Neurofeedback An analysis of existing practices and predictions for the future

Romke van der Meulen June 24, 2011

Abstract In this paper I survey the eld of neurofeedback. Neurofeedback involves measuring brain wave patterns from a subject, processing the data and comparing it to a target value, and feeding the results back to the subject. Typically, audio and visual feedback are used, and the neural activity is measured using an EEG with two or three sensors. Neurofeedback can be used to inhibit or enhance brain waves, depending on the desired eect. Neurofeedback has been used to train theta, alpha, beta, SMR waves and slow cortical potentials. Neurofeedback has notably been applied to the treatment of a number of disorders with mental components, such as ADHD, epilepsy and PTSD. Neurofeedback was rst used in the 1970s, and has been continually developed since. It is now becoming more accepted as a viable treatment method. Neurofeedback has a number of advantages compared to traditional medical treatments: it is cheap, it has few side eects and it actively involves the patient in the treatment. As such, we can expect neurofeedback to become a widely accepted treatment method in the future.

Keywords: biofeedback, neurofeedback, therapy, EEG, QEEG

Introduction
Neurofeedback is a specic case of biofeedback. In biofeedback, biological data is recorded from a subject and fed back to this subject online, typically using both visual and audio feedback. The goal for the subject is to attain a particular state as often and for as long as possible. This training is done continuously through several sessions, with the goal being that the subject learns to attain this state at will, without requiring feedback. This practice is used in therapy, for example by teaching people with hypertension to lower their own blood-pressure levels. In neurofeedback, what is fed back to the subject is a measure of their brain activity. Typically, an EEG is measured and analyzed. According to the training goals, particular brain patterns are selected and fed back to the subject. Typical neurofeedback training includes enhancing beta waves, alpha waves or alpha/gamma ratio. By training people to alter their brain patterns, a range of ailments with distinct mental components may be treated. Neurofeedback has been applied to the treatment of Attention-Decit/Hyperactivity Disorder (ADHD), PostTraumatic Stress Disorder (PTSD), autism-spectrum disorders, epilepsy, and many others. Neurofeedback was rst explored and popularized by the work of Joe Kamiya in the 1960s. He used early EEG measures to train people to induce a state of heightened alpha wave activity (Kamiya, 1971). Neurofeedback continued to develop, but was still a minor eld in biofeedback. In 1993, several meetings were held to advance the eld. Out of one of these, the precursor to

Student Human Machine Communications, Department of Articial Intelligence, Rijksuniversiteit Groningen

the International Society for Neurofeedback Research (www.isnr.org) was formed. At a meeting of the Association for Applied Psychophysiology and Biofeedback (www.aapb.org), the section of the organisation concerned with EEG grew to become the biggest section in the organisation. Neurofeedback is now becoming an established practice, in the United States in particular. In this paper, I present a survey of the eld of neurofeedback. I will in particular highlight neurofeedback practices, applications and eectiveness. Based on this, I will present an outlook on the future of neurofeedback research. To gather this information, I made a study of existing literature. I also interviewed Drs. Roland Verment, a neurofeedback practitioner at Neurobics in Groningen (www.neurobics.nl).

Methods
Neurofeedback setups consist of three components: a device for measuring brain activity, a mathematical analysis of the data, and a method of feeding back the results to the subject. Many combinations of methods have been applied, but there are some standards that have been most widely used. A typical neurofeedback setup uses (Q)EEG measurements and presents audio and visual feedback. A quantitative electroencephalogram (QEEG) is a measurement taken using an electrode cap with 19 electrodes. The subjects brain activity is measured for an extended time, artifacts are removed from the signal, and the data is compared to normative data to identify obvious abnormalities. A QEEG may be used at the start of neurofeedback training, to aid the practitioner in identifying problems and designing a training regimen and during training to update assessment (Hammond, 2006). During a neurofeedback training session, two electrodes and an ear clip suce to get brain wave readings for feedback. The signal is analyzed, the appropriate brain wave signal is isolated and compared to the target value. The result is used to generate an audio and/or visual signal, which is fed back to the subject. (Hammond, 2006) The type of feedback can vary greatly. There seems to be a consensus that for the best results, a combination of modalities, mostly visual and audio, should be used (Vernon et al., 2004, p. 65). Neurobics, for example, in one type of training, shows the subject a movie. A chime sounds whenever the subject maintains the target state for half a second, and the size of the movie projection varies with the proximity of the brain pattern to the target pattern. Another approach is to display a bar next to the movie, where the bar height is an indication of the current strength of the target brain pattern, and a line indicates the target height. Children seem to respond well to positive reinforcement and lots of it. Not much hardware is actually involved: a simple EEG clip and amplier, and a computer. Neurobics has in some instances tried letting subjects perform training sessions at home, supervised over the internet. Drs. Verment reports mixed results: is some instances, home training can be a positive inuence, but in many cases the subject cannot relax and focus on the training as well at home, with numerous distractions, as in the specially designed facilities at Neurobics. Interestingly, Cortoos et al. (2010) did a study where patients with primary insomnia used neurofeedback training at home two or three times a week over an eight week period. The group whose neurofeedback training focused on inhibition of theta and high beta, as well as enhanced SMR, showed a signicant increase in total sleep time. Of several groups in the experiment, only the group that did neurofeedback training at home showed an increase in subjective sleep measures. The brain pattern to train, and the target value of the signal, are parameters of the training session. The practitioner determines these based on the subjects problems/goals, and on the QEEG results. When the desired result is a calm state, slow brain waves such as theta or alpha 2

