Neurofeedback therapy in patients with non pain syndromes of chronic and paroxysmal character-literature review and own experience

Alicja Kubik1,2, Marek Kaciński2

  1. Instytut Neuromedica, Kraków. Director: Alicja Kubik, MD
  2. Chair of Pediatric and Adolescent Neurology, Jagiellonian University. Head: Prof. Marek Kaciński

Neurofeedback has been used in treatment of many other than pain clinical syndromes

This group includes chronic as well as paroxysmal syndromes previously treated pharmacologically. However due to non satisfactory results of this treatment introduction of non-pharmacological therapy has been examined. Observations from our 9-year experience of neurofeedback therapy used in children and adult patients with epilepsy, Asperger syndrome, depression, neurosis, personality disorders, drug addiction and other (not pain) syndromes have been presented in this paper. Positive influence of neurofeedback therapy on symptoms intensity, frequency, duration and social relations of treated patients has been confirmed by our own and other authors observations. Neurofeedback therapy has been tried by patients with other difficult life problems and has been effective in some of them. The effectiveness of the therapy has been confirmed by patients, their relatives and also by neurophysiological results. Additionally, preliminary results of neurofeedback therapy used in management of computer addiction in children and adolescents have been presented herein.

Neurofeedback (EEG-biofeedback) znalazł zastosowanie w leczeniu wielu zespołów klinicznych przebiegających bez bólu. Chodzi tu zarówno o zespoły o charakterze przewlekłym jak i napadowym, które w większości przypadków leczone już były farmakologicznie. Jednak z uwagi na niepełną skuteczność takiego leczenia, koniecznym było poszukiwanie innych nie farmakologicznych metod terapii. Autorzy tej pracy dzielą się spostrzeżeniami z 9 lat stosowania neurofeedbacku w leczeniu dzieci i pacjentów dorosłych z padaczką, zespołem Aspergera, depresją, nerwicami, zaburzeniami osobowości i lekomanią oraz innymi zespołami nie bólowymi. Obserwacje własne w większości przypadków potwierdzają spostrzeżenia innych autorów o korzystnym wpływie terapii neurofeedback na nasilenie objawów, częstość ich występowania i czas trwania oraz relacje środowiskowe leczonych. Wskazano również na zjawisko poszukiwania terapii neurofeedback przez ludzi z innymi trudnymi problemami życiowymi. Także u części z nich zastosowanie neurofeedbacku okazało się skuteczne, zarówno w opinii leczonych jak i osób im najbliższych, znajdując potwierdzenie w wynikach neurofizjologicznych. Autorzy prezentują ponadto wstępne doświadczenia własne z leczenia za pomocą neurofeedbacku uzależnienia komputerowego dzieci i młodzieży.

Introduction

This article has been written after acceptance of biofeedback as one of clinical method used in treatment of patients by Polish Clinical Neurophysiology Society. Not until 2011 did it happen, many years after it had been approved by different foreign scientific societies [3]. It seems that such delay has been caused by regarding biofeedback as paramedic relaxation method. For a long time physicians were not considered as the only qualified personnel specialized in biofeedback treatment management. Nowadays, biofeedback trainings can be performed by therapists only after previous examination and determination of individual therapeutic protocol by physician specialized in biofeedback. Every individual neurofeedback therapy is preceded by quality EEG examination and also quantitative EEG analysis (QEEG) (nowadays more frequently performed). Duration of treatment depends on clinical result and scientific data. Neurophysiological result is estimated on the basis of quality (and also more often quantitative) analysis of final EEG recording. EEG findings next to clinical outcomes are important indicators of final therapy result [5].

Treatment of drug resistant epilepsy and attention deficit hyperactivity disorders, with the use of neurofeedback has been used since introduction of this method in 1970-s

Clinical knowledge and acquaintance with algorithms used in mathematics and computer science is needed for performance of this procedure [1]. Slow and sensorimotor potentials are analyzed and sympathetic skin response should be examined [11]. However, on the basis of these results prognosis of final therapy outcome still cannot be made [21]. We have discussed effectiveness of neurofeedback therapy in patients with pain syndromes (chronic and acute) in different publication [7]. In this paper treatment of other then pain syndromes: epilepsy, drug addiction, psychiatric disorders and other has been reviewed.

Chronic syndromes

Among childhood syndromes treated with neurofeedback autism, sequels of craniocerebral trauma, insomnia, migraine, depression, and epilepsy take important place [8]. However, it is particularly effective in Attention-deficit hyperactivity disorder (ADHD). This is the most common chronic behavioral disorder in children, with the prevalence between 3% and 5% of school-aged children worldwide. It occurs far more frequently in boys than girls in clinic and population studies. Increased incidence of ADHD in first-degree (up to 25%) and second-degree relatives of children with ADHD was noticed. The quantified EEG in ADHD has abnormal features. Neurofeedback constantly competes with pharmacotherapy in children with ADHD [12]. This issue was thoroughly discussed in our previous two reports (109 children were included). Clinical and neurophysiological results of neurofeedback therapy were presented. Effectiveness of neurofeedback therapy in children with ADHD, ADHD with concomitant emotional disorders, tics, dyslexia and behavior disorders was revealed. In treated with neurofeedback children significant positive changes in EEG recordings were seen [5,6].

Publications concerning application of neurofeedback therapy in children with Asperger’s syndrome and antisocial behaviour can also be found. Symptoms of this disorder are flat affect, insensitivity to social cues, and obsessively indulged special interests. Speech and gestures are deviant, stiff, limited, inexpressive, and stilted. Children are severely impaired in reciprocal social interaction, for witch they have little enthusiasm. Their interests are quite circumscribed, and they impose many routines and rituals on themselves. Male to female ratio is 4:1. Positive clinical effect and significant reduction of 3-7 Hz bioelectric activity and increase of 12-15 Hz activity have been achieved. Results of this study were thoroughly verified in the aspect of anxiety level reduction, concentration disorders, social functioning and improvement of intellectual functioning and school progress [18]. Similarly, our own experience indicates effectiveness of neurofeedback therapy in Asperger’s syndrome. 47 children with this syndrome have undergone the therapy. Obtained results are differentiated due to combined treatment used in these cases including behavioral therapy and normal family and school education.

