Neurofeedback: A new modality for treating
brain problems
by
James Lawrence Thomas, PhD, BCIA-EEG
published in the Archives of Medical
Psychology, Vol 3 (1), May 2012
Neurofeedback is one modality of biofeedback which
aims to train the electrophysiology of the patient’s brain to become more
normal. A basic assumption is that if the brain physiology becomes more
normal, the related symptoms of psychological and neurological conditions would
improve. Helping someone to control their own physiology will likely result in
lower medical costs, which will give patients empowerment over their health.
I will first give a brief overview of biofeedback,
and then explain the basics of neurotherapy and neurofeedback. Some background
in describing the underlying concepts of the electrophysiology of the brain
will be necessary in order to understand the research in this area. Finally,
the research on neurofeedback and neurotherapy for a few disorders will be
noted, as well as directions for the future.
An Overview of Biofeedback. Biofeedback is a method of
treatment in which the patients are trained to become aware and learn to
control their own physiology in order to improve physical and psychological
health. For example, a patient who is trained to control his/her temperature
can help such diverse disorders as headaches, hypertension, anxiety, tinnitus,
as well as enhance general relaxation (Schwartz & Andrasik, 2003) There
are several modalities of biofeedback treatment, and some of these might be of
interest to treatment for psychological health, and are often used in
conjunction with neurotherapy treatment. For example, training a person in
heart rate variability can be beneficial for those with cardiac conditions.
Temperature training could also benefit patients who need a method of overall
relaxation or for disorders mentioned above. Both heart rate variability and
temperature training can be prior to neurofeedback as a means of relaxing the
patient for the neurofeedback session. In all cases, biofeedback trains people
to monitor and control aspects of their own physiology to improve their
health. Training the EEG or brain waves is the modality of biofeedback we will
consider in this article. First, we need to introduce other aspects of
biofeedback since this treatment involves the use of very sophisticated
equipment, and demands a substantial amount of training.
In all biofeedback procedures, specialized equipment
measures the physiology of various modalities, which in turn are fed back to
the patient (usually on a computer) so that the patient knows what is going on
with regard to their physiology. For example, in temperature training, the
degrees of the body where the sensor is (typically on the finger) can be
displayed on the computer screen so that the patient can see if the temperature
is raised by specified exercises, such as imagining that the hand is getting
warmer. Modern biofeedback instruments are quite sensitive, and in the case of
temperature training, the resolution is to the 100th of a degree. Thus, even
small changes can be seen on the computer in a graph or other visual display.
Biofeedback for heart rate variability measures a detailed and complex spectral
frequency of the heart rate over a range of values; this kind of physiological
information is understood only by cardiologists. Muscle tension is measured in
microvolts (millionths of a volt) The EEG is also measured in microvolts, and
one possible display is to see one’s own brain waves in microvolts pass in
front of you while learning how to control them.
As you might imagine, a substantial amount of
training is necessary in order to learn how to use this kind of equipment, and
there are several different systems one can choose (e.g., Thought Technology,
Nexus, J & J Engineering) Each has detailed and complex software. Some
biofeedback systems do all the modalities mentioned above (Thought Technology
and Nexus) while others specialize in neurofeedback (e.g., BrainMaster and
pirHEG) Still other forms of neurotherapy deal with aspects of treatment that
do not deal with feedback per se, but train the brain waves in a direct
stimulation method (e.g., MindAlive) I will use the term neurotherapy to
indicate all forms of training the brain with specialized equipment such as
noted above.
Neurotherapy can be defined as any
method of training the brain to enhance the functioning of the patient. This
broad term can include neurofeedback (also known as EEG biofeedback), as well
as hemoencephalography (HEG), and audio-visual entrainment or stimulation (AVE
or AVS), as well as other methods. In all these cases, equipment is used in
the treatment.
Neurofeedback consists of training the
patient to control their brain waves. Ordinarily this means training the
patient to become aware of and learn to train their brain waves or
electroencephalograph, also known as EEG. Thus, neurofeedback is also called EEG
Biofeedback. Now I will introduce and simplify some aspects of
electrophysiology of the brain which are important in understanding what
neurofeedback does. The vast majority of the research in neurotherapy is in
the area of neurofeedback.
