Peak Stability: Seizure & Migraine

Electrodermal Activity Biofeedback Alters Evolving Functional Brain Networks in People With Epilepsy, but in a Non-specific Manner

There is evidence that biofeedback of electrodermal activity (EDA) can reduce seizure frequency in people with epilepsy. Prior studies have linked EDA biofeedback to a diffuse brain activation as a potential functional mechanism. Here, we investigated whether short-term EDA biofeedback alters EEG-derived large-scale functional brain networks in people with epilepsy. In this prospective controlled trial, thirty participants were quasi-randomly assigned to one of three biofeedback conditions (arousal, sham, or relaxation) and performed a single, 30-min biofeedback training while undergoing continuous EEG recordings. Based on the EEG, we derived evolving functional brain networks and examined their topological, robustness, and stability properties over time. Potential effects on attentional-executive functions and mood were monitored via a neuropsychological assessment and subjective self-ratings. Participants assigned to the relaxation group seemed to be most successful in meeting the task requirements for this specific control condition (i.e., decreasing EDA). Participants in the sham group were more successful in increasing EDA than participants in the arousal group. However, only the arousal biofeedback training was associated with a prolonged robustness-enhancing effect on networks. Effects on other network properties were mostly unspecific for the different groups. None of the biofeedback conditions affected attentional-executive functions or subjective behavioral measures. Our results suggest that global characteristics of evolving functional brain networks are modified by EDA biofeedback. Some alterations persisted after the single training session; however, the effects were largely unspecific across the different biofeedback protocols. Further research should address changes of local network characteristics and whether multiple training sessions will result in more specific network modifications.

Resting-state quantitative spectral patterns in migraine during ictal phase reveal deviant brain oscillations: Potential role of density spectral array

Background. Migraine headache may have a substantial bearing on the brain functions and rhythms. Electrophysiological methods can detect changes in brain oscillation. The present work examined the frequency band power through quantitative electroencephalogram (qEEG) and density spectral array (DSA) to elucidate the resting state neuronal oscillations in migraine. Methods. Clinical details were inquired, and EEG was recorded in migraineurs and healthy controls. The acquired data were analyzed to determine power spectral density values and obtain DSA graphs. The absolute and relative powers for the alpha, theta, and delta frequencies in frontocentral, parieto-occipital, and temporal regions were determined. A correlation of significant EEG findings with clinical features of migraine was sought. Results. Forty-five participants were enrolled in the study. The spectrum analysis revealed an increase in the relative theta power (P < .001) and a reduction in relative alpha power (P < .001) in the observed cortical areas among the migraineurs as compared to the healthy controls. Relative delta power was increased over the frontocentral region (P = .001), slightly more on the symptomatic side of the head. In addition, frontocentral delta power had a moderate positive correlation (r = .697, n = 22, P = .000) with migraine severity. Conclusion. The study supports the evidence of a neuronal dysfunction existing in the resting state during the ictal phase of migraine. qEEG can reveal these aberrant oscillations. Utility of DSA to depict the changes in brain activity in migraine is a potential area for research. The information can help formulate new therapeutic strategies towards alteration in cortical excitability using brain stimulation techniques.

The use of EEG neurofeedback in the rehabilitation of childhood epilepsy

Epilepsy is one of the most common serious neurological disorders. Epilepsy is characterized by a long-term risk of recurring seizures. The most common are seizures. These seizures can be of different types, depending on which part of the brain is involved and the age of the person affected. People suffering from epilepsy have an increased risk of death. Various treatments are used, but the results are not always effective. Neurofeedback is used in the treatment of many diseases, thanks to this therapy the patient learns to consciously control the functions of the body. The aim of this study is to determine the state of the literature on the effectiveness of EEGv (electroencephalography) biofeedback on patients with childhood epilepsy. Epilepsy is a chronic, incurable disease involving disruptions of electrical discharges in the brain. Neurofeedback therapy, based on brain wave training, is fully justified in this matter. The English-language literature from 2014-2021 was reviewed to illustrate the state of knowledge on the above-mentioned topic. 51 papers focused on various aspects of the science of the brain and its disorders, especially epilepsy, were qualified for further analysis. It was found that the state of the literature is satisfactory to conduct independent research on its basis and it was assumed that the development of this form of therapy is an expected issue.

Brain Oscillations and Migraine

The Efficacy of Neurofeedback for Pediatric Epilepsy

Approximately 470,000 children (birth to 18 years old) are afected by Epilepsy (CDC in Epilepsy. https://www.cdc.gov/epile psy/index.html, 2018). Since the initial fndings in the 1970s, Sensorimotor Rhythm (SMR) has been continuously utilized for the treatment of seizures. Studies have consistently demonstrated that SMR reduces the frequency and severity of seizure activity. Although a mix of pediatric cases, adolescents and adults have been sampled in previous studies, no age efects have been reported. There continues to be a lack of research in the area of neurofeedback for the treatment of epilepsy in the pediatric population. To date, no randomized control trial specifc to pediatric epilepsy has been published. The existing research regarding the use of neurofeedback in the treatment of epilepsy provides strong evidence that neurofeedback training might be an efective treatment for pediatric epilepsy. However, existing studies are not specifc to the pediatric population. Moreover, there is a lack of rigor in the studies in which the efects of neurofeedback in children and adolescents with epilepsy are documented. Therefore, based on the current literature, there is not enough evidence to state that neurofeedback is efcacious for the treatment of pediatric epilepsy. However, the APBB criteria for evidence-based practices indicate that neurofeedback for pediatric epilepsy is Possibly Efcacious (Level 2). Future research in which a randomized controlled trial approach is utilized will greatly help to increase support for the use of neurofeedback as an efcacious treatment for epilepsy.

An update on EEG in migraine

Introduction: In the past few years, brain functional analysis has provided scientific evidence supporting the neuronal basis of migraine. The role of electroencephalography (EEG) in detecting subtle dysfunctions in sensory temporal processing has been fully reevaluated, thanks to advances in methods of quantitative analysis. However, the diagnostic value of EEG in migraine is very low, and migraine diagnosis is completely based on clinical criteria, while the utility of EEG in migraine pathophysiology has only been confirmed in more recent applications. Areas covered: The present review focuses on the few situations in which EEG may provide diagnostic utility, and on the numerous and intriguing applications of novel analysis, based on time-related changes in neuronal network oscillations and functional connectivity. Expert opinion: Although routine EEG is not particularly useful for the clinical assessment of migraine, novel methods of analysis, mostly based on functional connectivity, could improve knowledge of the migraine brain. Application is worthy of promotion and improvement in support of neuroimaging data to shed light on migraine mechanisms and support the rationale for therapeutic approaches.

Finding Parameters around the Abdomen for a Vibrotactile System: Healthy and Patients with Parkinson's Disease

Freezing of Gait (FOG) is one of the most disabling gait disorders in Parkinson's Disease (PD), for which the efficacy of the medication is reduced, highlighting the use of non-pharmacological solutions. In particular, patients present less difficulties in overcoming FOG when using feedback and especially with Biofeedback Systems. In this study it is intended to detect the frequency threshold and the minimum interval of perception of the vibrotactile feedback, through a proposed wearable system, a waistband. Experimental tests were carried out that considered a temporal, spatial and spatiotemporal context, for which 15 healthy and 15 PD patients participated. It was detected as threshold frequency 180 Hz and for minimum interval of vibration perception 250 ms. The identification of this threshold frequency and this interval will allow us to select the frequency and the minimum interval of vibration to be used in a Vibrotactile Biofeedback Device for patients with PD, in order to help them to overcome FOG.

Robust desynchronization of Parkinson's disease pathological oscillations by frequency modulation of delayed feedback deep brain stimulation

The hyperkinetic symptoms of Parkinson's Disease (PD) are associated with the ensembles of interacting oscillators that cause excess or abnormal synchronous behavior within the Basal Ganglia (BG) circuitry. Delayed feedback stimulation is a closed loop technique shown to suppress this synchronous oscillatory activity. Deep Brain Stimulation (DBS) via delayed feedback is known to destabilize the complex intermittent synchronous states. Computational models of the BG network are often introduced to investigate the effect of delayed feedback high frequency stimulation on partially synchronized dynamics. In this study, we develop a reduced order model of four interacting nuclei of the BG as well as considering the Thalamo-Cortical local effects on the oscillatory dynamics. This model is able to capture the emergence of 34 Hz beta band oscillations seen in the Local Field Potential (LFP) recordings of the PD state. Train of high frequency pulses in a delayed feedback stimulation has shown deficiencies such as strengthening the synchronization in case of highly fluctuating neuronal activities, increasing the energy consumed as well as the incapability of activating all neurons in a large-scale network. To overcome these drawbacks, we propose a new feedback control variable based on the filtered and linearly delayed LFP recordings. The proposed control variable is then used to modulate the frequency of the stimulation signal rather than its amplitude. In strongly coupled networks, oscillations reoccur as soon as the amplitude of the stimulus signal declines. Therefore, we show that maintaining a fixed amplitude and modulating the frequency might ameliorate the desynchronization process, increase the battery lifespan and activate substantial regions of the administered DBS electrode. The charge balanced stimulus pulse itself is embedded with a delay period between its charges to grant robust desynchronization with lower amplitudes needed. The efficiency of the proposed Frequency Adjustment Stimulation (FAS) protocol in a delayed feedback method might contribute to further investigation of DBS modulations aspired to address a wide range of abnormal oscillatory behavior observed in neurological disorders.

Vibrotactile Feedback Alters Dynamics Of Static Postural Control In Persons With Parkinson's Disease But Not Older Adults At High Fall Risk

BACKGROUND: Aging and Parkinson's disease are often associated with impaired postural control. Providing extrinsic feedback via vibrotactile sensation could supplement intrinsic feedback to maintain postural control. RESEARCH QUESTION: We investigated the postural control response to vibrotactile feedback provided at the trunk during challenging stance conditions in older adults at high fall risk and individuals with Parkinson's disease compared to healthy older adults. METHODS: Nine older adults at high fall risk, 9 persons with Parkinson's disease and 10 healthy older adults performed 30s quiet standing on a force platform under five challenging stance conditions with eyes open/closed and standing on firm/foam surface with feet together, each with and without vibrotactile feedback. During vibrotactile feedback trials, feedback was provided when participants swayed >10% over the center of their base of support. Participants were instructed vibrations would be in response to their movement. Magnitude of postural sway was estimated using center of pressure path length, velocity, and sway area. Dynamics of individuals' postural control was evaluated using detrended fluctuation analysis. RESULTS: Results showed that vibrotactile feedback induced a change in postural control dynamics among persons with Parkinson's disease when standing with intact intrinsic visual input and altered intrinsic somatosensory input, but there was no change in sway magnitude. However, use of vibrotactile feedback did not significantly alter dynamics of postural control in older adults with high risk of falling or reduce the magnitude of sway. SIGNIFICANCE: Considering the effects of vibrotactile feedback were dependent on the population and stance condition, designing an optimal therapeutic regimen for balance training should be carefully considered and be specific to a target population. Furthermore, our results suggest that explicit instructions on how to respond to the vibrotactile feedback could affect training outcome.

Comparing auditory, visual and vibrotactile cues in individuals with Parkinson's disease for reducing risk of falling over different types of soil

INTRODUCTION: Several researchers have demonstrated the positive benefits of auditory and visual cueing in the gait improvements among individuals with Parkinson's disease (PD). However, few studies have evaluated the role of vibrotactile cueing when compared to auditory and visual cueing. This paper compares how these stimuli affect the risk of falling while walking on six types of soil (concrete, sand, parquet, broken stone, two types of carpet). METHODS: An instrumented Timed Up and Go (iTUG) test served to evaluate how audio, visual and vibrotactile cueing can affect the risk of falling of elderly. This pilot study proposes 12 participants with PD (67.7 ± 10.07 years) and nine age-matched controls (66.8 ± 8.0 years). Both groups performed the iTUG test with and without cueing. The cueing frequency was set at 10% above the cadence computed at the lower risk level of falling (walking over the concrete). A computed risk of falling (ROFA) index has been compared to the TUG time (total TUG duration). RESULTS: The index for evaluating the risk of falling appears to have a good reliability (ICC > 0.88) in this pilot study. In addition, the minimal detectable change (MDC) suggests that the proposed index could be more sensitive to the risk of falling variation compared to the TUG time. Moreover, while using the cueing, observed results suggest a significant decrease in the computed risk of falling compared to 'without cueing' for most of types of soil, especially for deformable soils, which can lead to falls. CONCLUSION: When compared to other cueing, it seems that audio could be a better neurofeedback for reducing the risk of falling over different walking surfaces, which represent important risk factors for persons with gait disorder or lost functional autonomy.

