Neurofeedback

Neurofeedback (NFB), also called neurotherapy, is a type of biofeedback that presents real-time feedback from brain activity in order to reinforce healthy brain function through operant conditioning. Typically, electrical activity from the brain is collected via sensors placed on the scalp using electroencephalography (EEG), with feedback presented using video displays or sound. There is significant evidence supporting neurotherapy for generalized treatment of mental disorders,[1][2] and it has been practiced over four decades, although never gaining prominence in the medical mainstream. NFB is relatively non-invasive and is administered as a long-term treatment option, typically taking a month to complete. A 30-minute to 60-minute neurofeedback session is typical.

Neurofeedback training process diagram

Several neurofeedback protocols exist, with additional benefit from use of quantitative electroencephalography (QEEG) or functional magnetic resonance imaging (fMRI) to localize and personalize treatment.[3][4] Related technologies include functional near-infrared spectroscopy-mediated (fNIRS) neurofeedback, hemoencephalography biofeedback (HEG) and fMRI biofeedback.

Applications

ADHD

Since the first reports of neurofeedback treatment in attention deficit hyperactivity disorder (ADHD) in 1976, many studies have investigated the effects of neurofeedback on different symptoms of ADHD such as inattention, impulsivity and hyperactivity. Recent investigation into the effectiveness of neurofeedback for ADHD has found neurofeedback to have durable effects following treatment,[5][6] although prior work has contradicted this conclusion.[7] Standard neurofeedback protocols for ADHD include theta/beta, SMR and slow cortical potentials are well investigated and have demonstrated specificity.[8]

Depressive and anxiety disorders

Neurofeedback training, particularly localized neurofeedback training, has been found to be therapeutic for patients for depression and self-regulation.[3][9] Individuals with post-traumatic stress disorder (PTSD) also have been found to benefit from neurofeedback, including children with developmental trauma.[10][11][12]

Traumatic brain injury and stroke

Neurofeedback has been used to treat traumatic brain injury (TBI) in military and civilian populations.[13][14] Neurofeedback has been also found to be generally positive for stroke recovery, with improvements found in motor function and behavior comparable with conventional occupational therapy.[15][16][17]

Epilepsy

Neurofeedback has been found to be a viable alternative for patients who did not find benefit from other medical treatment. The most common protocol for seizure control was sensorimotor rhythm (SMR), which was found to significantly reduce weekly seizures.[18][19]

Performance enhancement

The applications of neurofeedback to enhance performance extend to the arts in fields such as music, dance, and acting. A study with conservatoire musicians found that alpha-theta training benefitted the three music domains of musicality, communication, and technique.[20] Historically, alpha-theta training, a form of neurofeedback, was created to assist creativity by inducing hypnagogia, a "borderline waking state associated with creative insights", through facilitation of neural connectivity.[21] Alpha-theta training has also been shown to improve novice singing in children. Alpha-theta neurofeedback, in conjunction with heart rate variability training, a form of biofeedback, has also produced benefits in dance by enhancing performance in competitive ballroom dancing and increasing cognitive creativity in contemporary dancers. Additionally, neurofeedback has also been shown to instil a superior flow state in actors, possibly due to greater immersion while performing.[21]

However, randomized control trials have found that neurofeedback training (using either sensorimotor rhythm or theta/beta ratio training) did not enhance performance on attention-related tasks or creative tasks.[22] It has been suggested that claims made by proponents of alpha wave neurofeedback training techniques have yet to be validated by randomized, double-blind, controlled studies,[23] a view which even some supporters of alpha neurofeedback training have also expressed.[24]

Neurofeedback has been used to improve athletic psychomotor and self-regulation ability.[25] Sensorimotor rhythm neurofeedback training of accuracy has been used in top-level sports, especially in target-based sports (e.g. golf).[26]

History

In 1924, the German psychiatrist Hans Berger connected a couple of electrodes (small round discs of metal) to a patient's scalp and detected a small current by using a ballistic galvanometer. During the years 1929–1938 he published 14 reports about his studies of EEGs, and much of our modern knowledge of the subject, especially in the middle frequencies, is due to his research.[27] Berger analyzed EEGs qualitatively, but in 1932 G. Dietsch applied Fourier analysis to seven records of EEG and became the first researcher of what later is called QEEG (quantitative EEG).[27]