may be trained. If greater focus is desired, beta wave training is more appropriate. Goals may be set to absolute values for some brain wave frequency, but may also aim at altering the ratio of certain types of brain wave, e.g. the ratio of theta to alpha. The assignment of brain wave types to frequency bands is usually xed, but some research has suggested that these should be determined individually for optimal results, though this remains to be proven (Vernon et al., 2004). The duration of each training session, and the frequency of sessions, are also free parameters. A typical session at Neurobics lasts for 40-50 minutes, once a week. According to Drs. Verment, positive eects outside the training session manifest quickly, often after only 5 to 10 sessions. Subjects often report feeling dierent mentally after even the rst session. In recent years, some alternatives to EEG as the measurement for neurofeedback have emerged. Yoo and Jolesz made a pilot study of using fMRI in neurofeedback (Yoo and Jolesz, 2002). They trained several subjects to move muscles in their hand to produce a target level of cortical activity. Although fMRI had a signicantly lower temporal resolution compared to EEG (data was only fed back to the subjects after a one minute block), they theorized that the increased spatial resolution means that this method might be successfully applied to aid in motor functional rehabilitation after neurological damage. Johnston et al. (2010) show a more recent application of fMRI to neurofeedback. They trained thirteen participants to increase activity in a target area on demand. First they showed the participants emotionally negatively aective pictures, to determine the individuals emotion network in stead of relying on anatomically dened areas. The participants were then instructed to increase activity in the target area, alternated with rest periods. A thermometer, updated at 2s intervals, represented activity in the target area. The participants spent an average of 14 minutes in this feedback training. Participants were told to nd their own mental strategy to increase activity, most chose negative emotional memories. They found that participants were quickly able to increase activity in the target area. By using mental imagery, activity also increased in areas outside the target, but no signicant activation increases were found outside the target across runs. Another recent development is an interest in the application of electromagnetic tomography, or inverse EEG. This involves analyzing the EEG signal on multiple places on the scalp to reconstruct activity at a specic location in the brain. Congedo et al. published a study in which they used 19 electrodes placed according to the 10-20 system to enhance the beta to alpha ratio in the Anterior Cingulate of six undergraduate students, which they claim to be the rst application of inverse EEG to neurofeedback (Congedo et al., 2004). Drs. Verment tells me interest in this method has grown in recent years, but the additional benet remains to be proven. There are a number of free parameters in setting up a neurofeedback training regimen. Unfortunately, though there have been a large number of publications on individual clinical trials, there has been very little systematic research into the inuence of each parameter on the end result, and what the optimal approach would be. Vernon et al. (2004), in their comparative study of papers on the treatment of ADHD, have given a number of points for future research, and also conclude that research of this kind is required but lacking. Drs. Verment also indicated a lack of this type of research, which is unlikely to be done by commercial practitioners as such research would entail giving suboptimal training to paying customers. As long as this research is not done, aside from some established practices, neurofeedback practitioners have to nd optimal treatment procedures for themselves.

Applications
Neurofeedback has been applied to a wide range of disorders, and also to enhancing performance in healthy individuals. The ISNR website (www.isnr.org) holds links to studies in a number of applications. I will list and evaluate a number of these applications here. This is not an exhaustive list: over the last few decades, neurofeedback has been applied to a great number of uses.