Neurofeedback therapy has been also tested in patients with personality disorders. In some of them, aged 19-48 years, intensity of symptoms was so great that precluded environmental adaptation and caused antisocial behaviour. Neurofeedback trainings were controlled with the use of QEEG. 80-120 trainings were performed in every patient. Neurometric analysis revealed improvement of their personality features and better estimation of their life parameters by their parents and relatives [15]. Our own experience includes scarce number of patients (19 patients at the age range from 16 to 45 years). Temporary improvement has been achieved in these patients. (influence of neurofeedback treatment itself or interest in it). Particularly in these cases neurofeedback therapy may help preserve the integrity of personality and prevent from coming into conflict with the law.

Among patients reporting for neurofeedback therapy patients with depression and neurosis should be pointed out. We examined 65 patients aged 8-60 years. On average 60 neurofeedback trainings, 2-4 times a week, have been performed. In these cases stability of therapy results has been a problem. Our own 8-9 year experience in this matter is not sufficient, however multi-year remission has been observed, which was particularly important in patients with depression.

Other problems than pain syndromes are drug addiction and alcoholism. Acute alcohol intake by children initially induces a depression of the CNS, and if untreated, it causes marked hypoglycemia and convulsions after ingestion. In these difficult clinical, social and personal problems neurofeedback is used together with other therapeutic methods so its effectiveness is hard to define. Alpha-theta trainings for alcoholics and beta trainings for drug addicts (psychostimulant addiction, combined addiction) are recommended [13]. Our own experience involves neurofeedback therapy results of many addicts however they have been very individualized. During 9 years neurofeedback treatment was performed in 29 patients, 21 adults and 8 adolescents. 50-60 trainings, 2-3 times per week were performed. Good results of the therapy have been observed in 11 patients and in the rest they have been satisfactory and temporary.

Computer addiction is a new problem in Poland and its treatment with the use of controlled videogame may be surprising. Chaotic activities are replaced with organized and controlled ones additionally positive changes of neurophysiological parameters can be achieved in treated children. Self regulation with the use of neurofeedback involves teaching of a patient to produce specific brain wave patterns associated with changes of behaviour pattern. With the use of back coupling treated patients observe how their EEG recording changes in association with their state of mind. Recognition of ability to control one’s mind results in increased willingness to work and its efficacy. 17 children with computer addiction, aged 10-18 years were treated in the years 2010-2011. 40-60 trainings, 3 times per week were performed. 3-12 month observation period is too short for elaboration of final conclusions. However preliminary results are encouraging.

The group of patients hardest one for scientific evaluation, is the group with so called life problems. They result from condensation of very difficult unsolved problems. Some of them are exogenous and cause emotional tensions and other are endogenous and result in difficulties with communication. These disorders have significant influence on cognitive functions and development of a child. This issue is discussed based only on author’s own experience. Positive effect has been observed after neurofeedback therapy in 20 adult patients and adolescents with such problems. However, the therapy success relays on long term treatment (at least 1 year).

Paroxysmal syndromes

Among other than pain syndromes epilepsy is one of the most important indication for neurofeedback therapy. In general idiopathic and secondary epilepsies are considered. The characteristics for its are recurrent convulsive and nonconvulsive seizures. Localization-related epilepsies (partial or focal) seizures are classified into simple, complex, and secondarily generalized. Other problem is so-called epileptic syndromes which are distinctive in that they demonstrate characteristic age of onset, seizure types, EEG features, and prognosis. Results of conventional pharmacotherapy are not satisfactory in approximately 30% epileptic patients [17]. One should not be surprised application of neurofeedback therapy, with reduction of seizures in these cases [10,17]. Observations of neurophysiological disorders concern mainly SMR potentials. Application of neurofeedback in treatment of epilepsy is based on sensorimotor thalamocortical coupling by which decrease of seizure threshold may be achieved [2]. Clinical response and normalization of EEG recording should be evaluated in a standardized manner [14].

Our experience is only refers to foreign publications. During 9 years 170 patients at the age range from 4 to 52 years, with difficult to treat epilepsy underwent neurofeedback therapy. Pharmacotherapy was not withdrawn however significant drug reduction (usually resulting in monotherapy) was used in some of patients with good result. In these patients neurofeedback training was focused on improvement of SMR/beta frequency bands and inhibition of slow frequencies theta and delta.

Neurophysiological data obtained after application of neurofeedback therapy are documented mainly with the use of quantitative analysis of EEG [19,20]. In about 2/3 of patients with epilepsy complete control of clinical seizures with simultaneous control of slow cortical potentials (SCP) has been observed. However in the remaining group of patients improvement have not occurred [4]. Attempts of influence on epileptic bioelectric activity with the use of computer have not produced positive results [20]. Influence of neurofeedback on presence of epileptic graphoelements in EEG recordings of children with ADHD and with ADHD and disleksia, emotional disorders and behavior disorders was not observed in our previously published result [6].

Summary

Neurofeedback has been used in chronic other than pain syndromes, including ADHD. Neurofeedback therapy has been used in patients with epilepsy however its application should be tested in patients with pseudoepileptic seizures.

Recent observations have revealed reduction of theta/SMR index and frequency of pseudoeplieptic seizures after neurofeedback trainings, despite lack of epileptic elements in EEG recording [16].


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