurofeedback. 2008. Available at: http://www.aapb.org/. Accessed on January 9, 2009.
2.. Campbell JK, Penzien DB, Wall EM. Evidenced-based guidelines for migraine headache: Behavioral and physical treatments. U.S. Headache Consortium 2000. Available at: http://www.aan.com/professionals/practice/pdfs/gl0089.pdf. Accessed on January 9, 2009.
3.. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Biofeedback. NCD #30.1 Effective date not posted. Available at: http://www.cms.hhs.gov. Accessed on January 9, 2009.
4.. Hayes Inc. Hayes Medical Technology Directory. Biofeedback for Headache and Chronic Musculoskeletal Pain. Lansdale, PA: Hayes, Inc.; November 3, 2004. Updated December 16, 2007.
5.. Hayes Inc. Hayes Medical Technology Directory. Biofeedback for the Treatment of Hypertension. Lansdale, PA: Hayes, Inc.; February 27, 2006. Updated March 3, 2008.
6.. National Institute of Neurologic Disorders and Stroke (NINDS). Headache information page. December 11, 2008. Available at: http://www.ninds.nih.gov/disorders/headache/headache.htm. Accessed on January 12, 2009.
7.. Silberstein, SD. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000; 55:754-762.
8.. U.S. Food and Drug Administration 510(k) Premarket Notification Database. Information on releasable 510(k) Biofeedback Devices. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/search/search.cfm. Accessed on January 9, 2009.
Index

Biofeedback-assisted Relaxation Therapy (BFRT)
BrainMasterTM
EEG Biofeedback
Neurofeedback
ProComp-2T
Temporomandibular Joint Disorder
Thermal Biofeedback
TMD

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available.

Document History
Status Date Action
Revised 02/26/2009 Medical Policy & Technology Assessment Committee (MPTAC) review. Revised subject of document to Biofeedback Therapy and Neurofeedback. Clarified position statement as follows: 1) Added “supervised” to the medically necessary statement and removed “when performed in an outpatient setting under the medical supervision of a qualified clinician, such as an adult or pediatric psychiatric or psychologist;” 2) Removed “thermal biofeedback or biofeedback-assisted relaxation therapy (BFRT)” from the investigational and not medically necessary statement, and added “unsupervised” to the home biofeedback device statement. Revised the description/scope, rationale, background/overview, and references. Removed the definition section.
Reviewed 10/01/2008 Updated coding section with 10/01/2008 ICD-9 changes.
Reviewed 02/21/2008 MPTAC review. Updated description, background, coding and references. The phrase “investigational/not medically necessary” was clarified to read “investigational and not medically necessary.” This change was approved at the November 29, 2007 MPTAC meeting.
Reviewed 03/08/2007 MPTAC review. Updated references.
Reviewed 03/23/2006 MPTAC review. Updated references.
11/17/2005 Added reference for Centers for Medicare and Medicaid Services (CMS) – National Coverage Determination (NCD).
Revised 04/28/2005 MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.
Pre-Merger Organizations Last Review Date
Document Number
Title

Anthem, Inc. 04/27/2004
MED.00023 Biofeedback Therapy
WellPoint Health Networks, Inc. 12/02/2004
2.10.16 Biofeedback for Headache
06/24/2004
10.10.01 Neurofeedback

It appears that those in the field of neurofeedback / biofeedback have their work cut-out for them in order to gain acceptance by major insurance companies.

Dr. Ochs described this new development as follows:

It [LENS] is an FDA-certified Class II medical device. It is “510K exempt.” The “Class II 510K exempt” medical device classification is a less restrictive certification than a 510-K certification, meaning that it is considered by the FDA as safer than the 510-K devices – which includes most other biofeedback and neurofeedback devices. The FDA notification letter immediately allows us to market the LENS as a biofeedback device for relaxation and self-regulation. How it is used is a function of what the provider’s licensing board allows.

The Behavioral Medicine Report congratulates Dr. Ochs on this fine accomplishment!

LENS is an intriguing treatment approach, and hopefully future articles on the LENS technology will be posted to The Behavioral Medicine Report. In the mean time, here are a few resources for those who want to learn more about LENS:

Books:

• Lens: The Low Energy Neurofeedback System, by D. Corydon Hammond, Ph.D.
• The Healing Power of Neurofeedback: The Revolutionary LENS Technique for Restoring Optimal Brain Function, by Stephen Larsen

Website:

• Och Labs

For your quick reference, neurofeedback is mentioned on pages 26, 32, and 33. Page 33 also has a particularly attractive sidebar entitled, “The Exciting Potential of Neurofeedback.”

Download the PDF from NIDA here.

CFisher

D. Corydon Hammond, Ph.D., Professor, Physical Medicine & Rehabilitation University of Utah School of Medicine, who is a highly regarded neurotherapist and researcher in the field of neurofeedback maintains and regularly updates the Comprehensive Neurofeedback Bibliography with the latest respected neurofeedback research. The citations cover a wide range of available neurofeedback research for various physical and mental disorders, such as fibromyalgia, Tourette’s Syndrome, autism, schizophrenia, autoimmune disorder, and post-traumatic stress disorder (PTSD). References are neatly organized by category throughout the bibliography, which makes for quick and easy browsing.

Download
Download the free PDF here
An online version is here.

