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.