Impact of sensorimotor rhythm neurofeedback on quality of life in patients with medically-refractory seizures

Introduction: Published studies suggest that augmentation of the sensorimotor rhythm (SMR), a commonlyused neurofeedback protocol for patients with epilepsy, changes thalamocortical regulatory systems and increases cortical excitation thresholds. Recent meta-analyses showed that at least 50% of patients with medically refractory epilepsy had a post-therapy reduction in seizure frequency after neurofeedback training. However, data on neurofeedback outcomes outside of seizure frequency are limited. Methods: The records for all consecutive patients trained using SMR neurofeedback in the University of Colorado Neurofeedback Clinic prior to March 2015 (n = 9) were retrospectively reviewed, abstracted, and analyzed. Patients completed the Quality of Life in Epilepsy-31 (QOLIE-31) survey as a part of their clinic intake interview and at intervals throughout their training. Results: 214 total training sessions were reviewed. The average total QOLIE-31 baseline score in our patients was 49.3 ± 8.8. Seven patients completed follow-up QOLIE-31 surveys with an average score of 54.9 ± 6.5. Seventy-eight percent of the patients had improvement in their QOLIE-31 scores with training. The largest absolute improvements were in the seizure worry and cognitive subscores of the QOLIE-31. Conclusion: In this small case series, SMR neurofeedback training modestly improved short-term follow-up QOLIE-31 scores in patients with epilepsy

Passive Infrared Hemoencephalography (pIR HEG) for the Treatment of Migraine without Aura

Objective: To evaluate the impact of Passive Infrared Hemoencephalography (pIR HEG) in reducing headacherelated disability in adults with migraine without aura (MWOA). Methods: This quasi-experimental study enrolled 31 adults (M age = 38.65 years, range = 20-65 years) who met the International Classification of Headache Disorders (2nd ed.) criteria for migraine without aura (MWOA; IHS, 2004). All participants received the treatment. Participants completed a 10-week protocol of pIR HEG. Changes in headache impact were assessed at three points in time: baseline, after six treatment sessions, and after 10 treatment sessions. Outcome Measures: Headache Impact Test (HIT-6) and the Migraine Disability Assessment (MIDAS) questionnaire. Results: Significant reductions in HIT-6 scores were found between Pretest and Midtreatment, p < .001, and between Pretest and Posttest, p < .001. Significant reductions in MIDAS scores were found between Pretest and Posttest, p < .001. Results indicated MIDAS subscale A scores did not significantly change across the three time points. Significant reductions in MIDAS subscale B scores were found between Pretest and Midtreatment, p < .001, and between Pretest and Posttest, p < .001. In this study, pIR HEG appeared to be effective by the end of treatment in reducing the impact of headache-related disability among the participants.

LORETA Z-score Neurofeedback in Patients with Medically Refractory Epilepsy

Methods: The records for all consecutive patients seen in the Neurofeedback Clinic at a single academic medical center over a one year period (n=6) were retrospectively reviewed. All patients had medically-refractory epilepsy and were either not candidates for epilepsy surgery (based on consensus decision of the center’s faculty) or had refused to consider surgery for personal reasons. Data on patient demographics, duration of epilepsy prior to training, seizure types and frequencies, antiepileptic drugs (AEDs), psychiatric and medical comorbidities, imaging results, neurophysiological results, and the duration of neurofeedback training were abstracted and analyzed. Patient-reported seizure frequency was also analyzed. Results: 125 total training sessions were reviewed. Mean patient age was 33 +/- 6.1 years with mean duration of epilepsy prior to training of 17.2 +/- 3.2 years. Five out of six patients had focal onset epilepsy. None of the patients had a structural lesion on MRI that correlated with their seizure focus. Five out of 6 patients had a history of comorbid mood disorder. No patient had ever been seizure free for more than 1 year. Patients had been trained using LORETA z-score training within the DMN for an average of 20.8 +/- 5.2weeks (1-2 sessions per weekfor 20-30 minutes per session) at the time of analysis. Five out of 6 patients trained had a subjective reduction in reported weekly seizure frequency after LORETA z-score neurofeedback training began. Conclusions: In this small case series, DMN training using LORETA z-score neurofeedback techniques resulted in subjective improvement in seizure frequency from reported baseline for five out of the six patients in this series.Larger studies are needed to more definitively assess the effectiveness of these techniques for reducing seizure frequency in patients with medically-refractory seizures who are not, for either medical or personal reasons, candidates for surgical intervention.

Psychological Benefits of Nonpharmacological Methods Aimed for Improving Balance in Parkinson's Disease: A Systematic Review

Parkinson's disease (PD) is a serious condition with a major negative impact on patient's physical and mental health. Postural instability is one of the cardinal difficulties reported by patients to deal with. Neuroanatomical, animal, and clinical studies on nonparkinsonian and parkinsonian subjects suggest an important correlation between the presence of balance dysfunction and multiple mood disorders, such as anxiety, depression, and apathy. Considering that balance dysfunction is a very common symptom in PD, we can presume that by its management we could positively influence patient's state of mind too. This review is an analysis of nonpharmacological methods shown to be effective and successful for improving balance in patients suffering from PD. Strategies such as general exercise, robotic assisted training, Tai Chi, Qi Gong, Yoga, dance (such as tango or ballet), box, virtual reality-based, or neurofeedback-based techniques and so forth can significantly improve the stability in these patients. Beside this physical outcome, many methods have also shown effect on quality of life, depression level, enjoyment, and motivation to continue in practicing the method independently. The purpose of this review is to provide information about practical and creative methods designed to improve balance in PD and highlight their positive impact on patient's psychology.

Z-score LORETA Neurofeedback as a Potential Therapy for Patients with Seizures and Refractory Epilepsy

Approximately 30 % of epilepsy patients are resistant to conventional medical therapy. Therefore, alternative forms of treatment are needed to improve efficiency of these therapeutic regimens. Neurofeedback (NFB) has been becoming recognized as one of the promising therapies improving control of medically refractory epilepsy cases. This multi-case paper describes our experience with LORETA Z-score NFB as a tool for control of patients with seizures.

Balance and Gait Training With Augmented Feedback Improves Balance Confidence in People With Parkinson's Disease: A Randomized Controlled Trial

Background Fear of falling has been identified as an important and independent fall-risk predictor in patients with Parkinson's disease (PD). However, there are inconsistent findings on the effects of balance and gait training on balance confidence. Objective To explore whether balance and gait training with augmented feedback can enhance balance confidence in PD patients immediately after treatment and at 3- and 12-month follow-ups. Methods A total of 51 PD patients were randomly assigned to a balance and gait training (BAL) group or to an active control (CON) group. The BAL group received balance and gait training with augmented feedback, whereas CON participants received lower-limb strength training for 12 weeks. Outcome measures included Activities-Specific Balance Confidence (ABC) Scale, limits-of-stability test, single-leg-stance test, and spatiotemporal gait characteristics. All tests were administered before intervention (Pre), immediately after training (Post), and at 3 months (Post3m) and 12 months (Post12m) after treatment completion. Results The ABC score improved marginally at Post and significantly at Post3m and Post12m only in the BAL group (P < .017). Both participant groups increased their end point excursion at Post, but only the BAL group maintained the improvement at Post3m. The BAL group maintained significantly longer time-to-loss-of-balance during the single-leg stance test than the CON group at Post3m and Post12m (P < .05). For gait characteristics, both participant groups increased gait velocity, but only the BAL group increased stride length at Post, Post3m, and Post12m (P < .017). Conclusions Positive findings from this study provide evidence that BAL with augmented feedback could enhance balance confidence and balance and gait performance in patients with PD.

Failure of delayed feedback deep brain stimulation for intermittent pathological synchronization in Parkinson's disease

Suppression of excessively synchronous beta-band oscillatory activity in the brain is believed to suppress hypokinetic motor symptoms of Parkinson's disease. Recently, a lot of interest has been devoted to desynchronizing delayed feedback deep brain stimulation (DBS). This type of synchrony control was shown to destabilize the synchronized state in networks of simple model oscillators as well as in networks of coupled model neurons. However, the dynamics of the neural activity in Parkinson's disease exhibits complex intermittent synchronous patterns, far from the idealized synchronous dynamics used to study the delayed feedback stimulation. This study explores the action of delayed feedback stimulation on partially synchronized oscillatory dynamics, similar to what one observes experimentally in parkinsonian patients. We employ a computational model of the basal ganglia networks which reproduces experimentally observed fine temporal structure of the synchronous dynamics. When the parameters of our model are such that the synchrony is unphysiologically strong, the feedback exerts a desynchronizing action. However, when the network is tuned to reproduce the highly variable temporal patterns observed experimentally, the same kind of delayed feedback may actually increase the synchrony. As network parameters are changed from the range which produces complete synchrony to those favoring less synchronous dynamics, desynchronizing delayed feedback may gradually turn into synchronizing stimulation. This suggests that delayed feedback DBS in Parkinson's disease may boost rather than suppress synchronization and is unlikely to be clinically successful. The study also indicates that delayed feedback stimulation may not necessarily exhibit a desynchronization effect when acting on a physiologically realistic partially synchronous dynamics, and provides an example of how to estimate the stimulation effect.

A Review of Traditional and Novel Treatments for Seizures in Autism Spectrum Disorder: Findings from a Systematic Review and Expert Panel

Despite the fact that seizures are commonly associated with autism spectrum disorder (ASD), the effectiveness of treatments for seizures has not been well studied in individuals with ASD. This manuscript reviews both traditional and novel treatments for seizures associated with ASD. Studies were selected by systematically searching major electronic databases and by a panel of experts that treat ASD individuals. Only a few anti-epileptic drugs (AEDs) have undergone carefully controlled trials in ASD, but these trials examined outcomes other than seizures. Several lines of evidence point to valproate, lamotrigine, and levetiracetam as the most effective and tolerable AEDs for individuals with ASD. Limited evidence supports the use of traditional non-AED treatments, such as the ketogenic and modified Atkins diet, multiple subpial transections, immunomodulation, and neurofeedback treatments. Although specific treatments may be more appropriate for specific genetic and metabolic syndromes associated with ASD and seizures, there are few studies which have documented the effectiveness of treatments for seizures for specific syndromes. Limited evidence supports l-carnitine, multivitamins, and N-acetyl-l-cysteine in mitochondrial disease and dysfunction, folinic acid in cerebral folate abnormalities and early treatment with vigabatrin in tuberous sclerosis complex. Finally, there is limited evidence for a number of novel treatments, particularly magnesium with pyridoxine, omega-3 fatty acids, the gluten-free casein-free diet, and low-frequency repetitive transcranial magnetic simulation. Zinc and l-carnosine are potential novel treatments supported by basic research but not clinical studies. This review demonstrates the wide variety of treatments used to treat seizures in individuals with ASD as well as the striking lack of clinical trials performed to support the use of these treatments. Additional studies concerning these treatments for controlling seizures in individuals with ASD are warranted.

Evaluation of Neurofeedback Training in the Treatment of Parkinson's Disease: A Pilot Study

We assess the effects of EEG biofeedback training on levodopa-induced dyskinesia (LID) in patients with Parkinson's disease (PD) using a sham feedback controlled study design. Nine subjects were randomized into either a treatment group or control group and underwent 24 sessions of either active feedback training or sham feedback. The training protocol aimed at increasing 8–15 Hz activity while inhibiting excess 4–8 Hz and 23–34 Hz activity at the C3-C4 derivation. There were no statistically significant differences baseline to post-active neurofeedback training as compared to sham feedback training in primary outcome measures assessing change in dyskinesia severity, nor in secondary outcome measures assessing change in clinical features of PD. Nonsignificant trends were observed in subjects’ PD home diaries indicating a decrease in the severity of motor fluctuations. Baseline to post-training comparisons of secondary outcome measures in quantitative EEG analysis showed significant interaction effects within and between frontal and posterior regions, accompanied by decreases in 25–30 Hz (high beta) relative power, cross spectral power and phase resets per second activity, and significant increases in 8–12 Hz (alpha) relative power, cross spectral power, and coherence activity. These results indicate that EEG biofeedback training can affect the spectral EEG topography of individuals with PD and LID and that training to increase 8–15 Hz activity and decrease 23–34 Hz activity may have been associated with a nonsignificant decrease in dyskinesia severity and an improved sense of well-being.

Cognitive Function During Vagus Nerve Stimulation for Treatment-Refractory Epilepsy: A Pilot Study Using the Critical Flicker Fusion Test

This pilot study assessed neuro-cognitive functioning in 7 adults treated with Vagus Nerve Stimulation (VNS) for refractory epilepsy over a 12-month period. All patients were assessed using the Critical Flicker Fusion (CFF) test, a sensitive measure of the ability of the central nervous system to discriminate items of sensory information, along with a standardized battery of neuropsychological and behavioral measures. Reduction in seizure frequency and psychiatric ratings was accompanied by a selective but significant (p < .05) improvement in CFF performance. These findings suggest that the CFF test could be a useful indicator of improvement in neurocognitive functioning during VNS.

Clinical Neurofeedback: Case Studies, Proposed Mechanism, and Implications for Pediatric Neurology Practice

Trends in alternative medicine use by American health care consumers are rising substantially. Extensive literature exists reporting on the effectiveness of neurofeedback in the treatment of autism, closed head injury, insomnia, migraine, depression, attention deficit hyperactivity disorder, epilepsy, and posttraumatic stress disorder. We speculated that neurofeedback might serve as a therapeutic modality for patients with medically refractory neurological disorders and have begun referring patients to train with clinical neurofeedback practitioners. The modality is not always covered by insurance. Confident their child’s medical and neurological needs would continue to be met, the parents of 3 children with epilepsy spectrum disorder decided to have their child train in the modality. The children’s individual progress following neurofeedback are each presented here. A proposed mechanism and practice implications are discussed.

Efficacy of a vibrotactile neurofeedback training in stance and gait conditions for the treatment of balance deficits: a double-blind, placebo-controlled multicenter study

OBJECTIVE: Vestibular rehabilitation strategies mostly require a long-lasting training in stance conditions, which is finally not always successful. The individualized training in everyday-life conditions with an intuitive tactile neurofeedback stimulus seems to be a more promising approach. Hence, the present study was aimed at investigating the efficacy of a new vibrotactile neurofeedback system for vestibular rehabilitation. STUDY DESIGN: Double-blinded trial. PATIENTS: One hundred five patients who experience one of the following balance disorders for more than 12 months were included in the study: canal paresis, otolith disorder, removal of an acoustic neuroma, microvascular compression syndrome, Parkinson's disease, and presbyvertigo. INTERVENTIONS: Vibrotactile neurofeedback training was performed daily (15 min) over 2 weeks with the Vertiguard system in those 6 tasks of the Standard Balance Deficit Test with the most prominent deviations from the normative values. MAIN OUTCOME MEASURES: Trunk and ankle sway, dizziness handicap inventory, and vestibular symptom score were measured in the verum and placebo group before the training, on the last training day and 3 months later. RESULTS: A significant reduction in trunk and ankle sway as well as in the subjective symptom scores were observed in the verum group. Such an effect could not be found in any of the outcome parameters of the placebo group. CONCLUSION: The vibrotactile neurofeedback training applied in the present study is a highly efficient method for the reduction of body sway in different balance disorders. Because the rehabilitation program is easy to perform, not exhausting, and time saving, elderly patients and those with serious, long-lasting balance problems also can participate successfully.