The overall study design is complex. Please review the original article for a complete description. Primary outcome measures included pre/post naps, sleep onset latency times, sleep diaries, mood measures, declarative memory tasks, and polygraphic sleep recordings with sleep spindle analysis. 13 male and 14 female healthy subjects (mean age = 23.63; SD=2.69) were randomly assigned to receive SMR neurofeedback (experimental group) or randomized frequency neurofeedback (control group). The use of the randomized frequency neurofeedback is a brilliant way to ensure equal treatment of groups. Basically, persons in the control group are exposed to the exact same conditions as the experimental group except that the control group are reinforced with a different EEG frequency band (except 12-15 Hz, of course) at each session. I assume that subjects were blinded to condition, and it is unclear whether researchers were blinded to participant condition. Ten neurofeedback sessions were administered over 10 days (1/day) with a total session time of 1 hour. The neurofeedback protocol called for eight 3 minute blocks with each block containing a 3-second baseline (to calculate participant specific SMR amplitudes) followed by audio and visual reinforcement when SMR amplitudes exceeded threshold for 250ms (milliseconds) or longer.

The researchers report that participants benefited from SMR neurofeedback on number of sleep and memory related improvements. Specifically, participants in the experimental group exhibited significantly increased SMR amplitudes (demonstrates that conditioned learning occurred), enhanced sleep spindles, decreased sleep latency onset time, and improved memory after learning exercises at post-assessment. These are very impressive results, especially in light of the fairly low number of neurofeedback sessions (10). I wonder what additional improvements would be realized after 20-30 sessions?

The authors point out that while this experimental paradigm needs be investigated with an insomniac population, their findings combined with previous research strongly suggests that neurofeedback should be considered as a possible alternative treatment for primary insomnia. An additional question raised is whether increased SMR amplitudes per se accounted for the memory improvements or if they were due to heightened attention and/or relaxation. In fact, SMR training is commonly used for the treatment of Attention Deficit/Hyperactivity Disorder (ADHD) so these factors are certainly possible explanations for the improved memory recall.

I personally want to commend Hoedlmoser and colleagues for their notable creativity in this excellent neurofeedback design. Additional quality neurofeedback research is desperately needed that includes larger group sizes and randomized double blinded designs. I hope that the current study serves to inspire other neurofeedback researchers to refuse to accept sub-par study designs and to improve the credibility of their research through clever experimental paradigms.

CFisher

Reference:
*Hoedlmoser, K., Pecherstorfer, T., Gruber, G., Anderer, P., Doppelmayr, M., Klimesch, W., & Schabus, M. (2008). Instrumental conditioning of human sensorimotor rhythm (12-15 Hz) and its impact on sleep as well as declarative learning. Sleep, 31(10), 1401-1408.

Nine male and 4 female participants (n=13) diagnosed with antisocial personality disorder, aged 19-48, completed 80-120 QEEG-guided neurofeedback sessions. All subjects were medication free, received no other treatments, including psychotherapy, during neurofeedback, and had attended at least 1 other failed treatment (non-neurofeedback) before enrollment in this study. Pre/Post assessments included a clinical interview, QEEG assessment with normative database comparisons (NxLink), Minnesota Multiphasic Personality Inventory (MMPI), Test of Variables of Attention (TOVA), and the Symptom Assessment-45 Questionnaire.

The researchers reported that 12 of 13 subjects who completed treatment experienced remarkable improvements on measures of behavioral impulsivity (reductions in visual and auditory TOVA commission errors) and on all but one of the MMPI clinical scales, such as psychopathic deviancy, depression, psychasthenia (anxiety), and paranoia. For those more technically inclined, statistically meaningful improvements were noted on the following MMPI scales: L, F, K, Hs, D, Hy, Pd, Pa, Pt, Sc, Ma, and Si. Please see the article for examples of subject improvements reported by several participants. Neurofeedback was also believed to help treatment adherence. A 2-year follow up revealed that the 12 who benefited from treatment continued to do so, while the lone treatment non-responder had ongoing behavioral problems. The researchers did not elaborate on the details of the 2-year follow up.

Of course, this is a small clinical case series that did not include a control group. Thus one cannot say, “this caused that.” The methods used in this study suggest that the treatment gains could only be attributed to neurofeedback or a placebo effect (interactions with the researchers). If attributable to a placebo effect, this would one enormous, long lasting effect in this notoriously difficult to treat population! A controlled study would settle this debate.

The study also provided initial potential EEG phenotypes for persons with anti-social disorder. The researchers reported that all participants had excessive frontal alpha, theta, and beta amplitudes and coherences when compared to a normative database.

Several side notes: You may have noticed the large number of neurofeedback sessions used in this study. This is consistent with my training at the UNT Neurotherapy Lab where I learned that the more severe disorders, such Reactive Attachment Disorder (RAD), often require 100 or more sessions. The current study suggests that this may be true with personality disorders as well. Also, neurofeedback has many names, including “neurotherapy” and “EEG biofeedback.” The researchers in the current study introduced a new name (at least for me) for neurofeedback: neurobiofeedback.

CFisher

Reference:
*Surmeli, T., & Ertem, A. (2009). QEEG guided neurofeedback therapy in personality disorders: 13 case studies. Clinical EEG and Neuroscience, 40(1), 6-10.