The neurofeedback patient often obtains a
quantitative EEG in order to identify where the brain waves need to be trained,
or changed. The electrode is then placed in one or more areas, and the patient
is displayed a feedback so that the dysfunctional frequencies are trained down,
and the “good” waves are trained up. The display can be the brain waves
themselves (good for some patients), or a display generated by the computer.
The patient is asked to keep the animation going (for example), and by operant
conditioning the patient trains his/her brain waves to be more normal.
Neurofeedback is considerably more complex than most other biofeedback modalities,
and it is the newest modality in the field of biofeedback. Nonetheless, there
is a fair amount of research regarding its effectiveness (see Monastra, 2005;
Lubar, 2003: Yucha & Montgomery, 2008; Thompson & Thompson, 2003)
Neurofeedback has been shown to be effective for attention deficit disorder,
chronic pain, traumatic brain injury, and other brain disorders (Yucha &
Montgomery, 2008) Frank Duffy, a well-known neurologist, stated in a special
issue of the Jnl Clinical Electroencephalography devoted to
neurofeedback (2000) that “if any medication had demonstrated such a wide
spectrum of efficacy, it would be universally accepted and widely used” (p. v)
Of importance is that there seem to be actual
changes in the brain as a result of neurofeedback. In a study by Canadians
Levesque, Beauregard and
Mensour (2006),
pre and post fMRI and neuropsychological tests were done with a neurofeedback
treatment group and controls of ADHD children, in a randomized, double blind,
placebo controlled study. Both the children and the therapists were blinded to
whether they received the treatment or not. The treated children improved in
functioning and in neuropsychological test scores, and their brain physiology
improved in the predicted areas according to the post fMRI. So it appears that
neurofeedback can change the brain.
Several substantial volumes supporting the
effectiveness of neurofeedback with a variety of populations can be consulted
for research in this area (Evans, 2007; Budzynski, et al., 2009; Thompson &
Thompson, 2003; Evans
& Abarbanel, 1999), as well as a frequently updated bibliography by Cory
Hammond (2012).
Brain physiology. Everyone has electricity
all over their body, and in the brain this electrical activity is measured in
terms of its brain waves; the unit of measure is microvolts. Brain waves occur
in different frequencies, understood in cycles per second, or in hertz
(abbreviated Hz) All frequencies occur in all parts of the brain, but in
different conditions of the brain, the distribution of the frequencies can take
on specific proportions. The slowest brain wave frequency is Delta, 0.5 to
4Hz, and next is Theta, 4-8Hz. Alpha is often considered 8-12Hz, Beta is from
12-30Hz, and Gamma is from about 30-45Hz. Be aware that different researchers
define these bands in different ways. Here is a table that may help make this
clear.
Brain wave Frequency
band Characteristic
Delta 0.5
to 4 Hz Slow waves, often associated with sleep
Theta 4-8
Hz Dreamlike or slow processing
Alpha 8-12
Hz Relaxation, brain idling
Beta 12-30
Hz Active thinking
Gamma 30-45 Hz Very
active processing
The frequencies of the brain waves are measured at
certain locations or sites. There is a system of location called the 10-20 system
which specifies the sites (19 or 21 sites, depending on the system) where brain
waves are measured. For example, Cz is at the top of the head; Fpz is in the
middle of the forehead, about an inch up from the mid point between your
eyebrows. Frontal sites include Fz, F3, F4, and posterior sites include P3,
P4, PZ. You can choose to train some frequencies up (or to be more active),
and some frequencies down, or to be inhibited. Thus, one protocol could be to
train Fz 12-18Hz up and 4-7Hz down (or “inhibit”) at the same time. This
particular protocol is used for many ADD children, because Theta is often too
high and Beta is too low at Fz (mid-way between Fpz and Cz) Successful
training of these frequencies to be more normal can reduce the typical ADD symptoms
(Levesque,
Beauregard & Mensour,
2006) In order to determine precise protocols for doing neurofeedback, it is
common to assess the patient’s brain waves with a quantitative EEG (QEEG),
sometimes called a “brain map.”
Quantitative EEG. The technology of the
electroencephalogram (EEG) has progressed far beyond the original invention of
the EEG by Hans Berger in 1929, so that the electrophysiological data is now
analyzed in very sophisticated ways; only the simplest presentation can be made
here.
