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Journal of Neurotherapy: Investigations in
Neuromodulation, Neurofeedback and Applied
Neuroscience
What is Neurofeedback: An Update D. Corydon Hammond
a
a Physical Medicine & Rehabilitation , University of Utah
School of Medicine , Salt Lake City,
Utah, USA
Published online: 30 Nov 2011.
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WHAT IS NEUROFEEDBACK: AN UPDATE
D. Corydon Hammond
Physical Medicine & Rehabilitation, University of Utah
School of Medicine, Salt Lake City, Utah, USA
Written to educate both professionals and the general public,
this article provides an updateand overview of the field of
neurofeedback (EEG biofeedback). The process of assessmentand
neurofeedback training is explained. Then, areas in which
neurofeedback is being usedas a treatment are identified and a
survey of research findings is presented. Potential risks,side
effects, and adverse reactions are cited and guidelines provided
for selecting a legiti-mately qualified practitioner.
INTRODUCTION
In the late 1960s and 1970s it was learned thatit was possible
to recondition and retrainbrainwave patterns (Kamiya, 2011;
Sterman,LoPresti, & Fairchild, 2010). Some of this workbegan
with training to increase alpha brainwaveactivity for the purpose
of increasing relaxation,whereas other work originating at
University ofCalifornia, Los Angeles focused first on animaland
then human research on assisting uncon-trolled epilepsy. This
brainwave training iscalled EEG biofeedback or neurofeedback.Prior
to a more detailed discussion, the authorwill review some
preliminary information aboutbrainwave activity. Brainwaves occur
at variousfrequencies. Some are fast, and some are quiteslow. The
classic names of these EEG bands aredelta, theta, alpha, beta, and
gamma. They aremeasured in cycles per second or hertz (Hz).The
following definitions, although lacking inscientific rigor, will
provide the general readerwith some conception of the activity
associatedwith different frequency bands.
Gamma brainwaves are very fast EEGactivity above 30Hz. Although
further researchis required on these frequencies, we know thatsome
of this activity is associated with intenselyfocused attention and
in assisting the brain to
process and bind together information fromdifferent areas of the
brain. Beta brainwavesare small, relatively fast brainwaves
(above13–30Hz) associated with a state of mental,intellectual
activity and outwardly focusedconcentration. This is basically a
‘‘bright-eyed,bushy-tailed’’ state of alertness. Activity in
thelower end of this frequency band (e.g., thesensorimotor rhythm,
or SMR) is associatedwith relaxed attentiveness. Alpha
brainwaves(8–12Hz) are slower and larger. They aregenerally
associated with a state of relaxation.Activity in the lower half of
this range representsto a considerable degree the brain shifting
intoan idling gear, relaxed and a bit disengaged,waiting to respond
when needed. If peoplemerely close their eyes and begin
picturingsomething peaceful, in less than half a minutethere begins
to be an increase in alpha brain-waves. These brainwaves are
especially largein the back third of the head. Theta
(4–8Hz)activity generally represents a more daydream-like, rather
spacey state of mind that is associa-ted with mental inefficiency.
At very slowlevels, theta brainwave activity is a very
relaxedstate, representing the twilight zone betweenwaking and
sleep. Delta brainwaves (.5–3.5Hz) are very slow, high-amplitude
(magni-tude) brainwaves and are what we experience
Received 1 August 2011; accepted 15 August 2011.Address
correspondence to D. Corydon Hammond, PhD, Physical Medicine &
Rehabilitation, University of Utah School of
Medicine, 30 North 1900 East, Salt Lake City, UT 84132-2119,
USA. E-mail: [email protected]
Journal of Neurotherapy, 15:305–336, 2011Copyright # 2011 ISNR.
All rights reserved. ISSN: 1087-4208 print=1530-017X online DOI:
10.1080/10874208.2011.623090
305
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in deep, restorative sleep. In general, differentlevels of
awareness are associated with domi-nant brainwave states.
It should be noted, however, that each of usalways has some
degree of each of these variousbrainwave frequencies present in
different partsof our brain. Delta brainwaves will also occur,for
instance, when areas of the brain go ‘‘offline’’ to take up
nourishment, and delta is alsoassociated with learning
disabilities. If someoneis becoming drowsy, there are more delta
andslower theta brainwaves creeping in, and ifpeople are somewhat
inattentive to externalthings and their minds are wandering, there
ismore theta present. If someone is exceptionallyanxious and tense,
an excessively high fre-quency of beta brainwaves may be present
indifferent parts of the brain, but in other casesthis may be
associated with an excess of inef-ficient alpha activity in frontal
areas that areassociated with emotional control. Personswith
Attention-Deficit=Hyperactivity Disorder(ADD, ADHD), head injuries,
stroke, epilepsy,developmental disabilities, and often
chronicfatigue syndrome and fibromyalgia tend to haveexcessive slow
waves (usually theta and some-times excess alpha) present. When an
excessiveamount of slow waves are present in the execu-tive
(frontal) parts of the brain, it becomesdifficult to control
attention, behavior, and=oremotions. Such persons generally have
prob-lems with concentration, memory, controllingtheir impulses and
moods, or hyperactivity.They have problems focusing and
exhibitdiminished intellectual efficiency.
As the reader can see, there can be com-plexity involved in how
the brain is operating.Research (Hammond, 2010b) has found
thatthere is heterogeneity in the EEG patternsassociated with
different diagnostic conditionssuch as ADD=ADHD, anxiety, or
obsessive-compulsive disorder. For example, scientificresearch has
identified a minimum of threemajor subtypes of ADD=ADHD, none of
whichcan be diagnosed from only observing theperson’s behavior and
each of which requiresa different treatment protocol. The
picturecan become even more complicated by thefact that sometimes
there are other comorbid
problems present, and not simply ADD=ADHDalone. Therefore,
appropriate assessment isimportant prior to beginning to do
neurofeed-back to determine what EEG frequencies areexcessive or
deficient, or if there are problemsin processing speed or
coherence, and in whatparts of the brain. Proper assessment allows
thetreatment to be individualized and tailored tothe patient.
Neurofeedback training is EEG (brainwave)biofeedback. During
typical training, one ormore electrodes are placed on the scalp
andone or two are usually put on the earlobes.Then, high-tech
electronic equipment providesreal-time, instantaneous feedback
(usually audi-tory and visual) about your brainwave activity.The
electrodes allow us to measure the electri-cal patterns coming from
the brain—much likea physician listens to your heart from the
surfaceof your skin. No electrical current is put intoyour brain.
Your brain’s electrical activity isrelayed to the computer and
recorded.
Ordinarily, patients cannot reliably influ-ence their brainwave
patterns because they lackawareness of them. However, when they
cansee their brainwaves on a computer screen afew thousandths of a
second after they occur,it gives them the ability to influence and
gradu-ally change them. The mechanism of action isgenerally
considered to be operant condition-ing. We are literally
reconditioning and retrain-ing the brain. At first, the changes
areshort-lived, but the changes gradually becomemore enduring. With
continuing feedback,coaching, and practice, healthier
brainwavepatterns can usually be retrained in mostpeople. As is
reviewed later in the article, mostresearch suggests that
significant improvementsseem to occur 75 to 80% of the time. The
pro-cess is a little like exercising or doing physicaltherapy with
the brain, enhancing cognitiveflexibility and control. Thus,
whether symptomsstem from ADD=ADHD, a learning disability, astroke,
head injury, deficits following neurosur-gery, uncontrolled
epilepsy, cognitive dysfunc-tion associated with aging,
depression,anxiety, obsessive-compulsive disorder, autism,or other
brain-related conditions, neurofeed-back training offers additional
opportunities
306 D. C. HAMMOND
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for rehabilitation through directly retraining theelectrical
activity patterns in the brain. Theexciting thing is that even when
a problem isbiological in nature, there is now another treat-ment
alternative to simply relying on medi-cation. Neurofeedback is also
being usedincreasingly to facilitate peak performance in‘‘normal’’
individuals, executives, and athletes.