ADHD
One of the most frequent applications of neurofeedback is in the treatment of ADHD. Common ADHD treatments using neurofeedback include inhibiting theta waves and enhancing SMR or low-beta waves. (Vernon et al., 2004) Theta waves (4-8 Hz) are one of the slower brain waves, associated with relaxation and low arousal. ADHD patients typically show an excess of theta waves, and the training to inhibit theta is common to most ADHD treatments. The cause of this excess theta activity is unclear, but under arousal and developmental deciencies have been implicated. The SMR pattern (12-15 Hz) is related to inhibition of motor movements. An increase in this type of activity translates into an increased sense of calm. Therefore, training to enhance SMR is given to ADHD patients where hyperactivity/impulsiveness is one of the symptoms. Low-beta (15-20 Hz) training was rst given to ADHD patients because QEEG results showed patients to have a lower level of this activity. Also, low-beta has been linked by a number of researchers to mental activities related to (maintained) focus and attention. Training to enhance low-beta activity may therefore be most benecial for ADHD patients where low attention and/or low arousal are the primary symptoms.

Epilepsy
Since epilepsy is a disorder arising from uncontrolled brain activity, neurofeedback is ideally suited to help patients get the condition under control. This is why epilepsy was one of the rst disorders to be treated with neurofeedback. Monderer et al. (2002) reviewed thirty years worth of research on the use of neurofeedback training to treat epilepsy. They intended to do a meta-review of all results, but found insucient rigorously controlled studies to produce accurate results. They instead reviewed existing research more informally. They found two major training procedures that have been applied to epilepsy: inhibition of negative SCP and enhanced SMR. Epilepsy has been linked to large oscillations in the Slow Cortical Potential (SCP). Positive shifts are linked to relaxation, negative shifts with higher arousal and increased cortical activity. Therefore much research has focused on training patients to suppress negative SCP, hoping that thereby the patient can learn to inhibit seizures. Monderer et al. reviewed a number of studies that showed signicant benets in patients thus trained: many had decreased seizure frequencies, while others even became seizure free. Unfortunately, a number of patients failed to respond to the training. Elbert et al. (1980) suggested that factors such as increased age, stress and lack of motivation may be responsible. Training for enhanced SMR has been studied by a number of researchers since the 1970s. Few controlled studies were done, but a number of clinical trials were published. Many showed positive results, with seizure frequency being reduced even after training has ended.

Alpha/theta training
Alpha (8-12 Hz) and theta (4-8 Hz) brain waves are connected to rest and relaxation. Neurofeedback training to enhance these patterns can help a subject reach a relaxed state. A number of conditions can be treated by such training. Alpha/theta training has been applied, among others, to alcoholism, stress, depression, PTSD and schizophrenia. Peniston and Kulkosky from Colorado have researched a number of applications of alpha/theta training, including the treatment of alcoholism (Peniston and Kulkosky, 1990). Saxby and Peniston (1995) applied the same training method to the treatment of 14 alcoholics with depressive symptoms. They obtained behavioural measurements both before and after the training, and during a 21 month follow-up. They found signicant decreases in depressive and alcoholic symptoms, even at the 21 month follow-up. They did not obtain EEG measures to verify altered brain wave patterns in the subjects, a shortcoming common to many neurofeedback studies: more on this later. One of the most successful applications of alpha/theta training has been in the treatment of Post-Traumatic Stress Disorder (PTSD). Peniston and Kulkosky (1991) compared the results of alpha/theta training to a traditional medical control group. They obtained behavioural measures after the training and at a thirty month follow-up. They found that patients receiving alpha/theta training showed decreased scores for a number of depressive symptoms, while the control group only showed a decrease on the scale labelled schizophrenia. All fourteen alpha/theta training subjects who took psychotropic medication reduced their dosage after treatment, while only one of thirteen subjects in the control group did. At the thirty month follow-up, all fourteen subjects in the control group had relapsed, while of the fteen training subjects, only three had relapsed. This study did not have enough rigorous control for reliable scientic conclusions: the only measurements were behavioural data, and it was not established that this was due to altered brain wave patterns. However, these results did prove so promising that research into this type of treatment has continued since. Bolea (2010) describes the authors experience with the application of neurofeedback therapy to the treatment of schizophrenia. It describes one severe case which the author claims is representative of 70 schizophrenia patient he has likewise treated. Training included, among others, enhanced alpha and decreased beta activity. This patients, like many of the other 70, had been classied as hopeless after a range of therapies had been attempted. After a neurofeedback treatment of over a year, results were so good that the patient could resume living in the community.