To give an idea as to how complex this is, consider
that the QEEG method measures all frequencies (Delta, Theta, Alpha, Beta 1,
Beta 2, Beta 3, Gamma) at each of the 19 sites, plus all possible pairs of
sites in terms the connectivity variables of Coherence, Asymmetry and Phase,
plus the whole right side of the brain and the whole left side. The result is
some 2,500 variables. This complex brain wave data is analyzed by a computer
program and compared to people the same age, and the result is called a Quantitative
EEG, or QEEG. These are compared to the normative database which contains
the data for all ages; therefore, the patient in question is compared to those
members of the database which are the same age. Of importance are the
deviations the patient has compared to the norms with respect to all these
variables. What is so fascinating about the complexity of this data is that
the QEEG patterns are lawful and describe certain pathologies in a reliable
way. Thus, a child with attention deficit disorder (ADD) has a certain number
of patterns that are typical, such as a high Theta/Beta ratio in the frontal
area of the brain (at Fz) However, there are several specific
electrophysiological patterns in children with ADD (Chabot, de Michele, Prichep
& John, 2001) Dementia, affective disorder, traumatic brain injury, and
obsessive-compulsive disorder all have distinctive patterns to their QEEG. As
you might imagine, collecting data for a QEEG database is complex and needs to
be done in a very careful way since this database will be used in comparing
patient brains to see if they correspond to certain kinds of brain
dysfunction. A detailed history of this process can be found in a recent
chapter by Robert Thatcher and Joel Lubar (2009).
Some methods involve collecting the QEEG data under
different conditions — eyes closed, eyes open and doing several cognitive
tasks. In this way, we can understand how the brain is functioning under
different cognitive tasks and then train the brain while doing those tasks in
order to correct that cognitive function. One important researcher in this
area, Kirtley Thornton, has shown that QEEG data collected under different eyes
open conditions of cognitive functioning (e.g., memory, reasoning, visual and
verbal attention) are different than in the eyes closed condition (Thornton
& Carmody, 2005) This may lead to different kinds of neurotherapy
interventions than those described here. For example, one might be able to
target the enhancement of memory functioning specifically in relevant disorders
(e.g., early stage dementia) with this methodology.
Other methods of Neurotherapy. There are some other
modalities which have to do with training the brain. As mentioned above,
neurofeedback involves giving feedback to the patient, while neurotherapy can
be any method of training the brain. I will briefly explain audio-visual
stimulation, audio-visual entrainment and hemoencephalography.
Audio-visual stimulation (AVS) and
audio-visual entrainment (AVE) consists of flickering LED lights embedded in
glasses presented to the patient, along with sounds vibrations through ear
phones. The frequencies can vary according to EEG frequencies (e.g., Delta,
Alpha, Beta) Sometimes the AVS device is programmed to vary the frequencies according
to what is believed to be optimal for a given purpose. For example, if low
Beta (15-18 Hz) is thought to be beneficial for a patient, this frequency might
be programmed so that the patient see lights flicker at 15-18 Hz and hear the
15-18 Hz rhythm in the ear phones. Research has shown that entraining these
frequencies can enhance the same frequencies in the brain and its effects can
last for a long period of time (Collura & Siever, 2009) Sometimes a
variety of frequencies are programmed, so that the flickering lights can go
through a range of Delta flickering lights, then ramp up to Alpha and Beta,
then go back down to Delta. In a clinical study, Budzynski and colleagues
(2007) did some “Brain Brightening“ AVE sessions with 10 seniors (noted below),
and there were improvements on many of the measures from the MicroCog
computerized cognitive battery.
Hemoencephalography (HEG) biofeedback trains
the patient to control the cerebral blood flow in the frontal lobes. An
infrared camera sensor is placed on the forehead which reads the heat emanating
from the forehead (a close correlate of the blood flow), and the patient learns
to control the heat by the display being watched. In the case of the pir HEG,
the display is a movie — any DVD the patient wishes to see. If the frontal
lobe blood flow and temperature remains high, the patient can continue to watch
the movie. When the temperature drops (believed to be in the anterior
cingulate gyrus), the movie stops, and by focusing on a bar graph display, the
cortical activity increases such that the movie starts again. The therapist
can make the task easier or more difficult; the auto-threshold aspect of this
system follows the temperature of the frontal lobe (which naturally fluctuates)
so that sooner or later the movie will stop, and the patient needs to focus on
a part of the computer
The HEG method of neurofeedback is a new kind of
treatment, and there is little research as to its effectiveness, and none to my
knowledge with the elderly. This biofeedback system was originally designed
for migraine headache treatment, and has shown promising results. Carmen
(2004) took 100 migraine patients who had been through many previous
treatments, including many trying several medications, with little success.