More than a decade ago, Frank H. Duffy,MD, a professor and
pediatric neurologist atHarvard Medical School, stated in the
journalClinical Electroencephalography that scholarlyliterature had
already suggested that neurofeed-back ‘‘should play a major
therapeutic role inmany difficult areas. In my opinion, if any
medi-cation had demonstrated such a wide spectrumof efficacy it
would be universally accepted andwidely used’’ (Duffy, 2000, p. v).
‘‘It is a field tobe taken seriously by all’’ (p. vii).
Considerableresearch has been published since that time.This
article, written to educate both profes-sionals and the general
public about the fieldof neurofeedback, provides an overview of
thisliterature without seeking to cite every publi-cation with all
their methodological details.
ASSESSMENT PRIOR TONEUROFEEDBACK TRAINING
Some people wish that they could simply buytheir own
neurofeedback equipment and trainthemselves or their children. As
is explainedlater in this article, this is fraught with
potentialfor harm or ineffectiveness. To be done prop-erly,
neurofeedback needs to be conductedor supervised by someone with
specializedexpertise concerning brain function and whois
knowledgeable about much more than sim-ply how to operate equipment
and software.As just mentioned, for training to be successfuland
side effects avoided, it is vitally importantfor an assessment to
be performed and thetraining to be individualized to the
distinctivebrainwave patterns and symptoms of each per-son.
Everyone does not need the same trainingat the same locations, and
research has shownthat a person’s brainwave patterns simplycannot
be distinguished by only observing theperson’s behavioral symptoms.
Therefore, prior
to doing neurofeedback training, legitimatelicensed clinicians
will want to ask questionsabout the clinical history of the client
orpatient. Occasionally in more serious casesthey may suggest doing
neuropsychological orpsychological testing. Competent
clinicians(Hammond et al., 2011) will also do a carefulassessment
and examine brainwave patterns.Some practitioners may do an
assessment byplacing one or two electrodes on the scalpand
measuring brainwave patterns in a limitednumber of areas. Other
clinicians perform amore comprehensive evaluation by doing
aquantitative electroencephalogram (QEEG)brain map where 19 or more
electrodes areplaced on the scalp.
A QEEG is an assessment tool to objectivelyand scientifically
evaluate a person’s brainwavefunction. The procedure usually takes
about 60to 75min and consists of placing a snug cap onthe head,
which contains small electrodes tomeasure the electrical activity
coming fromthe brain. This is done while the client is
restingquietly with his or her eyes closed, eyes open,and sometimes
during a task. Afterward, acareful process is used to remove as
completelyas possible artifacts that occurred when theeyes moved or
blinked, from body movement,or tension in the jaw, neck, or
forehead. Thebrainwave data that were gathered are
thenstatistically compared to a sophisticated andlarge normative
database that provides scien-tifically objective information on how
the brainshould be functioning at the client’s age. Thisassessment
procedure allows the professionalto then determine in a scientific,
objectivemanner whether a client’s brainwave patternsare
significantly different from normal, and ifso, how and where they
differ.
Since the 1970s and 1980s there has beena great deal of research
with QEEG for a widerange of problems. Abundant evidence,
sum-marized in Thatcher (2010), has verified thereliability of QEEG
evaluation, and hundredsof scientific studies have been published
usingQEEG evaluations. These studies have foundthe QEEG to have
documented ability to aidin the evaluation of conditions such as
mildtraumatic brain injury (TBI; and sports-related
WHAT IS NEUROFEEDBACK 307
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concussions), ADD=ADHD, learning disabilities,depression,
obsessive-compulsive disorder,anxiety, panic disorder, drug abuse,
autism,and a variety of other conditions (includingschizophrenia,
stroke, epilepsy, and dementia;e.g., Alper, Prichep, Kowalik,
Rosenthal, & John,1998; Amen et al., 2011; Barry,
Clarke,Johnstone, McCarthy, & Selikowitz, 2009;Clarke, Barry,
McCarthy, & Selikowitz, 2001;Clarke et al., 2007; Harris et
al., 2001; Hoffmanet al., 1999; Hughes & John, 1999; Newtonet
al., 2004; Thatcher, 2010; Thatcher et al.,1999). QEEG has even
been able to predicttreatment outcomes from interventions
withconditions such as ADD=ADHD (Suffin &Emory, 1995), and
alcoholism and drug abuse(Bauer, 1993, 2001; Prichep, Alper,
Kowalik,John, et al., 1996; Prichep, Alper, Kowalik,
&Rosenthal, 1996; Winterer et al., 1998). TheAmerican
Psychological Association has alsoendorsed QEEG as being within the
scope ofpractice of psychologists who are appropriatelytrained, and
the International Society forNeurofeedback and Research (ISNR) has
simi-larly endorsed its use by qualified health careprofessionals
who are appropriately trained(Hammond et al., 2004) and created
standardsfor the use of QEEG in neurofeedback. Personswho are
certified in this assessment specialtymay be identified through
either the EEG &Clinical Neuroscience Society
(http://www.ecnsweb.com/provider-directory.html) or theQuantitative
Electroencephalography Certifi-cation Board
(http://www.qeegboard.org).
NEUROFEEDBACK TRAINING
Once the assessment is complete and treat-ment goals have been
established, most com-monly one or more electrodes are placed onthe
scalp and one or more on the earlobes forneurofeedback training
sessions. The traineethen usually watches a display on the
computerscreen and listens to audio tones, sometimeswhile doing a
task such as reading. These train-ing sessions are designed assist
the person togradually change and retrain their brainwavepatterns.
For example, some persons mayneed to learn to increase the speed or
size of
brainwaves in specific areas of the brain,whereas other
individuals need training todecrease the speed of and amplitude of
theirbrainwaves. Commonly initial improvementsbegin to be noticed
within the first five to 10sessions. Length of treatment may only
be 15to 20 sessions for anxiety or insomnia, but withother
conditions such as ADD=ADHD or learn-ing disabilities it will more
often involve 30 to50 sessions, depending on the severity of
theproblem. Each session usually lasts about 20to 25min once
equipment is attached. In treat-ing very complex conditions or when
multipledisorders or diagnoses are present, a cliniciancannot
always stipulate in advance how manytreatment sessions may be
required.
SPECIALIZED TYPES OFNEUROFEEDBACK
There are also several innovative forms ofneurofeedback that
should be explained. Theyeach differ in distinctive ways from the
tra-ditional neurofeedback methods that have justbeen described,
and yet each represents impor-tant and fascinating advances in our
technology.
Slow Cortical Potentials Training
Speaking very technically for a moment, slowcortical potentials
are the positive or negativepolarizations of the EEG in the very
slowfrequency range from .3Hz to usually about1.5Hz. They may be
thought of as the directcurrent baseline on which the alternating
cur-rent EEG activity rides. There is generally anegative shift in
direct current potentials thatoccurs during cognitive processing
(to createexcitatory effects) and positive slow corticalpotentials
occur during inhibition of corticalnetworks. During and prior to an
epileptic seiz-ure, for example, the cortex is electronegative,and
this same kind of hyperexcitability tendsto be seen before many
migraines. After aseizure, when the cortex is fatigued, it tendsto
be electro-positive. Slow cortical potentialneurofeedback training
has been done (e.g.,Kotchoubey, Blankenhorn, Froscher, Strehl,
&Birbaumer, 1997; Kotchoubey et al., 2001;Strehl et al., 2006),
particularly in Europe, with
308 D. C. HAMMOND
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epilepsy and ADHD. This type of neurofeed-back may also hold
strong potential in thetreatment of migraine (Kropp, Siniatchkin,
&Gerber, 2002). In this training, one electrodeis placed in the
center of the top of the headand one behind each ear, while the
clientfocuses on changing a visual display on thecomputer (Strehl,
2009).