Why Do Patients with Partial Epilepsy Improve Their IQ After Training to Self-Regulate Slow Cortical Potentials?

In patients with epilepsy, not only seizures but also cognitive, emotional, and social functioning are of increasing interest in research (Kelley, Jacobs, & Lowenstein, 2009). As a decrease in cognitive functions over the course of the illness is usually reported, we wanted to explore changes in Intelligence Scores observed after a neurofeedback treatment in patients with drug-resistant epilepsies. In a controlled study that compared the outcome of three different interventions (training to regulate slow cortical potentials, N = 34; training to regulate breath rate and the amount of carbon dioxide in the end tidal volume of the exhaled air, N = 11; modification of drug regime, N = 25), pre- and postmeasurements of a short version of the Wechsler Intelligence Scale were applied. The interval between the two assessments was more than 12 months, with a mean of 61 weeks. Mean age of the patients was 35, with a range from 17 to 57. The highly significant 7-point increment of IQ only after training of slow cortical potentials was not related to clinical (e.g., seizure reduction) or neuropsychological (e.g., attention and memory) variables. Instead, it was related to psychophysiological measures: IQ change was inversely related to the Latency of the P300 component of event-related brain potentials and directly related to the Latency of the P2 component and the increase of N2 Amplitude during training. We conclude that regulation training of slow cortical potentials improves IQ in patients with refractory partial epilepsy, which might be related to an improved ability for controlled allocation of cognitive resources.

Low-Frequency Repetitive Transcranial Magnetic Stimulation (rTMS) Modulates Evoked-Gamma Frequency Oscillations in Autism Spectrum Disorder (ASD)

Introduction It has been reported that individuals with Autism Spectrum Disorder (ASD) have abnormal reactions to the sensory environment and visuo-perceptual abnormalities. Electrophysiological research has provided evidence that gamma band activity (30-80 Hz) is a physiological indicator of the co-activation of cortical cells engaged in processing visual stimuli and integrating different features of a stimulus. A number of studies have found augmented and indiscriminative gamma band power at early stages of visual processing in ASD; this may be related to decreased inhibitory processing and an increase in the ratio of cortical excitation to inhibition. Low frequency or ‘slow’ (≤1HZ) repetitive transcranial magnetic stimulation (rTMS) has been shown to increase inhibition of stimulated cortex by the activation of inhibitory circuits.

Neurofeedback Efficacy in the Treatment of a 43-Year-Old Female Stroke Victim: A Case Study

Introduction. A 43-year-old Caucasian woman presented with a series of physical and mental deficits following a right hemisphere cerebral artery embolus suffered at age 42. Method. For both the pretreatment and posttreatment evaluation, the client's EEG data were collected. Prior to beginning neurofeedback a self-developed symptom checklist was provided to the participant and was repeated every 10 sessions. The participant received 52 neurofeedback sessions with the use of Neurocybernetics equipment. To determine statistical changes between the pretreatment and posttreatment conditions, average cross-spectral matrices were computed for bands delta (1–3.5 Hz), theta (3.5–7.5 Hz), alpha (7.5–12.5 Hz), beta1 (12.5–25 Hz), beta2 (25–32 Hz), and gamma (37–47 Hz). In this study the pretreatment cross-spectra for each epoch were then compared to the posttreatment epoch cross-spectra using the previously mentioned frequency band ranges. For each condition, cross-spectral matrices were computed and averaged over 2-s epochs resulting in one cross-spectral matrix for each epoch and for each of the discrete frequencies within each band. Based on previous LORETA analyses, we used a rectangular window. No time frame or frequency wise normalization was performed. Results. Following treatment, comparative QEEG and eLoreta analyses illustrated significant decreases in the absolute and relative power theta measures and significant elevations of absolute and relative power occipital beta. These findings correspond to client self-report data demonstrating improvement in cognitive functioning and depressed mood. Conclusion. Overall, findings suggest the utility of neurofeedback for the treatment of stroke,with particular gains noted in the areas of cognitive functioning, sleep quality, emotional regulation, and energy.

Neurofeedback and biofeedback with 37 migraineurs: a clinical outcome study

Traditional peripheral biofeedback has grade A evidence for effectively treating migraines. Two newer forms of neurobiofeedback, EEG biofeedback and hemoencephalography biofeedback were combined with thermal handwarming biofeedback to treat 37 migraineurs in a clinical outpatient setting.

Changes in EEG measurements in intractable epilepsy patients with neurofeedback training

To assess the effects of neurofeedback on brain electrophysiology and to determine how biofeedback works, power spectral density (PSD) and approximate entropy (ApEn) analyses are applied to the EEGs of six patients with intractable epilepsy who received neurofeedback training. After sessions of treatment, the EEG sensorimotor rhythm to theta PSD ratio calculated from the C4 electrode site becomes larger than that before the treatment, which is consistent with the biofeedback protocol. The ApEn over 16-channel EEG recordings all increase to different degrees. Larger increases occur in channels located near the training position (C4). All these results suggest that these EEG measurements are new criteria that can be used to evaluate the effect of neurofeedback.

Meta-Analysis of EEG Biofeedback in Treating Epilepsy

About one third of patients with epilepsy do not benefit from medical treatment. For these patients electroencephalographic (EEG) biofeedback is a viable alternative. EEG biofeedback, or neurofeedback, normalizes or enhances EEG activity by means of operant conditioning. While dozens of scientific reports have been published on neurofeedback for seizure disorder, most have been case series with too few subjects to establish efficacy. The purpose of this paper is to meta-analyze existing research on neurofeedback and epilepsy. We analyzed every EEG biofeedback study indexed in MedLine, PsychInfo, and PsychLit databases between 1970 and 2005 on epilepsy that provided seizure frequency change in response to feedback. Sixty-three studies have been published, 10 of which provided enough outcome information to be included in a meta-analysis. All studies consisted of patients whose seizures were not controlled by medical therapies, which is a very important factor to keep in mind when interpreting the results. Nine of 10 studies reinforced sensorimotor rhythms (SMR) while 1 study trained slow cortical potentials (SCP). All studies reported an overall mean decreased seizure incidence following treatment and 64 out of 87 patients (74%) reported fewer weekly seizures in response to EEG biofeedback. Treatment effect was mean log (post/pre) where pre and post represent number of seizures per week prior to treatment and at final evaluation, respectively. Due to prevalence of small groups, Hedges's g was computed for effect size. As sample heterogeneity was possible (Q test, p=.18), random effects were assumed and the effect of intervention was −0.233, SE= 0.057, z −4.11, p<.001. Based on this meta-analysis, EEG operant conditioning was found to produce a significant reduction on seizure frequency. This finding is especially noteworthy given the patient group, individuals who had been unable to control their seizures with medical treatment.

The Relative Efficacy of Connectivity Guided and Symptom Based EEG Biofeedback for Autistic Disorders

Autism is a neurodevelopmental disorder characterized by deficits in communication, social interaction, and a limited range of interests with repetitive stereotypical behavior. Various abnormalities have been documented in the brains of individuals with autism, both anatomically and functionally. The connectivity theory of autism is a recently developed theory of the neurobiological cause of autisic symptoms. Different patterns of hyper- and hypo-connectivity have been identified with the use of quantitative electroencephalogray (QEEG), which may be amenable to neurofeedback. In this study, we compared the results of two published controlled studies examining the efficacy of neurofeedback in the treatment of autism. Specifically, we examined whether a symptom based approach or an assessment/connectivity guided based approach was more effective. Although both methods demonstrated significant improvement in symptoms of autism, connectivity guided neurofeedback demonstrated greater reduction on various subscales of the Autism Treatment Evaluation Checklist (ATEC). Furthermore, when individuals were matched for severity of symptoms, the amount of change per session was significantly higher in the Coben and Padolsky (J Neurother 11:5–23, 2007) study for all five measures of the ATEC. Our findings suggest that an approach guided by QEEG based connectivity assessment may be more efficacious in the treatment of autism. This permits the targeting and amelioration of abnormal connectivity patterns in the brains of people who are autistic.

Power Spectral Frequency and Coherence Abnormalities in Patients with Intractable Epilepsy and Their Usefulness in Long-Term Remediation of Seizures Using Neurofeedback

Medically intractable seizures appear to be highly correlated with focal slow activity (delta or theta). They also correlate highly with decreases in the coherence of theta. Normalization of focal slowing and of decreased theta coherence will probably be the neurofeedback approaches most likely to decrease or eliminate seizures in future cases. Neurofeedback has been used for over 35 years to reduce the incidence and severity of seizures. With power training to decrease theta and increase the sensorimotor rhythm (12–15 Hz), an average of 82% of patients experienced a significant reduction in seizure frequency, and occasional remissions were seen. Recent improvements using QEEG to guide neurofeedback training have made it possible to eliminate seizures in most patients, even those with intractable seizures. Following our previous study in 2005, we report an additional 25 patients so treated. We also report an analysis of the frequency of QEEG abnormalities in this patient group. All of the intractable epileptic patients had one or more slow foci (excessive theta or delta compared with the normal database). One third had a relative deficiency of beta power. One fourth had a deficiency of absolute delta. Eighteen percent had excessive absolute alpha power, 18% had deficient absolute alpha power, 18% percent had excessive absolute beta power, and 18% percent had deficient absolute beta power. Hypocoherence of theta was found in 75%, and decreases in alpha coherence were noted in 42%. Hypocoherence of beta was found in 50%, and hypocoherence of delta was found in 25%. Increases in alpha coherence were noted in 33%. Seventeen percent had no coherence abnormalities. When most of the power and coherence abnormalities were normalized with neurofeedback training, all the patients became seizure-free; 76% no longer required an anticonvulsant for seizure control.

Neurofeedback Treatment of Type I Diabetes Mellitus: Perceptions of Quality of Life and Stabilization of Insulin Treatment–Two Case Studies

Background. This article is a case study review of the neurofeedback treatment of two female subjects with Type I diabetes mellitus. Both women had received regular medical treatment including the use of a restricted diet and short-term insulin treatment using an insulin pump. The study sought to discover the effects of neurofeedback treatment on the individuals' perceptions of their quality of life and, any effects on measured glucose blood levels. Method. Both the subjects received 20 sessions of neurofeedback training. These sessions took place three times a week, each session lasting approximately 45 minutes to 1 hour. The treatment consisted of training at C3, C4, and interhemispheric (C3-C4). The women were given symptom report checklists following each session and were interviewed prior to beginning of the treatment, at the conclusion of the 20 sessions, and 16 days after their final session. The interviews focused on self-reported changes in symptoms and the effect of these changes on their quality of life. Both the women also recorded their daily glucose levels and insulin dosage throughout the study. Results. The subjects reported improvement in their perception of their quality of life (QOL). Additionally, both reported improvement in glucose levels as well as fluctuations and reduced dosages of insulin required on a daily basis. Discussion. The existing research on the effectiveness of neurofeedback training for a broad variety of physical and emotional problems lead us to wonder if it might be helpful for either the physical or emotional aspects of Type I diabetes mellitus. Given the higher incidence of this condition, the significance of this research was considered to be important. The results of the study provide preliminary evidence that neurofeedback can be an important and valuable treatment for both the physical and emotional symptoms associated with Type I diabetes mellitus. Furthermore, research with larger numbers and stricter controls in the field is warranted.

Foundation and Practice of Neurofeedback for the Treatment of Epilepsy

This review provides an updated overview of the neurophysiological rationale, basic and clinical research literature, and current methods of practice pertaining to clinical neurofeedback. It is based on documented findings, rational theory, and the research and clinical experience of the authors. While considering general issues of physiology, learning principles, and methodology, it focuses on the treatment of epilepsy with sensorimotor rhythm (SMR) training, arguably the best established clinical application of EEG operant conditioning. The basic research literature provides ample data to support a very detailed model of the neural generation of SMR, as well as the most likely candidate mechanism underlying its efficacy in clinical treatment. Further, while more controlled clinical trials would be desirable, a respectable literature supports the clinical utility of this alternative treatment for epilepsy. However, the skilled practice of clinical neurofeedback requires a solid understanding of the neurophysiology underlying EEG oscillation, operant learning principles and mechanisms, as well as an in-depth appreciation of the ins and outs of the various hardware/software equipment options open to the practitioner. It is suggested that the best clinical practice includes the systematic mapping of quantitative multi-electrode EEG measures against a normative database before and after treatment to guide the choice of treatment strategy and document progress towards EEG normalization. We conclude that the research literature reviewed in this article justifies the assertion that neurofeedback treatment of epilepsy/seizure disorders constitutes a well-founded and viable alternative to anticonvulsant pharmacotherapy.

Neurofeedback treatment of epilepsy: from basic rationale to practical application

The treatment of epilepsy through operant conditioning of the sensorimotor rhythm electroencephalogram has a 35-year history. Neurophysiological studies have shown that this phasic oscillation reflects an inhibitory state of the sensorimotor system. Operant learning of sensory motor rhythm production results in an upregulation of excitation thresholds within the thalamocortical sensory and motor circuitry, which in turn is associated with reduced susceptibility to seizures. The clinical benefits derived from this neurofeedback training protocol, particularly in patients that are nonresponsive to pharmacotherapy, have been documented in many independent laboratories. Recent advances in computer technology have resulted in the availability of relatively inexpensive high-quality equipment for the application of neurofeedback therapy, thus presenting a viable and promising treatment alternative to the interested clinician.