The first study to demonstrate neurofeedback was reported by Joe Kamiya in 1962.[28][29] Kamiya's experiment had two parts. In the first part, a subject was asked to keep his eyes closed and when a tone sounded to say whether he thought he was in alpha. He was then told whether he was correct or wrong. Initially the subject would get about fifty percent correct, but some subjects would eventually develop the ability to better distinguish between states.[30] Many could then produce alpha and non-alpha states at will. In the second part of the study, a tone was sounded whenever alpha was present, and subjects were asked to increase the percentage time the tone was on. Most participants were able to increase their percent time spent in alpha within about four training sessions.[29] Maintaining the alpha state was found to be associated with relaxation, a sense of "letting go", and pleasant affect.[31] High alpha amplitude had been seen in advanced meditators,[32][33][34] combined with an emerging counter-cultural interest in altered states of consciousness, led to significant public interest in alpha training as an alternative to psychedelic drugs.[35] Several optimistic studies replicated Kamiya's findings and suggested alpha training could be useful for treating stress and anxiety.[36][37][38] However, other studies found that alpha was not reliably associated with calm and pleasant mental states, while eyes-closed alpha never increased above the resting baseline.[39] Hardt and Kamiya (1976) argued that the replication failures were an artifact of an incorrect method of measuring alpha,[40] and future studies continued to demonstrate learning of alpha based on feedback.[41][42]

In the late sixties and early seventies, Barbara Brown, one of the most effective popularizers of Biofeedback, wrote several books on biofeedback, making the public much more aware of the technology. The books included New Mind New Body, with a foreword from Hugh Downs, and Stress and the Art of Biofeedback. Brown took a creative approach to neurofeedback, linking brainwave self-regulation to a switching relay which turned on an electric train.

The work of Barry Sterman, Joel F. Lubar and others has been relevant on the study of beta training, involving the role of sensorimotor rhythmic EEG activity.[43] This training has been used in the treatment of epilepsy,[44][45] attention deficit disorder and hyperactive disorder.[46] The sensorimotor rhythm (SMR) is rhythmic activity between 12 and 16 hertz that can be recorded from an area near the sensorimotor cortex. SMR is found in waking states and is very similar if not identical to the sleep spindles that are recorded in the second stage of sleep.

For example, Sterman has shown that both monkeys and cats who had undergone SMR training had elevated thresholds for the convulsant chemical monomethylhydrazine. These studies indicate that SMR may be associated with an inhibitory process in the motor system.[45]

In the 2000s, neurofeedback took a new approach in taking a look at deep states.[47] Alpha-theta training has been tried with patients with alcoholism,[48] other addictions as well as anxiety.[48] This low frequency training differs greatly from the high frequency beta and SMR training that has been practiced for over thirty years and is reminiscent of the original alpha training of Elmer Green and Joe Kamiya.[48] Beta and SMR training can be considered a more directly physiological approach, strengthening sensorimotor inhibition in the cortex and inhibiting alpha patterns, which slow metabolism. Alpha-theta training, however, derives from the psychotherapeutic model and involves accessing of painful or repressed memories through the alpha-theta state.[49] The alpha-theta state is a term that comes from the representation on the EEG.

A recent development in the field is a conceptual approach called the Coordinated Allocation of Resource Model (CAR) of brain functioning which states that specific cognitive abilities are a function of specific electrophysiological variables which can overlap across different cognitive tasks.[50] The activation database guided EEG biofeedback approach initially involves evaluating the subject on a number of academically relevant cognitive tasks and compares the subject's values on the QEEG measures to a normative database, in particular on the variables that are related to success at that task.

Organizations

The Society of Applied Neuroscience (SAN) is an EU-based nonprofit membership organization for the advancement of neuroscientific knowledge and development of innovative applications for optimizing brain functioning (such as neurofeedback with EEG, fMRI, NIRS). The International Society for Neurofeedback & Research (ISNR) is a membership organization aimed at supporting scientific research in applied neurosciences, promoting education in the field of neurofeedback.

The Foundation for Neurofeedback and Neuromodulation Research is a non-profit organization that, through donations, provides grants for student research. The FNNR also issues awards for professionals and publishes books related to neurofeedback.

The Association for Applied Psychophysiology and Biofeedback (AAPB) is a non-profit scientific and professional society for biofeedback and neurofeedback. The International Society for Neurofeedback and Research (ISNR) is a non-profit scientific and professional society for neurofeedback.[51] The Biofeedback Federation of Europe (BFE) sponsors international education, training, and research activities in biofeedback and neurofeedback.