THE LOW ENERGYNEUROFEEDBACK SYSTEM
The Low Energy Neurofeedback System (LENS;Hammond, 2007b;
Larsen, 2006; Ochs, 2006)is a unique and passive form of
neurofeedbackthat produces its effects through feedback
thatinvolves a very tiny electromagnetic field, whichonly has a
field strength of 10�18watts=cm2.This feedback is so small that it
is the equivalentof only 1400 th of the strength of the input
wereceive from simply holding an ordinary cellphone to the ear and
only about the intensityof the output coming from a watch battery.
Itis delivered in 1-s intervals down electrode wireswhile the
patient remains relatively motionless,usually eyes closed. This
feedback is adjusted16 times a second to remain a certain numberof
cycles per second faster than the dominantbrainwave frequency. Most
preliminaryresearch and clinical experience are encour-aging with
articles published on LENS treatmentof conditions such as TBI
(Hammond, 2010c;Schoenberger, Shiflett, Esdy, Ochs, &
Matheis,2001), fibromyalgia (C. C. S. Donaldson, Sella,&
Mueller, 1998; Mueller, Donaldson, Nelson,& Layman, 2001),
anger (Hammond, 2010a),restless legs syndrome (Hammond, in
press),ADD=ADHD, anxiety, depression, insomniaand other conditions
(Larsen, 2006; Larsen,Harrington, & Hicks, 2006). LENS has
evenbeen used tomodify behavioral problems in ani-mals (Larsen,
Larsen, et al., 2006). Advantages ofthe LENS approach include that
it commonlyseems to produce results faster than
traditionalneurofeedback, and it can be used with veryyoung
children and with individuals who are lessmotivated and who do not
have the impulsecontrol or stamina required with other
neuro-feedback approaches.
Hemoencephalography
There are two different hemoencephalography(HEG) systems that
provide feedback, which isbelieved to influence cerebral blood
flow(Toomim & Carmen, 2009). Preliminaryresearch consisting of
case series reports onthe HEG applications appears
encouraging(Carmen, 2004; Coben & Pudolsky, 2007b;Duschek,
Schuepbach, Doll, Werner, & ReyesDel Paso, 2010; Friedes &
Aberbach, 2003;Mize, 2004; Sherrill, 2004; Toomim et al.,2004),
perhaps especially with migraine.
Live Z-Score Neurofeedback Training
Live Z-score training is a more recent innovationthat usually
utilizes two, four, or more electrodeson the head. Continuous
calculations are beingcomputed comparing the way that the brain
isfunctioning on different variables (e.g., power,asymmetries,
phase-lag, coherence) to a scien-tifically developed normative
database. Feed-back is then based on these moment-to-moment
statistical comparisons to norms forthe patient’s approximate age
group. As withother methods of neurofeedback, the feedbackthat is
provided is designed to guide the braintoward normalized function.
This feedbackoften consists of observing a DVDwhere the pic-ture
dims and flickers when the person is notdoing as well and becomes
more clear andbright when his or her brain is functioning closerto
norms. At this point, most of what has beenpublished on this
approach are case series data(Collura, 2008a, 2008b, 2009; Collura,
Guan,Tarrant, Bailey, & Starr, 2010; Collura, Thatcher,Smith,
Lambos, & Stark, 2009), with the excep-tion of a new controlled
study showing positiveresults with insomnia (Hammer, Colbert,
Brown,& Ilioi, 2011), but these preliminary results,which
include pre- and posttreatment QEEGs,are very encouraging. As this
is being written,an expansion of this approach has become
avail-able wherein an entire electrode cap with 19electrodes can
also be used for training.
LORETA Neurofeedback Training
LORETA refers to low resolution electromag-netic tomography.
This is a kind of QEEG
WHAT IS NEUROFEEDBACK 309
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analysis that provides an estimation of thelocation of the
underlying brain generators(e.g., the anterior cingulate, insula,
fusiformgyrus) of the patient’s EEG activity within afrequency
band. Very preliminary research(Cannon & Lubar, 2007; Cannon et
al.,2007; Cannon et al., 2006; Congedo, Lubar,& Joffe, 2004)
has been published about thisapproach. It does require more
labor-intensivepreparation where an entire electrode cap with19
electrodes must be applied in every session.It is believed that
this approach may havepotential to improve outcomes in difficult
casesand=or shorten the length of treatment, and apreliminary
report (Cannon & Lubar, 2011)suggests that changes may be
enduring.
Functional MRI Neurofeedback
Functional magnetic resonance imaging (fMRI)is a very
sophisticated type of neuroimagingthat examines brain activation to
evaluatebrain functioning (unlike the MRI, which exam-ines brain
structure). A fascinating scientificadvancement in the last several
years has beenutilization of the fMRI for neurofeedback (Cariaet
al., 2007; deCharms, 2007; deCharms et al.,2004; deCharms et al.,
2005; Haller, Birbau-mer, & Veit, 2010; Johnston, Boehm,
Healy,Goebel, & Linden, 2010; Rota et al., 2009;Weiskopf et
al., 2004; Weiskopf et al., 2003;Yoo et al., 2006). An advantage of
fMRI neuro-feedback is that it can examine functioning atdeep
subcortical areas of the brain. However,the serious practical
disadvantage of fMRIneurofeedback is that it would be
incrediblyexpensive and with equipment that costsapproximately $1
million or more, as well asextreme expenses associated with the
day-to-day operation of such equipment, this approachdoes not
appear to be something that will holdrealistic clinical promise as
a treatment optionin the foreseeable future.
AREAS OF APPLICATION FORNEUROFEEDBACK TREATMENTADD/ADHD
Since the late 1970s, neurofeedback has beenresearched, refined,
and tested with ADD=
ADHD and learning disabilities. Clinical workby Dr. Joel Lubar
and his colleagues (e.g., Lubar,1995) at the University of
Tennessee as well asmany others has repeatedly demonstrated thatit
is possible to retrain the brain. In fact, onerandomized controlled
study (Levesque,Beauregard, & Mensour, 2006) documentedwith
fMRI neuroimaging the positive changesin brain function in ADHD
children that mir-rored their behavioral changes following
neuro-feedback treatment. This and the research citednext all
provide strong support that demon-strate the effectiveness of
neurofeedback intreating ADD=ADHD. Whereas the averagestimulant
medication treatment study follow-upis only 3 weeks long, with only
four long-termfollow-up medication studies that lasted 14months or
longer, Lubar (1995) published10-year follow-ups on cases and found
that inabout 80% of clients, neurofeedback can sub-stantially
improve the symptoms of ADD andADHD and that these changes are
maintained.
Rossiter and LaVaque (1995) found that 20sessions of
neurofeedback produced compara-ble improvements in attention and
concen-tration to taking Ritalin. Fuchs, Birbaumer,Lutzenberger,
Gruzelier, and Kaiser (2003)and Rossiter (2005) likewise
demonstrated thatneurofeedback produced comparable improve-ments to
Ritalin. Drechsler et al. (2007) foundslow cortical potentials
training superior togroup therapy with ADHD children.
Neuro-feedback has also been found in randomizedcontrolled studies
to be superior to EMGbiofeedback (Bakhshayesh, 2007). In a
1-yearfollow-up, control group study, Monastra,Monastra, and George
(2002) found that neuro-feedback produced superior
improvementscompared to Ritalin, not requiring continuationof the
medication. In a randomized controlledstudy, Leins et al. (2007)
demonstrated that30 sessions of slow cortical potentials trainingor
of traditional neurofeedback were botheffective in producing
cognitive, attentional,behavioral, and IQ improvements,
whichremained stable 6 months after treatment.