Deactivation of Brain Areas During Self-Regulation of Slow Cortical Potentials in Seizure Patients

This study investigates the neurophysiological basis of EEG feedback for patients with epilepsy. Brain areas are identified that become hemodynamically deactivated when epilepsy patients, trained in EEG self-regulation, generate positive slow cortical potentials (SCPs). Five patients were trained in producing positive SCPs, using a training protocol previously established to reduce seizure frequency in patients with drug refractory epilepsy. Patients attempted to produce positive SCP shifts in a functional magnetic resonance imaging (fMRI) scanner. Two patients were able to reliably produce positive SCP shifts. When these successful regulators were prompted to produce positive SCPs, blood oxygen level-dependent (BOLD) response indicated deactivation, in comparison to a control state, around the recording electrode, frontal lobe, and thalamus. Unsuccessful regulators’ BOLD response indicated no deactivation in cortical areas proximal to the active electrode. No thalamic deactivation was found in poor regulators. Decreased seizure frequency from SCP training may be the result of positively reinforced inhibition in cortical areas proximal to active electrode placement, the frontal cortex, and the thalamus.

Neurofeedback treatment of epilepsy

With electroencephalographic (EEG) biofeedback (or neurofeedback), it is possible to train the brain to de-emphasize rhythms that lead to generation and propagation of seizure and emphasize rhythms that make seizures less likely to occur. With recent improvements in quantitative EEG measurement and improved neurofeedback protocols, it has become possible in clinical practice to eliminate seizures or reduce the amount of medication required to control them. In this article, the history of neurofeedback for epilepsy is presented followed by discussions of the relevant neurophysiology of epilepsy. A model of how neurofeedback might raise the seizure threshold is then presented. Clinical experience using a quantitative EEG-guided approach is described, including a representative case study.

Nonlinear analysis in treatment of intractable epilepsy with EEG biofeedback

About 25% epilepsy patients are suffering from medically intractable epileptic seizure. Many studies have shown that electroencephalogram (EEG) biofeedback therapy has the exciting potential for seizure control. In this paper, five patients with intractable epilepsy were trained to increase the production of sensorimotor (12 15 Hz) activity and decrease the production of slow theta (4 7 Hz) activity. Nonlinear analysis are proposed to evaluate the effect of biofeedback training. In all the five patients, the complexity and approximate entropy of EEG increased significantly (P<0.05) after (about 1-month) the biofeedback treatment

Passive Infrared Hemoencephalography: Four Years and 100 Migraines

Background. One hundred migraine sufferers were treated using passive Infrared Hemoencephalography (pIR HEG) over a period of four years. All subjects met the criteria for at least one of the categories set forth in the International Headache Society (IHS, 1988) classification criteria for headache disorders for primary migraine. Methods. Subjects were treated using the pIR HEG system in 30-minute sessions. A central forehead placement (approximately Fpz) was used for the sensor assembly for all subjects. Changes in headache patterns were examined. After two years, an infrared video imaging system was added to the data collection process and was available for 61 of the 100 subjects. Infrared forehead images were captured at the start and end of each session to examine changes in prefrontal cortical brain activity. Results. Most of the subjects improved control over their migraine headaches. Over 90% of those subjects who completed at least six sessions reported significant improvements in migraine activity. Conclusions. pIR HEG appears to have a strong impact on migraine headaches, even for people who have not had a positive response to medication. Headache response by the end of six sessions appears to be a good predictor of probability of improvement

Effects of neurofeedback-based EEG α and EEG β training in patients with chronically decompensated tinnitus

Background. Persisting tinnitus is an often devastating disease condition with restricted and rarely successful therapeutic options. Patients and methods. The present study investigates the therapeutic effect of short term neurofeedback-based EEG-Alpha- and EEG-Beta-training in 40 patients suffering from "chronic decompensated tinnitus". Patients were assigned to the Alpha or Beta group according to results of an initial EEG monitored stress-test. Four patients were excluded because they showed abnormal reactions in both EEG patterns. Results. During 12 sessions, 23 patients succeeded to increase EEG Alpha activity by 16% (p≤0.042) while 13 patients achieved no decrease of EEG Beta activity. However, both groups showed a significant reduction of subjective tinnitus annoyance by the end of the therapy (p≤0.001) Conclusions. The results indicate that neurofeedback may represent a new promising technique in the therapy of chronic decompensated tinnitus. However, it remains to be established whether the reduction of tinnitus annoyance results from the altered brain activity patterns supported by the neurofeedback learning process.

Neurofeedback to Improve Physical Balance, Incontinence, and Swallowing

An innovative neurofeedback protocol for the treatment of problems with physical balance, incontinence, and swallowing is described. Successful case reports from four consecutively treated cases are presented. This protocol holds potential promise for work with the elderly, stroke and head injury patients, primary nocturnal enuresis, and in peak performance training where balance is important. Further controlled research is warranted.

Neurofeedback for Cerebral Palsy

Neurofeedback with Cerebral Palsy and Mental Retardation: A Case Report

Neurofeedback Training for a Patient with Thalamic and Cortical Infarctions

One year after a left posterior and thalamic stroke, a 52-year-old male participant was treated with 14 weeks of theta reduction neurofeedback training. Imaging studies revealed left temporal, parietal, occipital, and bilateral thalamic infarctions along the distribution of the posterior cerebral artery. Neuropsychological testing demonstrated severe verbal memory, naming, visual tracking, and fine motor deficits. Additionally, alexia without agraphia was present. A pretraining quantitative electroencephalograph (QEEG) found alpha attenuation, lack of alpha reactivity to eye opening, and excessive theta activity from the left posterior head region. Neurofeedback training to inhibit 4–8 Hz theta activity was conducted for 42 sessions from left hemisphere sites. Over the course of the training, significant reductions in theta amplitude occurred from the training sites as assessed from the postsession baseline periods. Posttraining, a relative normalization of the QEEG was observed from the left posterior head region.

EEG-NeuroBioFeedback Treatment of Patients with Brain Injury Part 4: Duration of Treatments as a Function of Both the Initial Load of Clinical Symptoms and the Rate of Rehabilitation

Background. Twenty-seven patients with brain injury, primarily from car accidents and stroke, were treated by computer-assisted electroencephalographic NeuroBioFeedback (EEG-NBF). Methods. Patients were distributed into five clinical classes, and changes in power spectra and in cardiovascular parameters were surveyed. A rationale was proposed for the calculation of the load of symptoms for each patient of each class, which in turn provided indices of rehabilitation rates. Results. Statistically significant correlations were observed between the number of NeuroBioFeedback (NBF) treatment sessions (SN#) needed and both the initial load of symptoms (SL%) and the final rate of improvement of patients' clinical status (IMP%). When patients were considered in all five classes of defined SL%, the relationship exhibited a hyperbolic shape, although linearity could not be totally rejected, due to the variability of data. The improvement rates could be subdivided into two major classes, in which number (SN#) was hyperbolically related to the improvement rates. In addition, finger temperature responsiveness exhibited a significant correlation with the number of NBF sessions. Conclusion. The work suggests a rationale for the prediction of the duration of treatment, by considering the patients' initial clinical status and the levels of improvement and rehabilitation considered achievable.

EEG-NeuroBioFeedback Treatment of Patients with Brain Injury: Part 2: Changes in EEG Parameters versus Rehabilitation

Background. A sample of 27 patients with brain injury distributed in five clinical classes was examined for pre- and post-treatment symptoms and associated power spectra. Methods. Changes in electroencephalographic (EEG) compressed spectral arrays were analyzed with respect to the rate of rehabilitation and correlated with a checklist of symptoms for each patient and the group as a whole. Results. Targeted decreases in slower (3–7 Hz) and higher (24–32 Hz) frequencies, and EMG (70–90 Hz), and increases of alpha (8–12 Hz) and mid-range beta frequencies (15–18 Hz) were achieved following Neuro-BioFeedback (NBF) treatment using positive reward tones and a simultaneous visual reward. The impact of gender and age class influence was assessed against treatment results. Single lead EEG power spectra changes were analyzed for hemispherectomized patients, stroke, car accident and trauma patients. A common EEG pattern was observed for a group of patients exhibiting vertigo with two subgroups in which vertigo resolved or did not resolve showing EEG differences. Conclusions. EEG NeuroBioFeedback can successfully treat patients with brain injury with highly clinically-meaningful clinical results. Changes in Cz power spectra generally occur, but do not always immediately follow resolution of symptoms. Since EEG-NBF is limited to recording cortical surface potentials, it is possible that changes induced by the treatment which result in clinical changes may not always be reflected at the cortical surface and hence may not be available for recording and analysis there, despite subcortical integration.

Neurofeedback and epilepsy

Over the past three decades, researchers have examined various behavioral approaches to the treatment of epilepsy. One prominent line of inquiry concerns the effectiveness of neurofeedback, which entails the entrainment of specific electroencephalographic frequencies for the purpose of decreasing seizure frequencies in patients with epilepsy. This article reviews the current literature on the efficacy of neurofeedback in reducing seizure frequency. While it is clear that neurofeedback had a positive effect in most of the studies reviewed, these findings are limited due to multiple confounding factors. In the absence of any rigorously controlled studies, the relationship between neurofeedback and seizure frequency cannot be firmly established. Despite these limitations, the promising role of neurofeedback as a treatment for epilepsy is illustrated.

Biofeedback for Movement Disorders (Dystonia with Parkinson's Disease): Theory and Preliminary Results

Background. This paper presents a theoretical framework for using a combination of EEG biofeedback plus regular biofeedback with clients who have movement disorders. Method. A case study is included that describes intervention and results with a 47-year-old woman with the dual diagnosis of Parkinsonapos;s disease and dystonia. The rational for adding biofeedback interventions to traditional medical treatment hinges on the fact that muscle spindles, which are involved in muscle movement and tone, have double innervations, cholinergic and sympathetic (Passatore, Grassi, & Filippi, 1985). Both of these systems can be operantly conditioned using biofeedback. There were two learning goals: (1) increase the production of 12 to 15 Hz activity since this sensor motor rhythm (SMR) is associated with decreased firing of the red nucleus and the red nucleus, in turn, has links to the muscle spindles (Sterman, 2000); (2) train for calm, relaxed auto-nomic nervous system functioning (decreased sympathetic drive and parasympathetic ascendance) because this may also have a beneficial effect on muscle tone by means of influencing muscle spindle activity (Banks, Jacobs, Gevirtz, & Hubbard, 1998). Training for balanced autonomic system functioning is facilitated by diaphragmatic breathing at a rate of about six breaths per minute. Diaphragmatic breathing results in respiration and heart rate variability, presented as a line graph, following the same sinusoidal pattern when viewed on a biofeedback screen, a pattern termed respiratory sinus arrhythmia (RSA, Budzynski, 1989). This dual training of neurofeedback to enhance SMR activity and RSA biofeedback for relaxed autonomic nervous system (ANS) functioning was done for 30 sessions over a six-month period. Results. Training was associated with significant reduction in dystonic movements. Additionally, the client became able to use diaphragmatic breathing to cue herself to turn on a mental state associated with increased SMR production and thus control incidents of freezing, a common problem in advanced Parkinsonapos;s disease. With twelve more sessions over the next 18 months, the improved quality of life has been maintained. Discussion. This work is reported to put forth a theoretical model of why neurofeedback plus biofeedback is helpful in movement disorders and to encourage research in this area.

On the Pathophysiology of Migraine—Links for “Empirically Based Treatment” with Neurofeedback

Psychophysiological data support the concept that migraine is the result of cortical hypersensitivity, hyperactivity, and a lack of habituation. There is evidence that this is a brain-stem related information processing dysfunction. This cortical activity reflects a periodicity between 2 migraine attacks and it may be due to endogenous or exogenous factors. In the few days preceding the next attack slow cortical potentials are highest and habituation delay experimentally recorded during contingent negative variation is at a maximum. These striking features of slow cortical potentials are predictors of the next attack. The pronounced negativity can be fed back to the patient. The data support the hypothesis that a change in amplitudes of slow cortical potentials is caused by altered habituation during the recording session. This kind of neurofeedback can be characterized as “empirically based” because it improves habituation and it proves to be clinically efficient.

EEG-NeuroBioFeedback Treatment of Patients with Brain Injury: Part 1: Typological Classification of Clinical Syndromes

Background. A group of 27 patients with brain injury were treated by electroencephalographic (EEG) NeuroBioFeedback under drug-free conditions. They were studied for distribution in classes of major syndromes for evaluation of treatment efficiency and rehabilitation rates with respect to associated EEG and other physiological changes. Methods. A total of 48 clinical symptoms were listed, each present in at least one patient. Classes of clinical signs have been computed using both medical and statistical criteria. Claimed and presented chief complaints, secondary complaints and all associated signs were incorporated in multivariate analysis. Results. Substantial intersection of medical and statistical distributions was observed. This provided a classification of symptoms into six classes representing the following syndromes of impaired functions: Q1 = motor; Q2 = language; Q3 = cognitive; Q4 = psychosocial; Q5 = pain-related; Q6(a & b) = neuropsychiatric; Q7 = metabolic. Membership of a patient in a defined clinical class was based on a numerical index computed from: (a) a weighted coefficient for the patient's chief and secondary complaints, and (b) an index for both symptoms represented in the class and symptoms not represented in the class. Patients were unambiguously distributed in all classes except Q7. Conclusions. Using anon-selected group of head injured patients, this work provides a rationale for the membership of each patient in a set of classes of syndromes determined by the whole set of clinical signs specifically exhibited by this group of patients. Class-average rehabilitation rates ranged from 59% up to 87% following an average 23 to 132 treatment sessions, depending on syndromes.