Positive results were usually seen in six HEG sessions, and over 90 percent of
the patients reported significantly positive results, according to their own
report. I am including this method of neurofeedback because it is specifically
designed to train the cerebral blood flow of the frontal lobes to increase, and
this has been known to be an important area of brain functioning in the
elderly. You will recall that a typical problem in the elderly is the reduced
frontal lobe blood flow. This methodology may become an important part of
future treatment for elderly cognitive enhancement.
There are a number of disorders which have been
shown to respond to neurofeedback, and it is likely that as research grows in
this area, the number of disorders able to benefit will increase. At this
point, there is a reasonably good evidence that neurofeedback can help those
with attention deficit disorder, traumatic brain injury, epilepsy, depression,
and stopping the beginnings of cognitive decline in the elderly (Thomas, 2011).
HEG biofeedback has also had success in treating migraines (Carmen, 2004;
Toomin & Carmen, 2009). Some single case studies have shown that
QEEG-guided neurofeedback can also help obsessive-compulsive disorder (Hammond,
2003), and anxiety disorders (Hammond, 2005) A Turkish neuropsychiatrist has
used QEEG-guided neurofeedback to train schizophrenics, resulting in such a
reduction of symptoms so that they score as normal on several well-regarded
psychological and neuropsychological measures (Surmeli et al, 2012) These
developments will be discussed below.
Attention Deficit Disorder. A great deal of research
has been done with using neurofeedback to help alleviate the symptoms of
Attention Deficit Disorder (ADD) A number of studies can be found in review
articles by Monastra (2005) and in Yucha and Montgomery (2008) The early term
of EEG biofeedback has been updated to be called neurofeedback in most
publications. A variety of protocols have been used over the last three
decades, so it is hard to summarize them in a brief review. The overall trend
is to train the patient to lower the slow waves (especially theta) and increase
the fast waves (beta) in the frontal regions of the brain, i.e., the frontal
lobes.
The earliest studies were done by Joel Lubar and his
colleagues (Lubar & Shouse, 1976, 1977), and showed that in training down
the slow activity and training up the beta or faster brain activity, behaviors
improved in the ADD children. Lubar followed 52 patients over 10 years, and the
gains were maintained over that length of time. This answers the question as
to whether the benefits of neurofeedback training can last over time; but
clearly more follow-up studies are needed to demonstrate a permanent effect.
In another study, Linden, Habib, and Radojevic (1996), the children with
attention deficit disorder who received neurofeedback showed better control
over their attentiveness and had a Full Scale IQ gain of 10 points, while the
control groups showed no gains in these areas. Thompson and Thompson (1998)
have also shown similar IQ and behavioral improvements. In a large study by
Kaiser and Othmer (2000), significant improvements were found on the TOVA
continuous performance test, as well as gains of 10 points in Verbal and Performance
IQs.
In a randomized, placebo, control group study done
by Levesque,
Beauregard and Mensour
(2006), it was shown that with neurofeedback training, the experimental group
of ADD children improved on neuropsychological measures as well as pre- post-
fMRI measures of the anterior cingulate cortex, indicating that functional
neuroanatomical changes occur with neurofeedback training. In other words, the
areas of the brain involved in training showed actual physiological changes
which corresponded to the improved neuropsychological improvements.
Neurofeedback has also been demonstrated as a
treatment model in Asian countries. In a study by Zhang, Zhang and Jin (2006),
ADD children were randomly assigned to either a medication group
(methylphenidate) or EEG biofeedback. They were rated pre- and post treatment,
and at one, three and six month intervals. The EEG group showed substantially
improved scores on the Conners Parent Rating Scale and at 6 month follow-up.
In a study by Zhong-Gui, Hai-Qing, Shu-Hua, (2006), those children who did EEG
biofeedback training showed significant improvements on the TOVA continuous
performance test after 40 sessions.