Gevensleben et al. (2009b) in a randomizedcontrolled study
documented the superiority ofneurofeedback training (effect size¼
.60)
310 D. C. HAMMOND
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compared with computerized attention skillstraining (which would
have placebo controlcharacteristics). Behavioral and
attentionalimprovements were found to be stable on6-month follow-up
in research studies reportedby Strehl et al. (2006) and Gevensleben
et al.(2010), and the latter found that neurofeedbacktraining
produced superior results to computer-ized attention skills
training, as did Holtmannet al. (2009).
Two randomized, double-blind placebocontrolled studies (deBeus
& Kaiser, 2011;deNiet, 2011) have documented the effective-ness
of neurofeedback with ADHD. Otherrecent, large randomized
controlled studies(Gevensleben et al., 2009a; Wrangler et al.,2010)
should also do much to dispel concernsthat improvements from
neurofeedback trainingsimply reflect nonspecific placebo factors.
Thesestudies demonstrated protocol-specific changesin
electrophysiological brain function usingEEG and sophisticated
event-related potentialmeasures, replicating some earlier
findings(Heinrich, Gevensleben, Freisleder, Moll,
&Rothenberger, 2004) and showing distinctneuronal mechanisms
involved with differenttraining techniques. A 2-year follow-up
(Gani,Birbaumer, & Strehl, 2008) of the Heinrichresearch found
that not only were improve-ments in attention and behavior stable
but thatsome parent ratings had shown continuedimprovement during
the 2 years. Continuingimprovement on 6-week and 12-week follow-ups
were also found after the completion ofLENS treatment of adult
ADD=ADHD by deNiet(2011) in a randomized, double-blind
placebocontrolled study. Thus follow-up evaluationsranging from 3
months to 10 years after treat-ment (Gani et al., 2008; Heinrich et
al., 2004;Lubar, 1995; Monastra et al., 2002; Strehlet al., 2006)
provide strong support thatimprovements from neurofeedback with
ADD=ADHD should be enduring, unless of coursesomething such as a
head injury or drug abusewere to occur to negative alter brain
function.
A recent meta-analysis (Arns, de Ridder,Strehl, Breteler, &
Coenen, 2009) concludedthat neurofeedback treatment of
ADD=ADHDmeets criteria for being classified as an
efficacious and specific treatment—the highestlevel of
scientific validation (La Vaque et al.,2002). In comparison to
neurofeedback,a meta-analysis (Schachter, Pham, King,Langford,
& Hoher, 2001) of randomized con-trolled studies of medication
treatment forADD=ADHD concluded that the studies wereof poor
quality, had a strong publication bias(meaning that drug company
funded studiesthat failed to support the effectiveness of
theirproduct tended to never be submitted for pub-lication), and
often produced side effects. Theyfurther indicated that long-term
effects (beyondplacebo effects) for longer than a 4-weekfollow-up
period were not demonstrated.
A recent comprehensive review (DrugEffectiveness Review Project,
2005) of medi-cation treatment for ADD=ADHD concludedthat there was
no evidence on the long-termsafety of the medications used in
ADD=ADHDtreatment and that good quality evidence islacking that
drug treatment improves academicperformance or risky behaviors on a
long-termbasis, or in adolescents or adults. The latter
con-clusions were also reached by Joughin and Zwi(1999). The
largest randomized controlled mul-tisite study compared medication
treatment,‘‘routine community care,’’ and behavior ther-apy.
Outcome raters were not blinded, introdu-cing a bias, and most
subjects in communitycare were also on medications. At
14-monthfollow-up (MTA Cooperative Group, 1999), allgroups showed
improvements, and medicationproduced better improvements in
attentionand hyperactivity (the latter only on parent rat-ings),
but not in aggression, social skills, grades,or parent–child
relations. The ratings providedby the only blinded rater (a
classroom observer),however, showed no difference betweengroups,
and on 3-year follow-up (Swansonet al., 2007) there was no
difference on anyoutcome measures between groups, findingsthat were
confirmed on 8 year follow-up(Molina et al., 2009). Studies (e.g.,
Swansonet al., 2007) have confirmed loss of appetiteand growth
suppression as a side effect of medi-cation treatment, along with
other side effectssuch as increased heart rate and blood
pressure,insomnia, loss of emotional responsiveness,
WHAT IS NEUROFEEDBACK 311
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dizziness, headache, and stomachache. In theMTA study, 64% of
children reported sideeffects, 11% of them moderately severe and3%
severe. Side effects associated with ADD=ADHD medications are also
so common thatless than 50% of children maintain prescribeddosages
for more than 6 months (Hoagwood,Jensen, Feil, Vitiello, &
Blatara, 2000).
In light of these findings, neurofeedbackseems well validated as
providing a noninvasiveand relatively side effect free treatment
alterna-tive for ADD=ADHD. In the long run it is alsovery cost
effective. Some individuals expressconcern about the cost of
neurofeedback beinggreater than the expense involved in drug
treat-ment. Research has shown, however, that thecosts associated
with medication treatmentare actually quite sizable. For instance,
a study(Marchetti et al., 2001) of six different medica-tions for
ADD=ADHD treatment found that theaverage cost per school-aged
patient was$1,678 each year. Another study (Swensenet al., 2003)
examined the health care costs inmore than 100,000 families where
ADHDwas either present or not present. They foundthat in families
where a member had ADHD,the direct costs of health care
expenditures plusindirect costs (such as work loss) averaged$1,288
per year higher for the other familymembers (who had not been
diagnosed as hav-ing ADD=ADHD) in comparison with membersof
families where ADHD was not present. Thiswould mean that the cost
of medication justcited, combined with indirect costs each yearfor
a family with two children, one of whomhad ADHD, would be
$5,542.
Neurofeedback training for ADD=ADHDis commonly found to be
associatedwith decreased impulsiveness=hyperactivity,increased mood
stability, improved sleep pat-terns, increased attention span and
concen-tration, improved academic performance, andincreased
retention and memory, and with amuch lower rate of side effects. It
is fascinatingto note that ADD=ADHD or learning disabilitystudies
that have evaluated IQ pre- andposttreatment have commonly found
IQincreases following neurofeedback training.These improvements
ranged from an average
of 9 IQ points improvement in one study(Linden, Habib, &
Radojevic, 1996), to anaverage improvement of 12 IQ points in
astudy by L. Thompson and Thompson (1998),a mean of 19 IQ points in
another study(Tansey, 1991b), and even up to an averageincrease of
23 IQ points in a study by Othmer,Othmer, and Kaiser (1999).
Learning and DevelopmentalDisabilities
With regard to learning disabilities, Fernandezet al. (2003)
demonstrated in a placebo-controlled study that neurofeedback was
aneffective treatment, and the improvementswere sustained on 2-year
follow-up (Becerraet al., 2006). An additional report by
Fernandez(Fernandez et al., 2007) on 16 children withlearning
disabilities documented significantEEG changes 2 months after
neurofeedbackcompared to a placebo-control group wherethere were no
EEG changes, and 10 of 11 chil-dren in the neurofeedback treatment
groupshowed objective changes in academic perfor-mance compared
with one in five children inthe placebo group. Other articles have
alsobeen published on the value of neurofeedbackwith learning
disabilities (Orlando & Rivera,2004; Tansey, 1991a; Thornton
& Carmody,2005). A randomized controlled study withchildren
with dyslexia (Breteler, Arns, Peters,Giepmans, & Verhoeven,
2010) documentedsignificant improvement in spelling,
andWalker(2010a;Walker & Norman, 2006) found signifi-cant
improvements in reading ability in 41dyslexia cases. In the first
12 cases reportedby Walker (Walker & Norman, 2006) after 30to
35 sessions, all the children had improvedat least two grade levels
in reading ability.Barnea, Rassis, and Zaidel (2005)
identifiedimprovements in reading ability in learningdisability
children after 20 sessions.