Performance
Neurofeedback is not only applicable to therapeutic settings. Research has also been done into neurofeedback as a method of increasing performance in healthy subjects. Vernon (2005) reviewed a number of studies on this subject, categorized into training to enhance sports performance, cognitive performance or artistic performance. Some of the studies included application of neurofeedback to the enhancement of archery, athletics, dance, creativity, learning, memory and musical ability. The reviewed studies included theta, alpha, alpha/theta and beta training. Unfortunately, Vernon found that most studies were not rigorous enough to warrant strong conclusions. Some studies measured post-training brainwave patterns, but found no signicant change. Others obtained only post-training behavioural measurements, and some of these studies also found no signicant change. None of the studies was rigorously performed: of those few where there was a control group, the control group did not receive equivalent attention or training as the experimental group. Some did not have a control group at all. In fact, Vernon concluded that based on the reviewed material, the applicability of neurofeedback training to 5

performance enhancement was equivocal. However, the reviewed studies did show enough of an interesting trend to warrant further research.

Eectiveness
Until recently, though neurofeedback had already been successfully applied to a number of individual cases, there was little scientic proof to conclude that neurofeedback was a viable treatment, with signicant benets. Vernon et al. (2004) concluded that on the matter of the treatment of ADHD, there had been a number of published clinical trials, but most of these failed to control for a number of factors, or to show that beside an alleviation of symptoms, there was also a measured, persistent change in brain wave activity, so that the success of the treatment might just as well have been attributed to uncontrolled factors. In another review (Vernon, 2005), Vernon concluded that published studies on the eects of neurofeedback training to enhance performance in healthy individuals, there was also a lack of conclusive evidence due to inadequate control, low number of subjects and insucient data on the persistence of the altered brain activity. He recommended future studies use better control groups, pre- and post-training EEG baselines to check for altered neural activity, pre- and post- measures of behaviour, and correlation of changes in EEG to altered behaviour. Fortunately, in recent years there has been a new focus on this shortcoming, and large randomised controlled trials are now being held. Gevensleben and et al. (2009) did a study on 102 children with ADHD, distributed over a test and control group, where the control group received a carefully constructed placebo training designed to match the neurofeedback training as much as possible. Behavioural measures were obtained pre-, during and post-training, though post-training EEG data was not provided, failing some of Vernons recommendations. Their study did nd a signicant improvement in behavioural measures for the test group compared to the control group, which might prove conclusively that neurofeedback is a viable treatment for ADHD. Drs. Verment tells me that neurofeedback is recently becoming well accepted in many large Dutch organisations. Many medical insurance companies nance neurofeedback training in their extended packages, though ocial rulings prohibit them from oering it in their basic coverages plans. Insurance companies view the treatment very favourably, due to its low cost (EEG/processing equipment, space and man hours) and good results with disorders that normally require years of traditional treatment. There are also a number of other reasons why neurofeedback is considered a good alternative to traditional treatments. It actively involves the patient with his or her treatment, increasing motivation and success rates. It makes use of the human bodies own abilities to cure disorders, in stead of relying on foreign elements such as medication. Also, unlike medication, there are little to no negative side eects in neurofeedback training. In fact, experience has shown that subjects not only decrease symptoms but also gain a relaxed or focused mind-set and a sense of well-being. Besides therapeutic uses, neurofeedback has also been applied to neurological research. Keizer et al. (2010), for example, used neurofeedback to train two groups in a double-blind experiment. One group was trained for enhanced gamma band (36-44 Hz) activity, one for enhanced beta band (12-20 Hz) activity. The goal was to determine how the change in each band would aect short-term and longer-term feature binding related to long term memory. The gamma band group was able to increase frontal and occipital gamma activity, while the beta band group got increased synchrony in the beta band between frontal and occipital areas. Enhanced gamma activity led to a greater exibility in handling integrated information in short-term and long-term memory, while increased coordination in beta activity led to fa6

cilitation of familiarity-based processes. Keizer et al. concluded that neurofeedback can be a powerful tool in research, especially into the functional role of neural synchrony, which is one of the primary causes of EEG brain wave patterns.

Conclusion
In this paper, I have surveyed the research area of neurofeedback. Neurofeedback consists of measuring brain activity, typically using EEG data, processing these measures, comparing them to target values and feeding the results back to the subject. The subject then learns to control his or her own brain waves, to positive and persistent eect. Neurofeedback has been around for 40 years, and is starting to become accepted as a viable alternative treatment to a range of disorders with mental components, including but not limited to the treatment of ADHD, alcoholism, autism, depression, epilepsy, PTSD and stress, and has also been applied to the enhancement of performance in healthy individuals. The eectiveness of neurofeedback has recently been more and more well established, with rigorous control studies proving the benecial eects of neurofeedback in a number of applications. Neurofeedback has a number of advantages over traditional medical practices: it is cheap, has few side eects and actively employs the patient into using their natural processes to treat disorders. Neurofeedback will likely continue to grow in the public consciousness, and become an established therapeutic practice.

References
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