Many more studies of neurofeedback helping ADD
patients in improved functioning can be found in other references (Yucha &
Montgomery, 2008; Monastra, 2003; Lubar, 2003; Rossiter & LaVaque, 1995;
Rossiter, 2004) Additionally, it has been shown that the positive results
remain long after treatment has been completed (Thompson & Thompson, 2003;
Monastra, 2003; Yucha & Montgomery, 2008; Lubar, 2003) In Yucha and
Montgomery (2008), they conclude that the use of neurofeedback is strongly
supported in the treatment of ADD. This is despite the fact that treatment
protocols vary widely. In addition, several studies have shown that the
treatment effects last over time.
Traumatic Brain Injury. Traumatic brain injury
(TBI) can result in problems of cognition, behavior, emotional sensitivity, and
attention. Patients can frequently become much more impulsive, appear to have
poor judgment, have memory and word finding problems, and often are not very
aware of their problems. Planning and organizing can also be significant
deficits (Varney & Roberts, 1999) There are some two million brain
injuries every year in the USA, and while most appear to recover completely, a
substantial minority — up to 50 percent — can have enduring symptoms six months
or more after the injury (Jacobson, 1995)
The vast majority of the 2,000,000 brain injuries
per year in the United States are mild cases. By definition, mild TBI means a
loss of consciousness of less than 20 minutes, or a post-traumatic amnesia
(PTA) of less than 24 hours. Post-traumatic amnesia is defined as the period
of time when the accident occurs until there is reliable and consistent
memory. Brain injuries with longer durations of these variables are considered
moderate or severe brain injuries. It is commonly believed that deficits
resulting from moderate or more severe TBI injuries are permanent.
Neurofeedback is the biofeedback modality most
commonly used to treat traumatic brain injury. Mild TBI is the level usually
seen by the private practitioner; severe cases of brain injury are usually not
treated with neurofeedback, although there are exceptions (Larsen, 2009) As
professionals in the field of TBI accept neurofeedback, it is positive results
might be demonstrated with this population.
Thatcher (1999, 2000) advocates obtaining a
quantitative electroencephalograph (QEEG) in order to determine which of the
2500 variables to focus on with respect to neurofeedback with traumatic brain
injury. When the problematic sites are determined, these variables become the
focus of targeted treatment. The QEEG then can be a means of scientifically
noting progress in the TBI patient.
One interesting form of neurofeedback is called the
Low Energy Neurofeedback System, or LENS, which tracks the dominant brain wave
frequency of the site where the electrode is placed, and delivers a tiny
electromagnetic pulse to the brain at a prescribed difference (or offset) from
that dominant frequency (Larsen, 2009; Larsen, 2006; Schoenberger, et al.,
2001) The brain seems to respond to the tiny stimulus, and the brain
physiology appears to move towards a more healthy homeostasis, sometimes with
dramatic results (Larsen, 2006)
Neurofeedback Treatment for Substance Abuse. Neurofeedback has a long
history in treating substance abuse. The most well know protocol is called the
Peniston Protocol, which has had several replications and developments
in the last 35 years (Peniston & Kulkosky, 1989, 1991; Peniston, Marrinan, Deming & Kulkosky, 1993) Long term
follow-up has shown that benefits are enduring (Callaway & Bodenhamer-Davis, 2008) David Trudeau, however,
emphasizes that neurofeedback has not been validated as a stand-alone treatment
for addictive disorders (Trudeau, Sokhadze & Cannon, 2009)
The
development of the Peniston protocol is outlined in an excellent chapter by Trudeau and his colleagues
(2009); the details of the Peniston protocol are also outline in this chapter.
The basic elements of this method of treatment includes first training the
patient to control their temperature with the classic temperature training
model (see Schwartz and Andrasik, 2003), and at the same time, having the
patient create positive images of not drinking or taking the substance, and
what life would be without engaging in this behavior. Then, while doing the
neurofeedback of training alpha and theta frequencies to become stronger, the
imagery is presented to the patient. This positive imagery, while having the
body (and brain) relax, this tends to make the imagery become more absorbed.
The results of this treatment appear to be more successful than the usual
alcohol and substance abuse rehabilitation methods (Callaway & Bodenhamer-Davis, 2008).
A
further development in the Peniston protocol has been developed by William
Scott and David Kaiser (Scott & Kaiser, 1998) In the Scott-Kaiser
variation, beta and SMR training is added to the Peniston protocol, primarily
because their treatment group had mixed drug abuse, especially with stimulant
medication. This kind of neurofeedback is often given to those with attention
deficit disorder (ADD) with this variation of neurofeedback treatment, these
professionals improved the outcome compared to the classic Peniston protocol.