Although controlled research has not beendone, Surmeli and Ertem
(2007) evaluatedwhether QEEG-guided neurofeedback couldbe helpful
with Down Syndrome children. Alleight children who completed up to
60 treat-ment sessions (one child dropped out after onlyeight
sessions) showed significant improvement
312 D. C. HAMMOND
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in attention, concentration, impulsivity,behavior problems,
speech and vocabulary,and on QEEG measures. Surmeli and Ertem(2010)
treated 23 children diagnosed with mildto moderate mental
retardation with 80 to160 QEEG-guided neurofeedback
sessions.Twenty-two of 23 showed clinical improve-ment on the
Developmental BehaviourChecklist, and 19 of 23 showed improvementon
the Wechsler Intelligence Scale for Childrenand a computerized test
of attention.
Cognitive and Memory Enhancement
Neurofeedback also has documented results forcognitive and
memory enhancement in normalindividuals (Angelakis et al., 2007;
Boulay,Sarnacki, Wolpaw, & McFarland, 2011;Egner &
Gruzelier, 2003; Egner, Strawson, &Gruzelier, 2002; Fritson,
Wadkins, Gerdes, &Hof, 2007; Gruzelier, Egner, & Vernon,
2006;Hanslmayer, Sauseng, Doppelmayr, Schabus,& Klimesch, 2005;
Hoedlmoser et al., 2008;Keizer, Verment, & Hommel, 2010;
Rasey,Lubar, McIntyre, Zoffuto & Abbott, 1996;Vernon et al.,
2003; Zoefel, Huster, &Herrmann, 2010). Neurofeedback to
enhancecognitive functioning and to counter the effectsof aging has
been referred to as ‘‘brain brighten-ing’’ (Budzynski, 1996). Ros,
Munneke, Ruge,Gruzelier, and Rothwell (2010) producedevidence that
neurofeedback training withnormal persons may enhance
neuroplasticity.
Uncontrolled Epilepsy
Medication treatment of epilepsy is successfulonly in completely
controlling seizures in twothirds of patients (Iasemidis, 2003),
and thelong-term use of many antiseizure medicationscan have health
risks. When medication treat-ment is not successful, neurosurgery
is oftenrecommended, but it has limited success(Witte, Iasemidis,
& Litt, 2003). In addition,many epilepsy patients are also
women ofchild-bearing age who wish to have childrenbut fear the
effects of medications on the fetus.Therefore, a treatment option
other than or inaddition to medication and surgery would bedesired.
Research has shown that when medi-cation is insufficient to control
the occurrence
of seizures, neurofeedback can offer anadditional modality that
can be added to treat-ment, which has the potential to assist in
bring-ing seizures under control, allowing dosagelevels of
medications to be reduced, and help-ing to avoid invasive brain
surgery.
Research in this area began in the early1970s and is extensive
and rigorous, includingblinded, placebo-controlled, cross-over
studies(reviewed in Sterman, 2000, and in a meta-analysis by Tan et
al., 2009). The samples inthe studies that have been done
typicallyconsist of the most severe,
out-of-control,medication-treatment-resistant patients. How-ever,
even in this most severe group ofpatients, research found that
neurofeedbacktraining on average produces a 70% reductionin
seizures. In these harsh cases of medicallyintractable epilepsy,
neurofeedback has beenable to facilitate greater control of
seizures in82% of patients, often reducing the level ofmedication
required, which can be very posi-tive given the long-term negative
effects ofsome medications. Many patients, however,may still need
to remain on some level ofmedication following neurofeedback.
More recently Walker and Kozlowski(2005) reported on 10
consecutive cases, and90% were seizure free after
neurofeedback,although only 20% were able to cease
takingmedication. In another group of 25 uncon-trolled epilepsy
patients (Walker, 2008),100% became seizure free following
QEEG-guided neurofeedback, with 76% no longerrequiring an
anticonvulsant for seizure controlon follow-up, which averaged 5.1
years.Walker (2010b) reported on still an additional20 patients
with intractable seizures, 18 ofwhich were seizure free following
neurofeed-back training, whereas two continued to reportoccasional
seizures. Two of the 18 patientsremained on a single anticonvulsant
medi-cation. The average length of follow-up inthese cases was 4
years. In this same report,Walker indicated that he had seen
ninewomen who wished to stop taking anticonvul-sants to become
pregnant, and all ninehave remained seizure free for an average of6
years.
WHAT IS NEUROFEEDBACK 313
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TBI and Stroke
Concussions and head injuries that causeemotional, cognitive,
and behavioral problemsoccur as a result of many things such as
motorvehicle accidents, war (Trudeau et al., 1998),and sports
(McCrea, Prichep, Powell, Chabor,& Barr, 2010; McKee et al.,
2009), includingfootball (Amen et al., 2011), doing headers
insoccer (Tysvaer, Stroll, & Bachen, 1989), andboxing (Ross,
Cole, Thompson, & Kim, 1983).
Neurofeedback treatment outcome studiesof closed and open head
injuries have beenpublished (Ayers, 1987, 1991, 1999;
Bounias,Laibow, Bonaly, & Stubbelbine, 2001; Bounais,Laibow,
Stubbelbine, Sandground, & Bonaly,2002; Byers, 1995; Hammond,
2007a,2007b, 2010c; Hoffman, Stockdale, Hicks, &Schwaninger,
1995; Hoffman, Stockdale, &Van Egren, 1996a, 1996b; Keller,
2001;Laibow, Stubbelbine, Sandground, & Bounais,2001;
Schoenberger et al., 2001; Thornton,2000; Tinius & Tinius,
2001), as well as withstroke (Ayers, 1981, 1995a, 1995b,
1999;Bearden, Cassisi, & Pineda, 2003; Cannon,Sherlin, &
Lyle, 2010; Doppelmayr, Nosko,Pecherstorfer, & Fink, 2007;
Putnam, 2001;Rozelle & Budzynski, 1995; Walker, 2007;Wing,
2001), but further high-quality researchneeds to be done. One
article (Hammond,2007b) reported a case of moderate severityTBI
treated with the LENS, which resulted inthe complete reversal of
posttraumatic anosmia(complete loss of sense of smell) of 912
years’duration, which was previously unheard of,as well as
significant clinical improvement inpostconcussion symptoms.
A recent research review (Thornton &Carmody, 2008)
particularly suggests thatQEEG-guided neurofeedback is superior to
neu-rocognitive rehabilitation strategies and medi-cation treatment
in the rehabilitation of TBI.Traditionally physical medicine and
rehabili-tation physicians tell head injury patients that112 years
after a TBI they cannot expect furtherimprovement and must simply
adjust to theirdeficits. Clinical experience and research thusfar
clearly indicate that neurofeedback mayoften produce significant
improvements even
many years after a head injury. The accumulat-ing evidence
indicates that neurofeedbackoffers a valuable additional treatment
in therehabilitation of head injuries and with athleteswho have
suffered concussions.
Alcoholism and Substance Abuse
EEG investigations of alcoholics (and the chil-dren of
alcoholics) have documented that evenafter prolonged periods of
abstinence, they fre-quently have lower levels of alpha and
thetabrainwaves and an excess of fast beta activity.This suggests
that alcoholics and their childrentend to be hardwired differently
from otherpeople, making it difficult for them to relax.Following
the intake of alcohol, however, thelevels of alpha and theta
brainwaves increase.Thus individuals with a biological
predis-position to develop alcoholism (and their chil-dren) are
particularly vulnerable to the effectsof alcohol because, without
realizing it, alco-holics seem to be trying to self-medicate in
aneffort to treat their own brain pathology. Therelaxing mental
state that occurs following alco-hol use is highly reinforcing to
them because oftheir underlying brain activity pattern.