Changes in Lateralized Memory Performance in Subjects with Epilepsy Following Neurofeedback Training

Both seizure reduction and neuropsychological improvements have been reported following neurofeedback training directed to normalization of the sensorimotor EEG. These findings could be interpreted as nonspecific effects rather than specific changes brought about by EEG training. The present study demonstrated neuropsychological changes of a selective nature that would be difficult to interpret as nonspecific. Epileptic subjects with unilateral temporal lobe lesions were administered memory tests prior to EEG training, after control training, and after sensorimotor EEG normalization training. Successfully trained subjects showed exclusive improvement on memory tasks specific to the hemisphere contralateral to their lesion, and no improvement on memory tasks specific to the hemisphere with the lesion. Such selective changes are difficult to interpret as nonspecific effects of participating in a study, and would seem to require genuine alteration of neural substrates as a result of EEG training.

Modification of Slow Cortical Potentials in Patients with Refractory Epilepsy: A Controlled Outcome Study

Summary:  Purpose: To compare self-regulation of low-frequency EEG components (slow cortical potentials, SCPs) with other methods of seizure control for patients with drug-refractory partial epilepsy and to separate the real anticonvulsive effect from placebo effects. Methods: Results of a treatment program of SCP self-regulation (experimental group) are compared with two groups of patients, one of which learned self-control of respiratory parameters (end-tidal CO2 and respiration rate: RES group); the other received medication with new anticonvulsive drugs (AEDs) in combination with psychosocial counseling (MED group). Clinical, cognitive, behavioral, and personality measures were assessed before and after treatment. In addition, to control for placebo responses, patients repeatedly estimated their beliefs in the efficiency of the respective treatment, their satisfaction and expectations, and the quality of the relationship with their therapists. Results: SCP and MED groups showed a significant decrease of seizure frequency, but the RES group did not. Clear positive changes in the sociopsychological adjustment were obtained in all three groups, with the maximal improvement being attained in the RES group. Conclusions: All kinds of therapy result in considerable improvement of patients' emotional state, which may in part be due to potential placebo effects; however, this improvement is not related to the quality of the therapeutic effect proper (i.e., seizure reduction). Traditional double-blind control group designs are inappropriate for behavioral interventions or treatments with psychoactive pharmacologic drugs. Rather, specific tests can be developed to control the placebo effect and to separate it from the genuine therapeutic effects.

Basic Concepts and Clinical Findings in the Treatment of Seizure Disorders with EEG Operant Conditioning

Self-regulation of Slow Cortical Potentials in Children with Migraine: An Exploratory Study

Migraine patients are characterized by increased amplitudes of slow cortical potentials (SCPs), representing pronounced excitability of cortical networks. The present study investigated the efficiency of biofeedback training of SCPs in young migraineurs. Ten children suffering from migraine without aura participated in 10 feedback sessions. They were compared with 10 healthy children for regulation abilities of cortical negativity and with 10 migraineurs from the waiting list for clinical efficacy. During the first two sessions, the migraine children were characterised by lacking ability to control cortical negativity, especially during transfer trials, compared with healthy controls. However, there was no difference following 10 sessions of training. Feedback training was accompanied by significant reduction of cortical excitability. This was probably responsible for the clinical efficacy of the training; a significant reduction of days with migraine and other headache parameters was observed. It is suggested that normalization of the threshold regulation of cortical excitability during feedback training may result in clinical improvement.

Changes in EEG Power Spectra During Biofeedback of Slow Cortical Potentials in Epilepsy

The goal of the study was to explore parallel changes in EEG spectral frequencies during biofeedback of slow cortical potentials (SCPs) in epilepsy patients. Thirty-four patients with intractable focal epilepsy participated in 35 sessions of SCP self-regulation training. The spectral analysis was carried out for the EEG recorded at the same electrode site (Cz) that was used for SCP feedback. The most prominent effect was the increase in the θ2 power (6.0–7.9 Hz) and the relative power decrement in all other frequency bands (particularly δ1, α2, and β2) in transfer trials (i.e., where patients controlled their SCPs without continuous feedback) compared with feedback trials. In the second half of the training course (i.e., sessions 21–35) larger power values in the δ, θ, and α bands were found when patients were required to produce positive versus negative SCP shifts. Both across-subject and across-session (within-subject) correlations between spectral EEG parameters, on the one hand, and SCP data, on the other hand, were low and inconsistent, contrary to high and stable correlations between different spectral variables. This fact, as well as the lack of considerable task-dependent effects during the first part of training, indicates that learned SCP shifts did not directly lead to the specific dynamics of the EEG power spectra. Rather, these dynamics were related to nonspecific changes in patients' brain state.

Neurofeedback treatment of pseudoseizure disorder

Background: Previous research has shown that the suppression of theta wave activity and the enhancement of sensorimotor rhythm (SMR) through electroencephalographic (EEG) biofeedback is an effective treatment for epilepsy. The current research reports the results of EEG biofeedback treatment for patients presenting with seizure behaviors in the absence of eliptiform EEG activity. Methods: In addition to psychotherapy, 3 patients, 2 women and 1 man, were trained, using EEG feedback once per week, to reduce the ratio of theta band to SMR band EEG amplitudes. Results: The results showed that reductions in seizure activity were related to reductions in the theta–SMR ratio. Conclusions: These findings support the view that theta–SMR feedback training, in conjunction with psychotherapy, is an effective adjunctive treatment for pseudoseizure disorder.

Slow cortical potential biofeedback and the startle reflex

The negativity of slow cortical potentials (SCP) of the surface EEG is a measure of brain excitability, correlating with motor and cognitive preparation. Self-control of SCP positivity has been shown to reduce seizure activity. Following SCP biofeedback from a central EEG electrode position, subjects gained bidirectional control over their SCP. The current study used a modified feedback methodology, and found a positive relationship between negativity and magnitude of EMG startle response (a measure of cortical and subcortical arousal, particularly aversive response disposition). Greater success in SCP differentiation was associated with self-report of less relaxation during negativity training.

Cortical self-regulation in patients with epilepsies

The present study aimed at investigating to what extent the regulation of excitability in cortical networks, as indicated by surface-negative slow cortical potentials (SCPs), is impaired in epileptic patients and to what extent training of SCP self-regulation by means of biofeedback and instrumental learning procedures might affect seizure frequency. Twenty-five patients suffering from drug-refractory epilepsies (complex focal, grand mal, and absence type of seizures) participated in 28 1-h sessions of feedback and instrumental conditioning of their SCPs. Subjects' EEGs were obtained from the vertex. Depending on discriminative stimuli DC shifts towards increased or suppressed negativity relative to the pre-trial baseline were demonstrated by on-line visual feedback during intervals of 8 s each; each session comprised 110 trials. While performance on the SCP self-regulation task was initially below normal (as compared to healthy subjects), significant increases in SCP control were achieved by the patients across the 28 training sessions. In 18 patients at least 1-year follow-up data are available. Changes in seizure frequency were related to transfer of SCP control with six of the patients becoming seizure-free. Age affected the ability to acquire SCP control and its impact on seizure frequency.

Behavioural treatment of slow cortical potentials in intractable epilepsy: neuropsychological predictors of outcome.

The study aimed to explore the predictive value of neuropsychological tests within the context of acquisition of slow cortical potential (SCP) self-control, a technique which has beneficial effects on seizure frequency in epilepsy. Patients with epilepsy who successfully achieved SCP control had longer digit or block-tapping spans than less successful patients. Patients who showed a better learning rate across training also displayed better verbal memory and learning abilities. Seizure reduction was related to block-tapping spans only. The results indicate that measures of attention, as indicated by digit spans or block-tapping spans, offer some predictive value for acquisition of SCP control and treatment outcome, whilst measures of visuospatial or frontal lobe function are unrelated to SCP acquisition and seizure reduction.

Predictive factors for controlling seizures using a behavioural approach

A behavioural approach using EEG biofeedback for controlling complex-partial seizures has been successful at the Andrews/Reiter Epilepsy Research Program. Records for a random sample of 83 patients with uncontrolled seizures, one third of those receiving care between 1980 and 1985, document that 69 (83%) achieved control by completion of the programme. Additional data about initial age of seizure onset, number of years seizures had been uncontrolled and seizure frequency when treatment started were collected to determine whether these factors predicted seizure control. Only frequency was significantly related to whether seizures were controlled when treatment ended. Further study using discriminant analysis showed that earlier onset age and higher seizure frequency were associated with a significantly greater number of treatment sessions required. Thus, these two factors predicted difficulty in controlling seizures, as measured by number of sessions, although onset age did not predict whether control was eventually achieved. Since even the subgroup achieving the lowest rate of control (i.e., patients having daily seizures when treatment started) had 67% success, these results suggest that a behavioural approach can be useful for many people with currently uncontrolled complex-partial seizures regardless of their characteristics on factors examined in this study.

Neuropsychological Assessment of Subjects with Uncontrolled Epilepsy: Effects of EEG Feedback Training

Summary: A battery of neuropsychological tests was administered at baseline, postcontrol period, and post-training period to 24 drug-refractory subjects with epilepsy participating in a study of sensorimotor electroen-cephalographic (EEG) normalization feedback training. Results revealed the following. First, subjects exhibited significant baseline deficits in psychosocial, cognitive and motor functioning. Second, certain tests discriminated subjects before training who were subsequently above and below the median in seizure reduction following EEG training. Subjects who showed the greatest seizure reduction performed better on a test of general problem-solving ability but not on other cognitive tests and worse on tests involving strong motor components and were more intact psychosocially. These subjects also took significantly fewer medications in combination than did less successful subjects. Third, improvement on several measures occurred following participation in the study. Cognitive and motor functioning improved only in subjects with the greatest seizure reduction and only after actual training as opposed to control conditions. Psychological functioning, as measured by the Minnesota Multiphasic Personality Inventory (MMPI) improved in both outcome groups. MMPI improvement, unlike cognitive improvement, was as likely to occur after control conditions, when seizure reduction had not yet occurred, as after EEG training. Thus, MMPI changes apparently reflected the nonspecific benefits of participation in this study. RÉSUMÉ Une batterie de tests neuropsychologiques àété administerée péndant la periode de base, pendant la période suivant le contrôle et pendant la période post-entrainement à 24 patients présentant une épilepsie réfractaire inclus dans un programme d'entraînement à la normalisation de ľEEG par feedback sen-sorimoteur. Les résultats ont montré: 1) que les patients présentaient au départ des défecits significatifs de leur fonctionnement psychosocial, cognitif et moteur; 2) que certains tests se révélaient discriminants pour la sélection avant entraînement de sujets qui se situaient au-dessous ou au-dessus de la moyenne pour la réduction du nombre de crises après entraînement. Les sujets qui ont obtenu la plus forte réduction du nombre de crises ont eu de meilleurs scores lors ľun test explorant la capacityé générale à résoudre des problèmes, mais pas aux autres tests cognitifs, et des scores inférieurs aux tests impliquant une forte composante motrice; ils étaient aussi plus intacts sur le plan psychosocial. Ces patients avaient en outre significativement moins de médicaments associés que les sujets moins perfor-mants; 3) qu'une amélioration portant sur plusieurs paramètres a été observée après entraînement. Le fonctionnement cognitif et moteur n'a été amélioré que chez les sujects qui ont obtenu la plus forte réduction du nombre de crises, et seulement après entrainement réel, et non après la période contrôle. Le fonctionnement psychologique, mesuré par le MMPI, fut amélioré dans tous les groupes. ľamélioration au MMPI, contrairement a ľamelioration des fonctions cognitives, a été constatée tant après la phase contrôle. Le fonctionnement psychologique, mesuré par le MMPI, fut amélioré dans tous les groupes. ľamélioration au MMPI, contrairement àľamélioration des fonctions cognitives, a été constatée tant après la phase contrôle, pendant laquelle aucune réduction du nombre de crises n'avait encore été obtenue, qu'après ľentraînement par ľEEG. ľamélioration du MMPI semble done refléter le bénéfice non spécifique retiré de la simple participation àľétude. RESUMEN A 24 sujetos con epilepsía refractaria al tratmiento que participaban en un estudio de normalización del EEG mediante entrenamiento por “feed back” sensitivo-motor, se ha administrado una bateria de tests neuropsicológicos en el periodo basal, en el periodo post-control y en el periodo post-entrenamiento. Los resultados revelaron lo siguiente: (a) individuos que mostraron deficits significativos en el periodo basal en las funciones psico-sociales. cognitivas y motoras. (b) ciertos tests discriminaron los sujetos antes del entrenamiento que posteriormente mostraron una reducción de los ataques, por encima y por debajo del promedio, tras el entrenamiento del EEG. Los individuos que mostraron la mayor reducción de los ataques dieron resultados mejores en un test que medía la habilidad para resolver problemas generales pero no en otros tests cognitivos; mostraron peores resultados en los tests que medían fuertes componentes motores y aparecieron más intactos desde el punto de vista psicosocial. Estos sujetos también tomaban menos combinaciones medica-mentosas que los sujetos con resultados menos satisfactorios. (c) Se observo una majoría en las diversas medidas que occurió después de la participación en el estudio. Las funciones cognitivas y motoras mejoraron solamente en los sujetos con la mayor reducción en los ataques y sólo después de un entrenamiento reciente en contrapositión a las condiciones de control. La función psicológica medida con el MMPI, majoró en ambos grupos. Esta majoría en el MMPI, en discrepancia con la majorá en ambos grupos. Esta majoría en el MMPI, en discrepancia con la majorá cognitiva, tenía las mismas posibilidades de ocurrir después de las condiciones de control, cuando la reducción de los ataques no había ocurrido todavia, como después del entrenamiento del EEG. Asi pues los cambios en el MMPI aparente-mente reflejan beneficios no específicos de participación en este estudio.