Post-Traumatic Stress Disorder. The emergence of PTSD has
achieved a new prominence with the veterans returning from the Iraqi and
Afghanistan wars. There is some literature that supports the use of
neurofeedback and biofeedback with this population. A particular advantage in
using biofeedback and neurofeedback with soldiers is that it is not
"psychological" in the usual sense. The patient can be brought in to
master their temperature training, heart rate variability, brain waves (e.g.,
for focusing or relaxation), and they can be told — truthfully — that they are
learning to control their physiological aspects of their bodies so they can
improve their sleep, concentration or stress management. Thus, the stigma of
seeing a "shrink" is removed.
John Carmichael (2010) has developed an elaborate
system of treating PTSD in which neurofeedback in an important component. His
treatment model, spelled out in great detail in his book Post traumatic
stress disorder includes psychological methods (especially cognitive
behavior therapy), nutritional supplements, biofeedback, as well as
neurofeedback. He has reviewed the field of treatment of the various methods
for PTSD, and his particular focus is providing treatment methods for the
military. It is worth keeping in mind that the PTSD veteran may also be
suffering from traumatic brain injury, since blast injuries are common in
recent wars. An overview of military neuropsychology can be found in a new
book entitled Military Neuropsychology, edited by Carrie Kennedy and
Jeffrey Moore (2010)
The initial method of neurofeedback treatment for
PTSD was the Peniston protocol (Peniston, et al., 1993), and this may serve
many patients; but the most recent developments suggest QEEG-based
neurofeedback protocols for those who do not respond well to the initial
treatment methods (Carmichael, 2010) Indeed, for most disorders, although some
standard protocols have been shown to be effective, the complexity of any given
single patient may warrant a very specific assessment with a QEEG, as well as
the use of other modalities.
Epilepsy. Neurofeedback was
discovered as a treatment for epilepsy by Barry Sterman, a UCLA physiological
psychologist who began working in this area in the late 1960s. He was asked to
determine why fighter pilots sometimes went into seizures while flying their
planes, and discovered that a chemical in the jet fuel (hydrazine) triggered
the seizures. In working on this project, he tried to induce seizures into
some cats he had in his lab; some cats went into seizures but others did not.
Sterman learned that the cats who did not go into seizures (when they should
have) were ones which had been trained previously to increase certain brain
waves in previous experiments. Sterman concluded that the place and frequency
he had trained the cats (12-15hz at C4) seemed to be protective of seizures
happening, even when provoked with hydrazine. His continued work led to
eventually working with people, helping many to eliminate seizures in their
life. The scientific details, theory and references of this work can be found
in other sources (Sterman, 2000; Egner & Sterman, 2006; Thompson &
Thompson, 2003) Neurofeedback continues to be a viable method of treatment for
epilepsy (Yucha & Montgomery, 2008; Monastra, 2003) Yucha and Montgomery
(2008) claim that neurofeedback is a treatment which can be rated as being efficacious
or Level 4 according to the criteria of Chambless and Hollon (1998)
Depression. Neurophysiological
research by Davidson (1998a, b) has shown that some depressed patients have
excess left frontal alpha, for example, and that by training this pattern to
normal, the symptoms of depression can be lifted. A common pattern in those
with endogenous depression is more slow brainwave activity in the left frontal
area; when this part of the brain is more inactive and the right frontal area
is more dominant, the patient is predisposed to become depressed more easily as
well as anxious. The contributing factors may include a family history of
depression, or a mild head injury in the left frontal area that helped create
the frontal alpha abnormality.
Elsa Baehr, Peter Rosenfeld and their colleagues
discovered that by training the depressed patient to alter the abnormal alpha
asymmetry, the relevant symptoms can be alleviated (Baehr & Baehr, 1997;
Baehr, et al, 1997, 2001, 2004; Rosenfeld, 1997, 2000; Rosenfeld, et al, 1995,
1996) Other reviews of the literature has shown that neurofeedback can be
effective in treating depression (Hammond, 2001a, 2005; Walker, et al, 2007)
Another possible pattern of abnormal neurophysiology has included low alpha in
the posterior regions. Additionally, neurofeedback treatment has been found to
be permanent (Baehr et al, 2001).