Severalresearch studies now show that the best predic-tor of
relapse is the amount of excessive betabrainwave activity that is
present in bothalcoholics and cocaine addicts (Bauer, 1993,2001;
Prichep, Alper, Kowalik, John, et al.,1996; Prichep, Alper,
Kowalik, & Rosenthal,1996; Winterer et al., 1998).
Recently, neurofeedback training to teachalcoholics how to
achieve stress reduction andprofoundly relaxed states through
increasingalpha and theta brainwaves and reducing fastbeta
brainwaves has demonstrated promisingpotential as an adjunct to
alcoholism treatment.Peniston and Kulkosky (1989) used such
trainingin a study with chronic alcoholics compared to
anonalcoholic control group and a control groupof alcoholics
receiving traditional treatment.Alcoholics receiving 30 sessions of
neurofeed-back training demonstrated significant increasesin the
percentages of their EEG that was in thealpha and theta
frequencies, and increasedalpha rhythm amplitudes. The
neurofeedback
314 D. C. HAMMOND
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treatment group also demonstrated sharpreductions in depression
when compared tocontrols. Alcoholics in standard
(traditional)treatment showed a significant elevation inserum
beta-endorphin levels (an index of stressand a stimulant of caloric
[e.g., ethanol] intake),whereas those with neurofeedback
trainingadded to their treatment did not demonstratethis increase
in beta-endorphin levels. On4-year follow-up checks (Peniston &
Kulkosky,1990), only 20% of the traditionally treatedgroup of
alcoholics remained sober, comparedwith 80% of the experimental
group who hadreceived neurofeedback training. Furthermore,the
experimental group showed improvementin psychological adjustment on
13 scales of theMillon Clinical Multiaxial Inventory comparedto the
traditionally treated alcoholics whoimproved on only two scales and
became worseon one scale. On the 16-PF personality inven-tory, the
neurofeedback training group demon-strated improvement on seven
scales, comparedto only one scale among the traditional treat-ment
group. Similar positive results with 92%sobriety on 21-month
follow-ups were reportedby Saxby and Peniston (1995) in 14
depressedalcoholics, and encouraging results werereported on 3-year
follow-ups in a treatmentprogram with native Americans (Kelley,
1997).
Scott, Kaiser, Othmer, and Sideroff (2005)conducted a randomized
controlled study with121 individuals undergoing an inpatient
sub-stance abuse program. The patients received40 to 50 treatment
sessions. Persons who hadneurofeedback added to their
treatmentremained in therapy significantly longer—animportant
factor in the treatment of substanceabuse. On 1-year follow-up, 77%
of patientsreceiving neurofeedback remained sober ver-sus only 44%
of traditional treatment patients.Significant differences were
found in measuresof attention and in seven scales on the Minne-sota
Multiphasic Personality Inventory–2 com-pared with improvement on
only one scale inthose receiving traditional treatment. Reportsfrom
a similar treatment program (Burkett,Cummins, Dickson, &
Skolnick, 2005) with270 homeless crack cocaine addicts showedthat
the addition of neurofeedback to treatment
more than tripled the length of stay in therecovery center. On
1-year follow-up of the94 patients who completed treatment,
95.7%were nowmaintaining a residence, 93.6%wereemployed or in
schooling, 88.3% had nofurther arrests, and 53.2% had been
alcoholand drug free 1 year, whereas another 23.4%had used alcohol
or dugs only one to threetimes, corroborated by urinalysis.
Arani, Rostami, and Nostratabadi (2010)compared results from 30
sessions of neuro-feedback being provided to opioid
dependentpatients undergoing outpatient treatment(methadone or
Buprenorpine maintenance),compared with a control group that
receivedoutpatient treatment alone. Patients receivingneurofeedback
showed significantly moreimprovements in outcome measures (e.g.,
ofhypochondriasis, obsessing, interpersonal sensi-tivity,
aggression, psychosis, anticipation of posi-tive outcome, and
desire to use drugs) and onQEEGs. Preliminary research (Horrell et
al.,2010) has suggested that neurofeedback mayalso have potential
to reduce drug cravings incocaine abusers.
The evidence reviewed validates theimmensepotential
thatneurofeedback treatmenthas to likely double if not triple the
outcome ratesin alcoholism and substance abuse treatmentwhen it is
added as an additional component toa comprehensive treatment
program (Sokhadze,Cannon, & Trudeau, 2008). It may have
realpotential in not only treating but also remediatingsome of the
serious damage to the brain thatoccurs through drug abuse (e.g.,
Alper et al.,1998; Prichep, Alper, Kowalik, & Rosenthal,1996;
Struve, Straumanis, & Patrick, 1994).
Antisocial Personalityand Criminal Justice
Quirk (1995) reported reduced recidivism usinga combination of
neurofeedback and galvanicskin response biofeedback. Smith and
Sams(2005) showed improvements in attention andbehavior in a group
of juvenile offenders, anda study in a Boys Totem Town project
withseven juvenile felons (Martin & Johnson,2005) improvements
were noted on a varietyof measures. Most recently, Surmeli and
Ertem
WHAT IS NEUROFEEDBACK 315
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(2009) presented a case series of 13 patientswho received from
80 to 100 neurofeedbacktreatment sessions guided by QEEG
findings.Outcomes were measured with the MinnesotaMultiphasic
Personality Inventory, a test ofattention, QEEG results, and
interviews withfamily members. Twelve of the 13 patientsshowed
significant improvement, which wasmaintained on 2-year follow-up.
The abnormalrepresentation of learning disabilities, ADHD,head
injuries, childhood abuse, alcoholism,and substance abuse in an
incarceratedoffender population (Wekerle & Wall, 2002;Wilson
& Cumming, 2009) and of alcoholismand drug abuse in domestic
violence (Linet al., 2009) would suggest considerable poten-tial
for the use of neurofeedback, particularlygiven the high recidivism
rates that attest tothe limited effectiveness of traditional
psy-chotherapies and pharmacology treatment. Thiswill be another
fruitful area for further research.
Posttraumatic Stress Disorder
Peniston and Kulkosky (1991) added thirty30-minute sessions of
alpha=theta neurofeed-back training to the traditional VA
hospitaltreatment provided to a group of posttraumaticstress
disorder Vietnam combat veterans, andthen compared them at
30-months posttreat-ment with a contrast group who received
onlytraditional treatment. On follow-up, all 14 tra-ditional
treatment patients had relapsed andbeen rehospitalized, whereas
only three of 15neurofeedback training patients had
relapsed.Although all 14 patients who were on medi-cation and were
treated with neurofeedbackhad decreased their medication
requirementsby follow-up, among the patients receiving tra-ditional
treatment, only one patient decreasedmedication needs, two reported
no change,and 10 required an increase in psychiatric med-ications.
On the Minnesota Multiphasic Person-ality Inventory, neurofeedback
training patientsimproved significantly on all 10 clinical
scales—dramatically on many of them—whereas therewere no
significant improvements on any scalesin the traditional treatment
group. One study(Huang-Storms, Bodenhamer-Davis, Davis, &Dunn,
2006) has also reported positive
improvements in 20 adopted children withhistories of abuse
and=or neglect. Improve-ments were noted in externalizing and
interna-lizing problems, social problems, aggressive anddelinquent
behavior, anxiety=depression,thought problems, and attentional
problems.Neurofeedback seems very promising withposttraumatic
stress disorder, but further corro-borating research is needed.