EEG biofeedback and relaxation training in the control of epileptic seizures

Research utilizing sensorimotor rhythm (SMR) biofeedback with epileptics suggests that it is useful in decreasing seizures. Subjects were 6 young adults with a diagnosis of epilepsy of at least two years who had been unable to control their seizures with different regimens of anticonvulsant medications. Subjects ranged from severely mentally handicapped to above average functioning. Seizure type, frequency, and duration were recorded by subjects and caretakers. Measures of operant learning were percent time in SMR. The experiment utilized a single subject multiple baseline design which consisted of 6 phases: baseline one, relaxation training; baseline two, biofeedback training one; baseline three, biofeedback treatment two and follow-up. The results of this study are in agreement with other studies using SMR biofeedback. All subjects were able to significantly increase percent time in SMR. Five out of the 6 subjects demonstrated decreases in seizure frequency during the treatment phase. Two of the 6 subjects benefited from relaxation training. Four subjects demonstrated significant negative correlations between percent SMR and seizure rates. Consistent with other studies utilizing multiple baseline designs, a majority of the subjects did not follow the design of the study.

The response of a case of petit mal epilepsy to EEG sensorimotor rhythm biofeedback training

A 14-year-old girl, with a long history of absence seizures, sudden rages, spatial disorientation, and academic difficulties received long-term (33 sessions) EEG sensorimotor rhythm biofeedback training. Operantly conditioned increases in the average amplitude of the 14 Hz neural discharge rhythm, over the central Rolandic cortex and cerebrolongitudinal fissure, resulted in a total cessation of her absence seizures; which had, prior to the EEG sensorimotor rhythm biofeedback training, occurred at the rate of 4–5 absences per hour. Concurrently, her sudden rages, spatial disorientation, and academic functioning all evidenced significant remediation.

Recent Developments in the Diagnosis and Therapy of Epilepsy

Recent advances in the diagnosis of epilepsy include the development of a clinically useful classification of epileptic seizures and the recognition of specific epileptic disorders. These advances have been aided by the advent of x-ray computed tomography, long-term electroencephalographic telemetry, and video monitoring. Techniques for functional imaging of the human brain promise even greater diagnostic capabilities. New antiepileptic drugs have improved medical management, and technical and theoretical advances in pharmacokinetics have permitted physicians to design balanced dosing for individual patients. Although currently underused, surgical treatment of partial complex epilepsy can be safe and effective when used appropriately. Operant conditioning of electroencephalography may become another practical alternative therapy. Contributions of basic research to understanding the complications of status epilepticus have influenced treatment protocols and greatly improved the prognosis of this potentially lethal condition.

A double-blind investigation of the relationship between seizure activity and the sleep EEG following EEG biofeedback training

The sleep EEGs of eight medically refractory epileptic patients were examined as part of a double-blind, ABA crossover study designed to determine the effectiveness of EEG biofeedback for the control of seizures. The patients were initially reinforced for one of three EEG criteria recorded from electrodes placed over sensorimotor cortex: (a) suppression of 3- to 7-Hz activity, (b) enhancement of 12- to 15-Hz activity, or (c) simultaneous suppression of 3- to 7-Hz and enhancement of 11- to 19-Hz activity. Reinforcement contingencies were reversed during the second or B phase, and then reinstated in their original form during the final A′ phase. All-night polysomnographic recordings were obtained at the end of each conditioning phase and were subjected to both visual and computer-based power spectral analyses. Four of the patients showed changes in their nocturnal paroxysmal activity that were either partially or totally consistent with the ABA′ contingencies of the study. The spectral data proved difficult to interpret, though two trends emerged from the analyses. Decreases in nocturnal 4- to 7-Hz activity were correlated with decreases in seizure activity, and increases in 8- to 11-Hz activity were correlated with decreases in seizure activity. These findings were shown to strengthen the hypothesis that EEG biofeedback may produce changes in the sleep EEG that are related to seizure incidence.

Eight to Twelve Hertz Occipital EEG Training with Moderate and Severely Retarded Epileptic Individuals

Three retarded epileptic individuals, with a variety of seizure disorders, were provided with 8-12 Hz occipital EEG biofeedback training. While seizures were not totally eliminated in any of the subjects, the results of the study indicated that all subjects exhibited decreases in some aspect of their seizure activity. The inability of all of the subjects to increase 8-12 Hz activity may best be explained in terms of the differing degree of effectiveness of the feedback stimuli in terms of their functionality as reinforcers. The results of the study indicate that changes in procedures will be necessary in order to determine if 8-12 Hz occipital EEG training is effective in reducing epileptic seizures.

EEG operant conditioning in intractable epileptics

Eight epileptic patients with mixed seizures refractory to medical control participated in a double-blind crossover study to determine the effectiveness of operant conditioning of the EEG as an anticonvulsant procedure. Baseline levels of seizures were recorded for four months prior to the beginning of treatment. participants then received false (noncontingent) feedback for two months followed by an ABA-patterned training program lasting a total of ten months. Subjects were assigned to three treatment groups based on different schedules of EEG feedback. They were first trained (A1, phase) either to suppress slow activity (3 to 8 Hz), to enhance 12- to 15-Hz activity, or to simultaneously suppress 3- to 8-Hz and enhance 11- to 19-Hz activity. This was followed by a B phase, in which patients were trained to enhance slow activity (3 to 8 Hz). In the final phase (A2), the initial training contingencies were reinstated. Neuropsychological tests were performed before and after training, and changes in EEG activity as determined by Fast Fourier spectral analyses were analyzed. Five of eight patients experienced a decrease in their mean monthly seizure rate at the completion of feedback training as compared with their initial baseline level.

Sensorimotor rhythm feedback training and epilepsy: Some methodological and conceptual issues

This study examined the hypothesis that the enhancement of a 12–16 Hz sensorimotor rhythm in the EEG is inhibitory to epileptic seizure activity. The effects of training to enhance 12–16 Hz central EEG, to enhance 8–10 Hz central EEG, to suppress high voltage EEG activity, and of random feedback were compared over a period of 12 months in three adult patients suffering from chronic, drug-refractory epilepsy. All three patients experienced a significant reduction in seizure rate by the end of the study, but this was not related to any one particular training condition. It is suggested that the therapeutic mechanism might involve placebo effects, relaxation training, or a facilitation of EEG desynchronization, the effect being idiosyncratic to the individual patient.

Reducing Epileptic Seizures Through Operant Conditioning of Central Nervous System Activity: Procedural Variables

Operant conditioning of the sensorimotor rhythm of the human electroencephalogram with time-outs contingent on epileptiform activity reduces epileptic seizure rates in patients whose seizures are not well controlled by medication. A comparison of this procedure with time-out training alone demonstrates that operant conditioning of the sensorimotor rhythm is neither necessary nor sufficient for seizure reduction.

EEG Operant Conditioning for Control of Epilepsy

Summary: We report the results of 23 severely epileptic patients who were given EEG feedback training. The paradigm reinforced the patients' 18 Hz activity over the scalp approximation of their focus while suppressing temporalis EMG and low frequency EEG activity. In contrast to other studies using EEG feedback, only 43% of patients showed significant changes in seizure occurrence and a lesser number were felt to have benefited clinically. None of our neuropsychological test parameters were helpful in identifying (prospectively or retrospectively) patients most likely to respond to this treatment. Although a few patients were significantly helped by this training, the mechanism for this effect is unclear. RÉSUMÉ Les auteurs rapportent les résultats obtenu chez 23 épileptiques graves qui ont été soumis a un appren-tissage de l'EEG par retroaction biologique (EEG feedback). Le principe de l'apprentissage etait de renforcer les activites EEG rapides a 18 cps et de supprimer les activites EEG lentes et l'activité des muscles temporaux. Contrairement a ce qui a ete observe dans d'autres etudes utilisant l'EEG feedback, 43% seulement des patients ont montre une modification significative du nombre de leurs crises et un nombre moins important encore ont donne l'impres-sion de tirer un benefice clinque. Aucun des parametres de nos tests neuropsychologiques utilises chez les patients à permis d'identifier (prospectivement ou retrospectivement) ceux d'entre eux qui etaient les plus aptes à repondre a ce traitement. Bien que quelques uns des sujets ont été significativement aidés par cet apprentissage, le mécanisme de cet effet n'est pas évident. RESUMEN Damos cuenta de los resultados obtenidos en 23 pacientes con epilepsia severa que fueron entrenados en el metodo de autocontrol del EEG. El ejemplo hizo que los pacientes pudiesen aumentar la actividad de 18 Hz sobre el area epiléptica mientras que suprimi'an las bajas frecuencias en el EEG y la actividad temporal en el EMG. En contraste con otros informes en los que se us6 el mismo metodo, sólo el 43% de nuestros pacientes mostrt un cambio significativo en el numero de crisis y tan sólo un numero menor de enfermos recibieron beneficios clfnicos. Ninguno de los parametros de las pruebas neurofisiolbgicas llevadas a cabo fueron utiles (prospectiva o retrospectiva-mente) determinando que pacientes eran mas probables de beneficiarse de este tratamiento. Aunque unos pocos pacientes fueron ayudados por este entrena-miento, el mecanismo de este efecto no esta claro. ZUSAMMENFASSUNG Wir berichten uber die Ergebnisse eines EEG-Feedback-Trainings bei 23 schwer epileptischen Patienten. Das Muster verstarkte beim Patienten die Fahigkeit, eine 18 Hz Aktivitat über der Schädelober-flache in Nahe ihres Fokus zu steigern und gleich-zeitig temporal das EMG und die niederfrequente EEG Aktivitat zu vermindern. Im Gegensatz zu anderen Untersuchungen, die mit dem EEG-Feedback arbeiteten zeigten nur 43% der Patienten signifikante Veranderungen der Anfallshäufigkeit und eine kleinere Anzahl schien klinisch gebessert zu sein. Keine unserer neuropsychologischen Testparameter half zu unterscheiden (prospektiv oder retrospektiv), welche Patienten hochstwahrscheinlich auf diese Behandlung ansprechen werden. Obgleich einigen wenigen Patienten durch dieses Training geholfen werden konnte, ist der Mechanismus dieses Einflusses unklar.

EEG feedback training of epileptic patients: Clinical and electroencephalographic analysis

To evaluate the clinical efficacy and mechanisms underlying EEG feedback training of epileptic patients, 5 adult patients with poorly controlled seizures were studied for 4–10 months during which quantitative analysis of seizures, the EEG, and serum anticonvulsant levels was conducted. Sustained seizure reduction did not occur during the first 4–5 weeks in which feedback signals were presented randomly in relation to the EEG. When feedback was then made contingent upon central 9–14 c/sec activity, seizures declined by 60% in 3 patients. Power spectral analysis showed upward shifts in EEG frequency, decreases in abnormal slow activity, and enhancement of alpha rhythm activity as a function of contingent training, but no specific EEG change was associated with seizure reduction in all patients. No evidence was obtained for the hypothesized involvement of a ‘sensorimotor rhythm’ or motor inhibition in the training effects. The lack of effect in two patients could not be attributed to insufficient training, lack of motivation, or to differences in seizure classification. A second phase of research showed that continued laboratory training was both sufficient and necessary for maintaining clinical and EEG effects. Results indicate that: (1) significant seizure reductions can occur with EEG feedback training which are not related to placebo effects, non-specific factors or to changes in medication; (2) EEG changes associated with such training can best be described as ‘normalization’; (3) continued clinical investigation of EEG feedback training as a non-pharmacological adjunct to conventional therapy appears justified.