Certification

The Biofeedback Certification International Alliance (formerly the Biofeedback Certification Institute of America) is a non-profit organization that is a member of the Institute for Credentialing Excellence (ICE). BCIA certifies individuals who meet education and training standards in biofeedback and neurofeedback and progressively recertifies those who satisfy continuing education requirements. BCIA offers biofeedback certification, neurofeedback (also called EEG biofeedback) certification, and pelvic muscle dysfunction biofeedback certification. BCIA certification has been endorsed by the Mayo Clinic,[52] the Association for Applied Psychophysiology and Biofeedback (AAPB), the International Society for Neurofeedback and Research (ISNR), and the Washington State Legislature.[53]

The BCIA didactic education requirement includes a 36-hour course from a regionally accredited academic institution or a BCIA-approved training program that covers the complete Neurofeedback Blueprint of Knowledge and study of human anatomy and physiology. Applicants must also pass a written exam, complete 25 hours of mentoring, 10 case reviews, perform 100 hours of client sessions, and conduct 10 hours of personal NF. The Neurofeedback Blueprint of Knowledge areas include: I. Orientation to Neurofeedback, II. Basic Neurophysiology and Neuroanatomy, III. Instrumentation and Electronics, IV. Research, V. Psychopharmalogical Considerations, VI. Treatment Planning, and VII. Professional Conduct.[54]

Applicants may demonstrate their knowledge of human anatomy and physiology by completing a course in biological psychology, human anatomy, human biology, human physiology, or neuroscience provided by a regionally accredited academic institution or a BCIA-approved training program or by successfully completing an Anatomy and Physiology exam covering the organization of the human body and its systems.

Applicants must also document practical skills training that includes 25 contact hours supervised by a BCIA-approved mentor designed to teach them how to apply clinical biofeedback skills through self-regulation training, 100 patient/client sessions, and case conference presentations. Distance learning allows applicants to complete didactic course work over the internet. Distance mentoring trains candidates from their residence or office.[55] They must recertify every four years, complete 55 hours of continuing education (30 hours for Senior Fellows) during each review period or complete the written exam, and attest that their license/credential (or their supervisor's license/credential) has not been suspended, investigated, or revoked.[56]

Neuroplasticity

In 2010, a study provided some evidence of neuroplastic changes occurring after brainwave training. Half an hour of voluntary control of brain rhythms led in this study to a lasting shift in cortical excitability and intracortical function.[57] The authors observed that the cortical response to transcranial magnetic stimulation (TMS) was significantly enhanced after neurofeedback, persisted for at least 20-minutes, and was correlated with an EEG time-course indicative of activity-dependent plasticity[57]

Criticism of the medical application

The effectiveness of the medical treatment of psychiatric disorders using EEG neurofeedback was called into question by Thibault et al. (2015, 2017).[58] [59] However, the validity of the research by Thibault et al. (2017) was later called into question (Pigott et al., 2018).

A double-blinded, sham-controlled study of neurofeedback as a treatment for insomnia (Schabus et al., 2017) found that neurofeedback did not beat placebo.[60]

No neurofeedback device has yet been approved by FDA for treatment of ADHD. In 2019, the FDA permitted marketing of the first medical device (external Trigeminal Nerve Stimulation or eTNS) for treatment of ADHD.[61] eTNS is a nerve stimulation and not a neurofeedback device.[62]

See also

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Further reading
  • Othmer, Siegfried (2013). Brian's Legacy. Woodland Hills CA: EEG Info Inc. ISBN 9780989543200.
  • Arns M, Sterman MB (2019). Neurofeedback: How it all started. Nijmegen, The Netherlands: Brainclinics Insights. ISBN 9789083001302.
  • Evans JR, Abarbanel A (1999). An introduction to quantitative EEG and Neurofeedback. San Diego: Academic Press.
  • Hill RW, Robert W, Eduardo C (15 May 2009). Healing Young Brains: The Neurofeedback Solution (1st ed.). Hampton Roads Publishing.
  • Robbins J (2008). A Symphony in the Brain – The Evolution of the New Brainwave Biofeedback (2nd ed.). Grove Atlantic.
  • Steinberg M, Othmer S (2004). ADD: The 20-Hour Solution. Bandon OR: Robert Reed Publishers.
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