Autism and Aspberger’s Syndrome
There is a quite significant body of research thathas now
appeared on the neurofeedbacktreatment of autism and Asperger’s
Syndrome(Coben & Myers, 2010; Coben & Pudolsky,2007a;
Jarusiuwicz, 2002; Knezevic, Thompson,& Thompson, 2010;
Kouijzer, de Moor, Gerrits,Buitelaar, & van Schie, 2009;
Kouijzer, deMoor,Gerrits, Congedo, & van Schie, 2009;
Kouijzer,van Schie, de Moor, Gerrits, & Buitelaar, 2010;Pineda
et al., 2007; Pineda et al., 2008;Scolnick, 2005; Sichel, Fehmi,
& Goldstein,1995).
L. Thompson, Thompson, and Reid (2010)reported on a case series
of 150 Asperger’s Syn-drome patients and nine autism spectrum
dis-order patients who received 40 to 60 sessions,commonly with
some supplementary peripheralbiofeedback. They found very
statistically sig-nificant improvements in measures of
attention,impulsivity, auditory and visual attention, read-ing,
spelling, arithmetic, EEG measures, and anaverage full scale IQ
score gain of 9 points.
Some of the studies just cited were controlgroup studies. There
has also been a placebo-controlled study (Pineda et al., 2008), and
therehave been 6-month (Kouijzer et al., 2010) and1-year follow-ups
(Kouijzer et al., 2009) docu-menting maintenance of positive
results. Areview of neurofeedback with autism spectrumproblems,
which includes a review of unpub-lished papers presented as
scientific meetings,has been published by Coben, Linden, andMyers
(2010). In an as-yet-unpublished studycited by those authors using
neurofeedbackand HEG training, Coben found a 42%reduction in
overall autistic symptoms, includinga 55% decrease in social
interaction deficits andimprovements in communication and
social
316 D. C. HAMMOND
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interaction deficits of 55% and 52%, respect-ively. Overall,
neurofeedback has positiveresearch support as a beneficial
treatment withautism spectrum problems, with findings ofpositive
changes in brain function, attention,IQ, impulsivity, and parental
assessments ofother problem behaviors such as communi-cation,
stereotyped and repetitive behavior,reciprocal social interactions,
and sociability.Although neurofeedback is certainly not a curefor
these conditions, it appears to usually pro-duce significant
improvements in these chronicconditions.
Anxiety and Depression
Encouraging preliminary research has beenpublished for the
effectiveness of neurofeed-back in treating anxiety with 10
controlled stu-dies that have been identified (Hammond,2005c;
Moore, 2000). Of the eight studies ofanxiety that were reviewed,
seven found posi-tive changes. Another study (Passini,
Watson,Dehnel, Herder, & Watkins, 1977) used only10 hr of
neurofeedback with anxious alcoholicsand found very significant
improvements instate and trait anxiety compared to a controlgroup,
with results sustained on 18-monthfollow-up. A randomized, blinded,
controlledstudy (Egner & Gruzelier, 2003) was done
withperformance anxiety at London’s Royal Collegeof Music. They
evaluated the ability of alpha=theta neurofeedback to enhance
musical per-formance in high-talent-level musicians whenthey were
performing under stressful conditionswhere their performance was
being evaluated.When compared with alternative treatmentgroups
(physical exercise, mental skills training,Alexander Technique
training, and two otherneurofeedback protocols that focused moreon
enhancing concentration), only the alpha=theta neurofeedback group
resulted in enhanc-ement of real-life musical performance
understress. Similar randomized controlled studiesreducing
performance anxiety have beenconducted with musical performance
(Egner &Gruzelier, 2003), ballroom dance performance(Raymond,
Sajid, Parkinson, & Gruzelier,2005), and performance in singing
(Kleber,Gruzelier, Bensch, & Birbaumer, 2008; Leach,
Holmes, Hirst, & Gruzelier, 2008). In a rando-mized,
placebo-controlled study with medicalstudents (Raymond, Varney,
Parkinson, & Gru-zelier, 2005) neurofeedback enhanced
mood,confidence, feeling energetic and composed.
Neurofeedback has also been shown withobjective measures to
improve depression(Baehr, Rosenfeld, & Baehr, 2001;
Hammond,2001a, 2005b; Hammond & Baehr, 2009). Thedegree to
which depressed patients were ableto normalize their EEG activity
during neuro-feedback has been found to significantly corre-late
with improvement in depressive symptoms(Paquette, Beauregard, &
Beaulieu-Prevost,2009). A blinded, placebo-controlled study(Choi et
al., 2011) demonstrated the superiorityof neurofeedback over a
placebo treatment inreducing depression while improving
executivefunction. However, more research is neededon the use of
neurofeedback with depression.
Insomnia
A randomized, controlled study (Hoedlmoseret al., 2008)
demonstrated that only 10 neuro-feedback sessions focused on
reinforcing theSMR resulted in an increase in sleep spindlesand
reduced sleep latency. Because memoryconsolidation occurs during
sleep, this studyalso documented improved memory in the sub-jects.
This study replicated findings some earlierstudies (Berner,
Schabus, Wienerroither, &Klimesch, 2006; Sterman, Howe,
&MacDonald,1970). Hammer et al. (2011) published arandomized,
single-blind controlled study docu-menting the effectiveness of 20
sessions of liveZ-score training in the treatment of
insomnia.Individualized neurofeedback was also shownin control
group studies by Hauri (1981; Hauri,Percy, Hellekson, Hartmann,
& Russ, 1982) tohave long-lasting effects with insomnia
patients.A recent randomized control group study(Cortoos, De Valck,
Arns, Breteler, & Cluydts,2010) of primary insomnia patients
found anaverage of 18 sessions of home neurofeedbacktraining
administered over the Internet pro-duced a significant improvement
in the timerequired to fall asleep and a significant improve-ment
in total sleep time as measured in a sleeplab compared with a
control group. Even three
WHAT IS NEUROFEEDBACK 317
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schizophrenic or schizoaffective patients withdisturbed sleep
all showed improvement insleep quality when compared with a
controlgroup (Cortoos et al., in press).
Headaches and Migraine
Walker (2011) reported on 71 recurrentmigraine cases who
consulted a neurologicalpractice. Forty-six of the patients
consentedto QEEG-guided neurofeedback treatment,whereas 25 chose
drug treatment. Excess higherfrequency beta was present in all
cases. At1-year follow-up, 54% of the neurofeedbackgroup
experienced complete cessation ofmigraines compared with no one in
the medi-cation treatment group. In the neurofeedbackgroup, 39%
experienced a reduction of greaterthan 50% in migraines (compared
with 8% withdrug treatment), and a reduction of less than50% was
found in 4% of patients (comparedto 20% with medication treatment).
Sixty-eightpercent of the medication treatment groupreported no
change in headache frequency,whereas only one patient (2%)
receiving neuro-feedback reported no reduction in
frequency.Siniatchkin, Hierundar, Kropp, Gerber, andStephani (2000)
found a significant reductionin the number of days per month with
amigraine in children treated with slow corticalpotentials training
versus a waitlist control group.Carmen (2004) reported improvement
of morethan 90% in migraine sufferers who completedat least six
sessions of HEG training. For Stokesand Lappin (2010), 70% of
migraine patientsexperienced at least a 50% reduction in fre-quency
on more than 1-year follow-up from acombination of 40 neurofeedback
sessions com-bined with HEG training. Tansey (1991a) pub-lished
four case reports. Although encouraging,further controlled research
is needed.