Brain Brightening: Stopping cognitive decline
in the elderly. Some emerging results in the neurofeedback literature gives
some hope that early stages of cognitive decline in the elderly can show
improvement with neurofeedback. A chapter has been presented in a new book
entitled Enhancing cognitive fitness in adults, edited by Paula Hartman-Stein
and Sanest LaRue (2012) This exciting new area will be summarized below.
Brain changes in elderly. Cognitive decline in the
elderly may likely be associated with a drop in cerebral blood flow as one ages
(Hagstadius & Risberg, 1989; Gur et al, 1987) Alongside this, there is
likely an increase in slow waves throughout the brain. With such disorders as
mild cognitive impairment (MCI), there is often an excess of slower brain waves
(i.e., increases in Delta and Theta) in the frontal region. For those with the
beginnings of dementia, the presence of frontal slow waves is even more likely
and more pronounced. Therefore, it would appear logical that if one could
reduce the amount of slow waves and enhance the more active or “thinking” waves
(Beta and high Alpha) in the frontal lobe region, there might be an enhancement
of cognition. Likewise, with the drop in frontal cerebral blood flow in the
elderly, if there could be a method of enhancing frontal lobe blood flow, it
could improve cognition and maybe other functioning as well.
The term brain brightening refers to doing
neurotherapy with the elderly in order to enhance their cognitive abilities. Brain
brightening seems to have been coined by Thomas Budzynski in his 1996 paper
on this subject. It has, however, been adapted by many to include a number of
possible interventions for the same overall purpose — helping the elderly
improve cognitive functioning. In this article the term brain brightening
refers to the use of neurofeedback and neurotherapy for improving cognitive
functioning in the elderly.
Research on Brain Brightening. There is a limited
literature on neurotherapy for the elderly with regards to cognitive
enhancement. Budzynski (1996) presented a case study in which he employed
neurofeedback and audio-visual stimulation (AVS) which helped reduce cognitive
and memory symptoms. Budzynski and Budzynski (2000) presented another case
study of a 76 year old man who had a history of two cardiac bypass surgeries, a
pacemaker implantation, hearing problems and self-reported cognitive problems.
The patient was assessed with the MicroCog Battery (Powell, et al., 1993)
before and after treatment. After 30 sessions of neurofeedback, primarily
suppressing frontal slow waves (2-12 Hz) combined with 14 Hz AVS at the start
of each session, improvements almost all of the MicroCog scores were noted. He
also did home training with the AVS each day for 20 minutes. The post training
assessment also revealed a reduction in slow wave activity in the frontal area
(i.e., one to seven Hz), an increase in 7-9 Hz, and an improvement in hearing.
In one study reported by Budzynski, Budzynski and
Tang (2007), part of the Ponce de Leon Project, the authors administered
neurofeedback and audio-visual entrainment (AVE) to two elderly volunteers.
One of these volunteers, an 80 year old woman, was tracked carefully. After 20
neurofeedback sessions which also utilized AVS, her Wechsler Memory
Scale-Revised scores showed significant improvement after treatment and at
follow-up on the General, Visual and Delayed Recall scales.
In another study reported in Budzynski, et al
(2007), 31 volunteers ages 53 to 87 received audio-visual stimulation (AVS)
three days per week over three months. The AVS EEG frequencies were randomly
presented between 9 and 22 Hz, and session were 20 minutes each. Pre- and
post- measures consisted of MicroCog and the Buschke Remembering test (Buschke,
1973) Improvement was seen on the Buschke measure and seven of the nine
MicroCog measures for the AVS group. Other interesting results were reported,
however. Some participants experience a period of confusion for 15 to 30
minutes following the AVS session.
Jon Frederick and Marvin Berman (2009) did a study
with 26 subjects who had frontal-temporal lobe dementia, 15 of which were
assigned to neurofeedback treatment, and 11 to the control condition. Those in
the neurofeedback group received 30 or more sessions, with video, audio and
tactile reinforcers. Pre and post measures of neuropsychological tests as well
as QEEG were done. Improvements in the treatment groups were found in visual
and verbal memory, and ratings by self and a significant other in executive
functioning. One conclusion by the authors was that neurofeedback would be
more likely to be effective in cases of very early dementia.