Effects of Central Cortical EEG Feedback Training on Incidence of Poorly Controlled Seizures

Summary This study examined the clinical effects of central cortical EEG feedback training in 8 patients with poorly controlled seizures. After base‐line recordings, patients were trained in the laboratory and then initiated on a double or triple crossover design using portable equipment at home, with bimonthly laboratory test sessions. Performance at home was monitored by a strip chart recorder with the portable unit. Training was based on the simultaneous detection of two central cortical (C 3 ‐T 3 ) EEG frequency bands (6–9 Hz and either 12–15 or 18–23 Hz), with reward provided for the occurrence of one in the absence of the other. The design consisted of successive 3 month periods of training, with reward contingencies reversed after each period without the subject's knowledge. Seizure incidence records were compared statistically before, during, and after the design. Six of the 8 patients reported significant and sustained seizure reductions, which averaged 74%, following reward for either 12–15 or 18–23 Hz in the absence of 6–9 Hz. Response to positive reward for 12–15 Hz was specific, with seizure rates returning to base line when reinforcement contingencies were reversed. Reduced seizure rates following positive reward for 18–23 Hz were not altered with contingency reversals. A nonspecific interpretation of these effects is rejected in favor of an EEG normalizing hypothesis. RÉSUMÉ Cette étude envisage les effets cliniques de lapprentissage par rétroaction biologique (biofeedback) à renforcer l'EEG des régions centrales chez 8 épileptiques dont les crises étaient mal contrôlées par la thérapeutique. L'apprentissage a eu lieu au domicile des malades après un entrainement initial puis des contrôles bimensuels au laboratoire. L'unité portative comprenait un enregistreur sur papier pour surveiller la performance du malade. L'apprentissage avait pour but de permettre aux sujets de reconnaiire simultanément deux bandes de fréquences de l'EEG de la région centrale (6–9 Hz et 12–15 ou 18–23 Hz), la récompense étant donnée en présence d'une de ces fréquences et en l'absence de l'autré. On a utilise des périodes successives d'apprentissage durant 3 mois, avec une inversion des récompenses après chaque période, les inversions étant faites à l'insu du sujet. La fréquence des crises a été comparée statistiquement avant, pendant et après l'expérience. Six des huit malades ont rapporté une réduction significative de la fréquence des crises, avec une moyenne de 74%, dans le cas d'une récompense pour 12–15 ou 18–23 Hz en l'absence de 6–9 Hz. La réponse à une récompense positive pour 12–15 Hz était spécifique, avec un retour à la ligne de base lors de l'inversion des récompenses. La réduction de frequence des crises après une récompense positive pour 18–23 Hz n'a pas changé avec l'inversion des récompenses. L'interprétation non‐spécifique de ces résultats est rejetée, en faveur de l'hypothèse dune normalisation de l'EEG. RESUMEN En este estudio se han examinado los resultados clinicos en un grupo de ocho epilépticos mal controla‐dos que habian sido entrenados para la realización de un feedback electroencefalográfico central cortical. Después de practicar los registros de control, los enfermos fueron entrenados en el laboratorio y, posteriormente, iniciados en un plan de investigacibn con doble o triple superposición utilizando, en su domicilio, un equipo portatil de registro y estudios bimensuales en el laboratorio. Los resultados obtenidos en el domicilio se registraron en un registrador en banda portatil. El entrenamiento se basó en la detec‐ción simultánea de dos bandas de frecuencias elec‐troencefalograficas corticales centrales (C 3 ‐T 3 ) de 6–9 Hz y también de 12–15 6 18–23 Hz, dando una recompensa al sujeto cuando una banda de frecuencia apareciera en ausencia de la otra. El plan utilizado consistió en tres periodos sucesivos de entrenamiento, de tres meses cada uno, con contingencias de recompensa alternadas en cada periodo sin conocimiento del sujeto. Los registros de incidencia de los ataques se compararon estadisticamente antes, durante y después del plan. Seis de los ocho enfermos mostraron una reducción significativa y mantenida de los ataques que promedió un 74%, tras la recompensa de 12–15 ó 18– 23 Hz, en ausencia de 6–9 Hz. La respuesta a la recompensa positiva para 12–15 Hz fué especifica, con restauración de la frecuencia de ataques a los niveles previos cuando el refuerzo de las contingencias se alternaba. La reducción de la frecuencia de ataques conseguida con la recompensa positiva para 18–23 Hz no se modificó con la inversión de las contingencias. En favor de la hipótesis de la normalización del EEG se rechaza una interpretación inespecifica de los efectos descritos. ZUSAMMENFASSUNG Untersuchung über die klinischen Wirkungen des zentralen corticalen EEG feedback Trainings bei einer Gruppe von 8 schlecht kontrollierten Epileptikem. Nach Ableitung des Ausgangs‐EEGs wurden die Patienten im Labor geschult. Dann begann eine ambu‐lante Doppel‐ oder Dreifachcrossover‐Studie mit einer tragbaren Ausrilstung und 2‐monatlichen Labortests. Das Verhalten zu Hause wurde durch Lochstreifen‐aufzeichnungen mit der tragbaren Einheit festgehalten. Das Training beruhte auf der gleichzeitigen Ent‐deckung von 2 corticalen (C 3 ‐T 3 ) EEG‐Frequenz‐bandern(6‐9Hzundentweder 12–15 oder 18–23 Hz) mit Belohnungen fur das Erscheinen des einen in Abwesenheit des anderen Frequenzbandes. Der Ver‐suchszeitraum bestand aus aufeinanderfolgenden 3‐Monatstrainingsperioden mit Belohnungsquoten, die nach jeder Periode ohne Wissen des Patienten umge‐kehrt wurden. Die Häufigkeit der Anfälle wurde aufgezeichnet und statistisch verglichen vor während und nach dem Versuch. 6 von 8 Patienten berichteten signifikante und anhaltende Anfallsreduktionen (im Durchschnitt 74%) nach einer Belohnung für entweder 12–15 oder 18–23 Hz in Abwesenheit von 6–9 Hz. Die Reaktion auf eine Belohnung fur 12–15 Hz war spezifisch; die Anfallshäufigkeit kehrte zum Aus‐gangswert zurück, wenn die Verstärkerantwort umge‐kehrt wurde. Eine veränderte Häufigkeit nach Belohnung für die Erkennung von 18–23 Hz wurde nicht durch Umkehr der Belohnung geändert. Eine Interpretation dieser Wirkungen als nicht spezifisch wird zu Gunsten einer Hypothese der EEG‐Normalisierung zürtickgestellt.

Operant conditioning of the EEG in two patients with epilepsy: Methodologic and clinical considerations

Methodologic and clinical considerations are discussed in sensorimotor rhythm (SMR) biofeedback research on two dissimilar but severe epileptic males. The first case, an akinetic epileptic who prior to feedback training experienced 80–100 clinical seizures every 10 hours, showed considerable seizure reduction after 6 months of SMR and epileptiform training. A number of methodologic and instrumentation advances were pioneered with the akinetic patient: (1) development of and ultra-sharp band-pass filter; (2) use of epileptiform inhibit and feed-back circuitry; (3) use of monetary rewards as additional incentive; (4) use of correlational analysis for evaluation of acquisition in the major dependent variables and; (5) use of noncontingent feedback and rein-forcement as control techniques. The second case, a psychomotor epileptic, also showed therapeutic benefit from SMR training. Clinical information regarding the effect of anticonvulsant medications on the course and therapeutic outcome of SMR training are described. In conjunction with operant conditioning of 12 Hz activity, corresponding changes for other EEG parameters are examined.

Sensorimotor EEG operant conditioning: Experimental and clinical effects

Neurophysiological studies in cats have established a functional relationship between waking 12–15 Hz sensorimotor cortex rhythmic EEG activity (the sensorimotor rhythm or SMR) and a similar pattern during sleep, the sleep spindle. Both result from oscillatory thalamocortical discharge involving ventrobasal thalamus and sensorimotor cortex, and both are associated with a state of suppressed motor excitability. Enhancement of the SMR with operant conditioning methods in the cat clearly led to reduced seizure susceptibility. The experimental application of this approach to seizure control in epileptics has resulted in (A) evidence that EEG patterns can be manipulated significantly in man with operant conditioning, (B) suggestive observations concerning a potential component of pathology in epilepsy, and (C) strong preliminary evidence that SMR operant conditioning in epileptics is specifically therapeutic. Current research has focused upon the EEG during sleep in epileptics with primary motor symptomatology. This measure often reveals several hard signs of pathology. These include the presence of abnormal activity in the 4–7 Hz frequency band and the absence or disturbance of activity in the 11–15 Hz frequency band. Power spectral analysis is being utilized to quantify these sleep EEG components in five groups of epileptic patients, studied with different frequency patterns rewarded in an A-B-A design which provides for counterbalancing of order effects. Initial laboratory training is followed by 9–12 months of training at home with portable feedback equipment. Reward contingencies are reversed within each group at approximately three month intervals. Clinical EEG data, blood anticonvulsant measures and patient seizure logs supplement sleep EEG data obtained before training and after each phase of the design. Early results have again indicated specific therapeutic benefits following training of high frequency rhythmic central cortical activity.

Developing a biofeedback model: Alpha eeg feedback as a means for pain control

3 adept meditators voluntarily inserted steel needles into their bodies while physiological measures (EEG, EMG, GSR, EKG, and respiratbn)were recorded. Although each adept used a different passive attention technique, none reported pain. During the insertion, 2 of the 3 Ss increased their alpha EEG activity. The role of alpha EEG and its relationship to pain control is discussed.

Clinical Application of Biofeedback Training in Epilepsy

The research on biofeedback training in epilepsy is reviewed, with special regard to 1) extinction treatment of sensory induced epilepsia, and 2) sensory motor rhytm (SMR) feedback, where increase in SMR is supposed to decrease clinical seizures. Two cases, one of each of the two treatment techniques, illustrate the procedures. It is concluded that the extinction procedure is ready for clinical application, whereas SMR biofeedback is in need of further study before it can be recommended for general clinical application.

Kontrolliertes EEG-Alpha-Feedback-Training bei Gesunden und Kopfschmerzpatientinnen

Headache patients and healthy controls underwent alpha-EEG feedback training in 12 sessions. The present study does not support the literature which reports alpha increase by feedback training. The study included a patient group receiving feedback, a patient control group receiving pseudofeedback, and a volunteer group receiving feedback. Increase of alpha EEG was observed under feedback and pseudofeedback. However, there was always more alpha during baseline times than during training times. Alpha increase over time is suggested to be a habituation effect. Headache pain decreased with training (within the boundaries of a placebo effect), and there was no difference in headache decrease between feed-back and pseudofeedback patients.

Behavioral management of epileptic seizures following EEG biofeedback training of the sensorimotor rhythm

Eight severely epileptic patients, four males and four females, ranging in age from 10 to 29 years, were trained to increase 12–14 Hz EEG activity from the regions overlying the Rolandic area. This activity, the sensorimotor rhythm(SMR), has been hypothesized to be related to motor inhibitory processes(Sterman, 1974). The patients represented a crosssection of several different types of epilepsy, including grand mal, myoclonic, akinetic, focal, and psychomotor types. Three of them had varying degrees of mental retardation. SMR was detected by a combination of an analog filtering system and digital processing. Feedback, both auditory and/or visual, was provided whenever one-half second of 12–14-Hz activity was detected in the EEG. Patients were provided with additional feedback keyed by the output of a 4–7-Hz filter which indicated the presence of epileptiform spike activity, slow waves, or movement. Feedback for SMR was inhibited whenever slow-wave activity spikes or movement was also present. During the treatment period most of the patients showed varying degrees of improvement. Two of the patients who had been severely epileptic, having multiple seizures per week, have been seizure free for periods of up to 1 month. Other patients have developed the ability to block many of their seizures. Seizure intensity and duration have also decreased. Furthermore, the successful patients demonstrated an increase in the amount of SMR and an increase in amplitude of SMR during the training period. Spectral analyses for the EEGs were performed periodically. The effectiveness of SMR conditioning for the control of epileptic seizures is evaluated in terms of patient characteristics and type of seizures.

Effects of sham feedback following successful SMR training in an epileptic

After 1 year of SMR biofeedback training of a severe epileptic teenage male, incidence of atonic seizures decreased from 8/hr to less than 1/3 hr. SMR increased from 10% to 70%. Epileptiform discharges decreased from 45% to 15%. Unknown to the patient, his family, or certain members of our research staff, noncontingent feedback was introduced on 7/22/74, ending 9/11/74. A significant decrease occurred for SMR(down 8%), and a significant increase for epileptiform discharges(up 4%). Rate of seizures increased, but was not statistically significant over preceding months of contingent feedback. Incidence of seizures associated with urine loss increased from approximately 6/month to 23/month during noncontingent feedback, a significant increase. Urine-loss results suggest that although seizures did not become more frequent, those the patient did experience were “harder,” i.e., more severe. Contingent feedback was reinstituted following the 7-wk sham, and recovery of all variables to their former levels(prior to sham) occurred.

Reduction of seizures and normalization of the EEG in a severe epileptic following sensorimotor biofeedback training: Preliminary study

Sensorimotor rhythm (SMR) biofeedback training was attempted in a 13-year-old male with frequent epileptic seizures. Prior to training the subject was averaging almost eight clinical seizures an hour. The SMR filter was tuned sharply to 12 ± 1 Hz. Feedback was conducted over approximately six months and continues to the present. In that time the subject's percentage of SMR increased from about 10%, prior to training, to 65% after the 34th training session. Correspondingly, his rate of clinical seizures decreased by a factor of 10 and a significant reduction in percentage of epileptiform discharges was noted. Beginning with trial 35, the subject was provided feedback of epileptiform activity in combination with 12 Hz activity. The combined effect of these two treatment variables was to reduce the trial-to-trial variance in the dependent variables of interest.

Reduction of epileptic seizures through EEG biofeedback training

Biofeedback training of the sensorimotor rhythm (SMR) was carried out in three male and three female adolescent epileptics and in two normal controls. The patients represented a cross-section of epilepsies including grand mal, myoclonic, afocal and psychomotor types. Three of the cases were mentally retarded. 12–14 Hz (SMR) activity was detected by a combination of sharp analog filtering and digital processing. The patients were provided with feed-back whenever they produced 0.5 sec of 12–14 Hz activity of a specified amplitude. Additional feedback was provided for epileptiform activity slow waves or movement. Furthermore, feedback for SMR production was inhibited by digital logic circuitry when movement, slow waves or spikes were present. Seizure reduction was obtained in five of the six epileptics. Several patients showed increased percentage of SMR when feedback was provided and varying degrees of normalization in their EEG as demonstrated by fast Fourier, crossed power spectral density and coherence analyses.