The above noted research and case studies represent
beginning efforts in the possible value of using neurotherapy to treat
cognitive decline in the elderly. There are significant limitations in the
above papers, but there is enough evidence to consider developing more
extensive research proposals to see if neurotherapy can contribute to the
prevention of dementia if caught early enough in the disease process. It is
worth noting that in most of the Budzynski articles, neurofeedback sessions are
begun with audio-visual stimulation or entrainment. A likely reason is that AVS/AVE
seems to increase frontal cerebral blood flow. That is why I included the HEG
method of neurofeedback, because HEG specifically trains the patient to
increase frontal blood flow. But there are some limitations to what we can
expect from neurotherapy with dementia: Frederick and Berman (2009) concluded
in their work that if the pathological process in dementia has progressed too
far, there is little likelihood that neurotherapy will be helpful; but
neurofeedback can be useful in the very earliest stages of cognitive decline.
*****
A final aspect of neurotherapy is worth mentioning.
In dealing with patients learning to control their brain functioning, being
psychologically minded is not necessary. Indeed, neurofeedback training does
not require having any psychological insights. For some patients, this could
be very attractive, and could be especially important in treating those with
limited language abilities with respect to the therapist, or those who are not
comfortable with the usual psychological treatment situation. This could
apply, for example, the war veterans who do not want to go to a “shrink,” but
might go to someone to improve their attention or memory abilities. In
addition, training one’s own brain physiology by watching movies is another
attractive feature of doing neurotherapy.
Implications of integrating neurotherapy into
healthcare.
As research accumulates documenting the effectiveness of neurotherapy, this
will probably result in lowering overall medical costs for those with brain
problems. Some with attention deficit disorder may be able to reduce or
eliminate their medication; those with traumatic brain injury might be able to
improve their functioning, thereby need less support from society; those
suffering from depression might become more functional and lead more fulfilling
lives; those with seizure disorders have a good chance of reducing their
seizures as well lessening the probability of neurosurgical interventions; some
dementias may be stopped, while other cases may have a more benign course.
With future studies examining these treatment paths, it is likely that
neurotherapy and biofeedback will prove to be a cost-effective and humane
treatment modality. This will necessitate that professionals master this
technology and acquire the specific knowledge of the medical conditions under
question. We can hope that psychologists and other mental health professionals
may be able to attain these skills in the coming years.
Concluding remarks. Given the above applications
of neurofeedback in the treatment of various brain and psychological disorders,
it is hoped that well-designed studies be conducted to see if this modality can
help these difficult disorders. While there are methodological weaknesses in
the some studies and case reports, there is evidence that this treatment can be
beneficial. The result would be improved health. less use of medication and
lower medical care costs.
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James
Lawrence Thomas, PhD, BCIA-EEG
19 W 34th St., Penthouse, New York, NY 10001, 212-268-8900
nurosvcs@aol.com www.thebrainclinic.com
Credentials: James Lawrence Thomas,
PhD, is
a clinical psychologist and neuropsychologist, on the Faculty of several
universities for over 30 years (NYU Medical Center 32 years, Fordham, Albert
Einstein College of Medicine), with seven books to his credit, one of which is Do
you have Attention Deficit Disorder? (Dell, 1996). He has specialized in
diagnosing and treating adult ADD, LD and mild head injury for over three
decades, and has post-doctoral certificates in cognitive therapy, EEG
Biofeedback, and neuropsychology. Dr. Thomas has degrees from Yale, UC
Berkeley, and CUNY (Clinical Psychology, 1980), is Past President of the
Independent Practice Division of the New York State Psychological
Association (NYSPA) and the Neuropsychology Division of NYSPA. He is on
the Board of Directors of the International Dyslexia Association (now Everyone
Reading); he is a full member of the International Neuropsychology
Society, the National Academy of Neuropsychology, the American
Psychological Association, is a Lifetime Professional Member of the National
Brain Injury Foundation, and a Fellow of the Foundation for Behavioral
Health. He was awarded the Distinguished Service Award by the New
York State Psychological Association in June of 2000. In October of 2001, Dr.
Thomas was elected as Distinguished Practitioner of Psychology in the
National Academies of Practice.
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Multiple Sclerosis.
**Beauregard, M 2012. DVD. Neurofeedback training induces changes in grey
and white matter. Find at isnr.org, Store, item K3-12.