The Effects of Feedback on Focal Epileptic Discharges in Man

SUMMARY: The history of the control of epileptic disturbances by conditioning techniques is reviewed. The preliminary results of a three year trial of feedback techniques in 13 epileptic patients are presented. Thirteen epileptic patients (age 2.5 → 39 mean, 15.1 years) with lateralized focal discharges in the EEG were given repeated trials of feedback, the focal discharges being used to trigger auditory and somatosensory stimuli. Dosages and serum levels of medication were unchanged throughout the experimental period. The number of epileptic spikes per 15 seconds was assessed by automatic trend analysis during 20 to 30 minute control, biofeedback and post-feedback epochs. Ongoing EEG activity was quantified by 8 channel frequency analysis over 10 second epochs. The patients made efforts to increase and decrease the number of spike discharges with and without feedback and the results of both triggered and random auditory, somatosensory, photic and combined stimulation were compared at various intervals over a period of up to three years. A marked reduction in the number of focal discharges was noted in eight (61.5%) patients during and immediately following the sessions. Intermittent biofeedback sessions were not associated with a serial reduction in the number of focal EEG discharges. There was a reduction in the number of clinical epileptic disturbances in six patients (46%) and possible reasons for this improvement are discussed. One patient suffered an increase in focal temporal lobe discharges during triggered and random auditory stimulation whereas there was a marked reduction in the number of discharges during minimal electrical stimulation of the contralateral arm. The need for careful assessment of each patient to determine appropriate feedback stimulation is stressed. One aim of this research has been to assess the feasibility of using miniature units for continuous feedback of focal discharges in epileptic patients.

Biofeedback in Epileptics: Equivocal Relationship of Reinforced EEG Frequency to Seizure Reduction

SUMMARY It has been reported that biofeedback training of 12- to 14-Hz activity recorded over Rolandic cortex was accompanied by a reduction in seizure incidence in four human epileptics (Sterman et al., 1974). Biofeedback training of 12- to 14-Hz activity was provided for two epileptics and had no effect on clinical EEGs, seizure incidence, or proportion of EEG spectral power in the frequency range being trained. Subsequently, biofeedback training of 6- to 12-Hz Rolandic activity was provided for three epileptics. Two patients experienced reductions in seizure not accompanied by medication changes. Since no learning- of 6- to 12-Hz activity was detected, the changes in seizure incidence are not attributed to EEG biofeedback. It is suggested that the experience in the feedback setting provided these two patients with new techniques of relaxation. In view of the lack of statistical evidence of EEG changes following EEG biofeedback and the small number of patients trained to date, it appears wise to maintain a cautious attitude until the issue of causality is clear. RÉSUMÉ On a rapporté que le “biofeedback training” des activités á 12–14 Hz enregistrees sur le cortex rolandique, etait accompagne d'une diminution de la frequence des crises chez quatre sujets epileptiques (Sterman et al., 1974). Un tel “biofeedback training” des activités a 12–14 Hz effectue chez deux sujets epileptiques est reste‘ sans effet sur les EEG, le nombre des crises et la proportion des spectres de puissance de l'EEG pour les frequences interessSes par l'apprentissage. Ensuite, le měme traitement a été applique aux activités rolandiques a 6–12 Hz chez trois epileptiques. Chez deux sujets, les crises ont diminue sans changement du traitement. Puisqu'on n'a pas trouve d'apprentissage pour l'activite a 6–12 Hz cette diminution des crises ne peut pas etre attribute au biofeedback EEG. On suggere qu'a travers la situation de biofeedback on a realise chez ces deux patients une nouvelle forme de relaxation. En tenant compte d'une part de l'absence de modifications EEG statistiquement valables apres le biofeedback EEG et d'autre par du nombre reduit de sujets jusq'a maintenant entraihes, il semble raisonnable d'avoir une attitude reservee tant qu'on ne pourra pas 6tablir un rapport de causality entre cette méthode et les variations de la frequence des crises. RESUMEN Se ha publicado que el entrenamiento de la bioretroalimentación (biofeedback) de la actividad de 12–14 Hz registrada en la corteza rolandica, se acompanaba de una reduccion de la incidencia de ataques en cuatro enfermos epile“pticos (Sterman y col., 1974). El entrenamiento de la retroalimentacion bioldgica de la actividad de 12–14 Hz se realizo en dos epilepticos sin que se produjeran mod-ificaciones en los EEGs, incidencia de ataques o en la proporcion del espectro del EEG enr los maVgenes de la frecuencia sometida a entrenamiento. Seguidamente el entrenamiento por biofeedback de la actividad rolandica de 12–14 Hz se realizo en tres enfermos ep-ilepticos. En dos enfermos, sin modificar la medicacion, los ataques disminuyeron ennu-mero. Puesto que no se detectd aprendizaje de la actividad de 6–12 Hz, la reduccion de la incidencia de ataques no se atribuyo a la bioretroalimentacion electroencefalografica. Como sugerencia se propone que en estos dos enfermos la tecnica de bioretroalimentacion proporciono nuevos procedimientos de re-lajacion. En vista de la falta de evidencia estadfstica de alteraciones electro-encefalograficas tras la bioretroalimentacion del EEG y el reducido nfimero de enfermos en-trenados hasta la fecha, parece logico mantener una actitud cautelosa hasta que se aclare el tema de causalidad. ZUSAMMENFASSUNG Es ist berichtet worden, dass ein Biofeedback-Training von 12–14 Hz-Aktivitätüiber dem Rolandi'schen Cortex bei 4 anfallskranken Patienten mit einer Reduktion der Anfallshäufigkeit einherging (Sterman u.a., 1974). Ein Biofeedback-Training der 12–14 Hz-Aktivität wurde bei 2 Anfallskranken durchgefiihrt und zeigte keine Auswirkungen auf das klinische EEG, die Anfallshäufigkeit oder den Anteil des trainierten Prequenzbereichs am Powerspektrum des EEG. Daraufhin wurde ein Biofeedback-Training mit 6–12 Hz-Aktivitätüiber der Rolandi'schen Region bei 3 Anfallskranken durchgefiihrt, Bei 2 Patienten wurden die Anfalle reduziert ohne dass die Medikation geandert worden war. Da ein Lerneffekt der 6–12 Hz-Aktivität nicht entdeckt wurde, kann die Veranderung der Anfallshäufigkeit nicht dem EEG-Biofeedback zugeschrieben werden. Es wird vermutet, dass die Erfahrungen dieser beiden Patienten mit der Feedback-Methode ihnen neue Moglichkeiten der Entspannung vermittelten. Angesichts fehlender statistisch nachgewiesener Veranderungen im EEG nach Biofeedback und der kleinen Anzahl von Patienten, die bis heute trainiert wurde, scheint es angebracht, zuriickhaltend zu sein, bis die kausalen Zussammenhange klar sind.

THE TREATMENT OF HEADACHE BY MEANS OF ELECTROENCEPHALOGRAPHIC BIOFEEDBACK

A method of treatment of tension headache by means of relaxation training augmented by feedback of alpha frequency EEG is presented. The alleviation of headache symptoms and associated musculoskeletal tension in the majority of patients suggests that it is an effective treatment method. It is more effective than induced relaxation alone and appears to be more effective than EMG biofeedback used with this particular disorder.

Biofeedback Training of the Sensorimotor Electroencephalogram Rhythm in Man: Effects on Epilepsy

Summary Previous work in cats demonstrated a discrete 12–16 Hz rhythm in sensorimotor cortex (SMR), present only during absence of movement, that could be operantly conditioned. Trained cats were resistant to drug-induced seizures. Similar biofeedback training procedures were employed with epileptic and nonepileptic human subjects, utilizing lights, tones, and slides. Initially SMR activity was detected only at low voltage by tuned filters. Biofeedback training sessions resulted in a significant increase in this activity after 2 to 3 months. Learned SMR responses in nonepileptic subjects were trains of pure or polyrhythmic 12–16 Hz activity at 20 to 25 μV over central and frontal areas. Although epileptic subjects failed to develop the enhanced SMR amplitude, they did demonstrate increased occurrence of this frequency. Training in four epileptic patients, who previously were not controlled by chemotherapy, was accompanied by a significant reduction of EEG and clinical epileptic manifestations, as indicated by sequential power spectral analysis, clinical EEG records, and seizure logs. Tonic-clonic and myoclonic seizures were most markedly reduced. RÉsumé Des travaux antérieurs chez des chats ont démontré qu'il y a un rythme discret à 12–16 Hz dans le cortex sensorimoteur (SMR) évident seulement au repos mais suceptible d'étre conditioné. Les chats entrainés étaient résistants aux crises provoquées par des drogues. Des procédés analogues de biofeedback training ont été employeś chez des personnes avec ou sans épilepsie, en utilisant des lumières des sons et des diapositives. Au début, le rythme du cortex sensorimoteur était détecté seulement à des bas voltages avec des filtres à sonorisation appropriée. A la suite de séances de biofeedback training, il y avait après 2–3 mois, une augmentation significative de L'activité rythmique des régions sensorimotrices. Chez les sujets sans épilepsies, les activités acquises à la suite de L'apprentissage étaient constituées par des bouffées d'activités mono- ou polyrythmique à 12–16 Hz et de 20–25 μV d'amplitude, intéressant les régions centrales et frontales. Bien que les sujets avec épilepsie ne soient pas arriveés à augmenter L'amplitude des rythmes des régions sensorimotrices, ils ont cependant mis en évidence une augmentation quantitative de ces rythmes. Chez 4 sujets avec épilepsie qui avant L'entra înement n'étaient pas contrôlés par les médicaments, on a observéà la suite de L'entraînement une diminution significative des decharges paroxystiques sur L'EEG et des crises diminution objectiveée par L'analyse séquentielle des spectres de puissances et par le compte rendu du nombre des crises. Les crises tonico-cloniques et myocloniques etaient le plus remarquablement diminuées. RESUMEN Estudios previos en gatos nan demostrado que un discreto ritmo de 12 a 16 Hz en la corteza sensorial-motora (SMR), registrable solamente en ausencia de movimiento, podía ser condicionado. Los gatos entrenados eran resistentes a los ataques inducidos. Un entrenamiento semejante (bio-feedback) se utilizeó en enfermos epilépticos y en individuos sanos mediante el empleo de luces, tonos y diapositivas. Inicialmente la actividad SMR se registró solamente con voltajes bajos y filtros apropiados. El entrenamiento con retro-información boilógica (biofeedback) produjo un aumento significativo de esta actividad a los 2 o 3 meses. En individuos sanos, las respuestas SMR aprendidas, se expresaban en forma de trenes de una actividad, pura o polirítmica, de 12 a 16 Hz y de 20 a 25 micro-voltios en las areas frontal y central. Los enfermos epilépticos mostraron un aumento de estas frecuencias a pesar de que no se pudo conseguir un incremento de la amplitud SMR. En cuatro enfermos epilépticos entrenados sin posible control farmacológico previo, se consiguió una reducción significativa de las manifestaciones clínicas o electroencefalográficas de la epilepsyía, como demostró el análisis espectral secuencial y los trazados clónicos de EEG Los ataques tónico-clónicos y las mioclónias fueron los que más se redujeron. ZUSAMMEnfassung Frühere Untersuchungen bei Katzen liessen einen diskreten 12 bis 16 Hz-Rhythmus im sensomotorischen Cortex (SMR) erkennen. Er war nur bei Bewegungsruhe vorhanden und konnte konditioniert werden. Trainierte Katzen waren gegenüber medicamentös erzeugten Anfällen resistent. Ahnliche Programme mit biologischem Rückkopplungstraining wurden mit epileptischen und nicht epileptischen Patienten durchgeführt, wobei Licht, Töne und Dias verwendet wurden. Anfangs wurde die SMR.-Aktivität nur mit niedriger Amplitude durch abgestimmte Filter gefunden. Nach 2 bis 3 Monaten dauerndem Training der biologischen Rückkopplung wurde eine signifikante Zunahme dieser Aktivität gefunden. Bei nicht epileptischen Patienten bestanden die erlernten SMR-Ant-worten in Zügen reiner oder polyrhythmischer 12 bis 16 Hz-Aktivität mit 20 bis 25 μV über den zentralen und frontalen Ableitepunkten. Obwohl epileptische Patienten keine verstärkte SMR-Amplitude aufwiesen, zeigten sie doch eine vermehrte Häufigkeit dieser Frequenz. Das Training von 4 epileptischen Patienten, deren Anfälle durch Chemotherapie vorher nicht zu kontrollieren waren, wurde von einer signifikanten Verminderung der epileptischen Manifestationen im EEG und klinisch begleitet. Das zeigten die sequentielle Power-Spektrumanalyse, klinische EEG-Untersuchugnen und Anfallsaufzeichnungen. Tonisch-klonische und myoklonische Anfälle wurden am deutlichsten vermindert.

Suppression of seizures in an epileptic following sensorimotor EEG feedback training

Previous studies of a 12–14 c/sec slow wave rhythm localized to sensorimotor cortex in the cat indicated its functional relationship to thalamo-cortical inhibitory discharge, suppression of phasic motor behavior and suppression of drug-induced convulsions. Investigations in man showed the presence of a similar rhythm in rolandic cortex. Biofeedback techniques for the operant conditioning of this rhythm developed in studies of the cat provided a basis for similar EEG feedback training in man. The functional characteristics mentioned above suggested that this training could be of some benefit in the treatment of epilepsy. This communication reports preliminary findings from such a study in a 23-year-old female subject with moderately controlled major motor seizures of frontoparietal origin. Biofeedback training of this sensorimotor rhythm resulted in a striking enhancement of the rhythm's occurrence, differentiation from simultaneously recorded alpha rhythm activity, and a marked suppression of seizures. Changes in sleep patterns and personality were noted also.

Alpha enhancement as a treatment for pain: A case study

Drawing on past reports of raised pain thresholds of yogis in a meditative state, the high alpha content during meditation, and reports of operant alpha wave conditioning, a hypothesis was formulated that a high alpha state and pain are incompatible behaviors, and thus the production of alpha could be used for symptomatic treatment of pain. A patient, who suffered from severe headaches resulting from head injuries, went through 67 alpha conditioning sessions and increased his alpha activity from 20 per cent time alpha with eyes closed to 92 per cent time alpha with eyes closed and 50 per cent with eyes open. Although the patient was not able to rid himself of pain by achieving a high alpha state, he was in some instances able to prevent pain by going into a high alpha state before the headache began.