Peak or Optimal Performance Training
Neurofeedback is also being utilized in peakperformance training
(Vernon, 2005). Forexample, in a randomized, blinded
controlledstudy (Egner & Gruzelier, 2003)
neurofeedbacksignificantly enhanced musical performance,and a
similarly designed study (Raymond,Sajid, et al., 2005) documented
significant
improvements in ballroom dance performance.Such results have
also been reported with golf(Arns, Kleinnijenhuis, Fallahpour,
& Breteler,2007), archery (Landers, 1991; Landers et al.,1994),
improving fast reaction time and visuo-spatial abilities (which has
relevance to athleticperformance; Doppelmayr & Weber,
2011;Egner & Gruzelier, 2004), improving singingperformance
(Kleber et al., 2008; Leach et al.,2008), acting performance
(Gruzelier, Inoue,Smart, Steed, & Steffert, 2010), and
improve-ments in radar-monitoring tasks (Beatty,Greenberg, Diebler,
& O’Hanlon, 1974). Onefascinating study (Ros et al., 2009)
comparedtraining to either increase SMR or alpha andtheta brainwave
frequencies in opthalmicmicrosurgeons in training, compared to a
wait-list (no-treatment) group. In only eight sessionsof SMR
training the physicians demonstratedsignificant improvements in
surgical skill,decreases in anxiety, and a 26% reduction insurgical
task time. Research documentingimprovements in cognitive and memory
perfor-mance has already been reviewed earlier. Thepotential of
neurofeedback applications foroptimal performance will be very a
fruitful areafor further research.
Other Clinical Applicationsof Neurofeedback Training
Preliminary reports have also been publishedon the use of
neurofeedback with chronic fati-gue syndrome (Hammond, 2001b);
Tourette’s(Tansey, 1986); obsessive-compulsive disorder(Hammond,
2003, 2004; Surmeli, Ertem,Eralp, & Kos, 2011); Parkinson’s
tremors (M.Thompson & Thompson, 2002); tinnitus(Crocetti,
Forti, & Bo, 2011; Dohrmann, Elbert,Schlee, & Weisz, 2007;
Gosepath, Nafe,Ziegler, & Mann, 2001; Schenk, Lamm,Gundel,
& Ladwig, 2005; Weiler, Brill, Tachiki,& Schneider, 2001);
pain (Ibric & Dragomirescu,2009; Jensen, Grierson, Tracy-Smith,
Baciga-lupi, & Othmer, 2007; Sime, 2004); physicalbalance,
swallowing, gagging, and incontinence(Hammond, 2005a); children
with histories ofabuse and neglect (Huang-Storms et al., 2006)or
reactive attachment disorder (Fisher, 2009);cerebral palsy (Ayers,
2004); restless legs and
318 D. C. HAMMOND
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periodic limb movement disorder (Hammond,in press); physical and
emotional symptomsassociated with Type I diabetes mellitus(Monjezi
& Lyle, 2006); essential tremor; andfor ‘‘chemo fog’’ (Raffa
& Tallarida, 2010;Schagen, Hamburger, Muller, Boogerd, &
vanDam, 2001) following chemotherapy or radi-ation treatments.
Mixed results have been found with neuro-feedback treatment of
fibromyalgia. An uncon-trolled trial (Mueller et al., 2001) with
30patients with fibromyalgia (using an early versionof LENS) found
significant improvements inmood, clarity, and sleep. C. C. S.
Donaldsonet al. (1998) used an earlier version of LENS(and a small
amount of EMG biofeedback) andreported significant improvement in
77% ofpatients’ long-term follow-ups, but again thiswas an
uncontrolled case series. In contrast, theseresults were not
confirmed by Kravitz, Esty, Katz,and Fawcett (2006) in a
double-blind, placebo-controlled study, and Nelson et al. (2010)
foundimprovements in pain, fatigue, and cognitiveclouding, and
increased activity in comparisonto a sham placebo control group,
but the effectswere not enduring. On the other hand,
Kayiran,Dursan, Dursun, Ermutlu, and Karamursel(2010), in a
randomized, blinded, control groupstudy, compared 20 sessions of
neurofeedbackto treatment with Lexapro and found that
bothtreatments produced significant symptomaticimprovements, but
the benefits were significantlygreater in the neurofeedback
group.
Research has shown that it is possible forschizophrenics to
participate in neurofeebacktraining (Guzelier, 2000; Gruzelier et
al., 1999;Schneider et al., 1992) and clinical experiencewith
chronic schizophrenics (Bolea, 2010;Cortoos et al., in press; M.
Donaldson, Moran,& Donaldson, 2010; Surmeli, Ertem, Eralp,
&Kos, in press) provides encouragement that thismay be an
additional treatment interventionwhich holds potential.
IS MORE PLACEBO CONTROLLEDRESEARCH NEEDED?
Despite the considerable research cited in thisarticle, there
are many areas where more
controlled outcome research is still needed inthe application of
neurofeedback to variousproblems. Placebo-controlled studies are
oftenregarded as the very highest level of scientificvalidation. It
can be assumed that positiveresults from neurofeedback are due to a
com-bination of expectancy (placebo) effects andeffects specific to
the neurofeedback treatment(Hammond, 2011; Perreau-Linck,
Lessard,Levesque, & Beauregard, 2010), because pla-cebo effects
appear to be an active ingredientin virtually every therapeutic
modality. Weknow, however, that there are improvementsvery specific
to neurofeedback because thereare several placebo-controlled
studies thathave demonstrated significant efficacious andspecific
effects beyond placebo influences inneurofeedback training
(Raymond, Varney,et al., 2005), including with learning
disabilities(Becerra et al., 2006; Fernandez et al., 2003),ADD=ADHD
(deBeus & Kaiser, 2011; deNiet,2011), anxiety (Raymond, Varney,
et al.,2005), epilepsy (Lubar et al., 1981), sleeplatency and
declarative learning (Hoedlmoseret al., 2008), cognitive
enhancement in theelderly (Angelakis et al., 2007), autism
(Pinedaet al., 2008), and depression (Choi et al.,2011), although
one preliminary study didnot find such effects (Lansbergen, van
Dongen-Boomsma, Buitelaar, & Slaats-Willemse, 2010).Certainly
animal studies (e.g., Sterman, 1973;Larsen, Larsen, et al., 2006)
also suggest thatneurofeedback has therapeutic effects inde-pendent
of placebo effects. It would not beanticipated that cats would form
positiveexpectancies about being more seizure resist-ant simply
because an experimenter was put-ting electrodes on their heads.
In spite of the placebo-controlled studieswe have in
neurofeedback, some academicresearchers (e.g., Loo & Barkley,
2005),insurance companies, and proponents of medi-cation treatment
have complained that thereshould be more placebo-controlled
researchon neurofeedback, even though medical ethi-cists (Andrews,
2001; Lurie & Wolfe, 1997;Rothman, 1987), neurofeedback
advocates(La Vaque, 2001), and the Declaration ofHelsinki (World
Medical Association, 2000)
WHAT IS NEUROFEEDBACK 319
-
have expressed the view that requiringplacebo-controlled studies
in conditions wherethere is a known effective treatment
alreadyavailable is considered unethical. The primarybenefit of
placebo-controlled studies is thatthey clarify the mechanism of
action by whicha treatment works, but they are not necessaryto
determine the effectiveness of a treatment(e.g., the degree of
improvement in attentionand behavior in ADD=ADHD, and in
compari-son with stimulant drugs).
When considering how well validated com-mon medical and
psychiatric treatments actuallyare, it is enlightening to learn
that only 11% of2,711 cardiac medical treatment recommenda-tions
are based on multiple randomized con-trolled studies (Tricoci,
Allen, Kramer, Califf, &Smith, 2009) and only 41% are based on
evi-dence from a single randomized trial or nonran-domized studies,
whereas 48% are simply basedon ‘‘expert opinion’’ or only case
studies. As yet afurther example, the public is generally unawareof
the fact that studies (summarized in Kirsch,2010, and Moncrieff,
2009) of psychiatric medi-cation treatment of depression have
concludedthat they are only mildly (18%) more effectivethan a
placebo (and yet frequently associatedwith side effects and a
withdrawal syndrome).Despite these facts, insurance companies
acceptmedication treatment for depression and a largeproportion of
medical treatments as being wellestablished and effective. These
facts do notmean that more neurofeedback outcomes stu-dies are
desirable and needed, but it creates animportant perspective that
much of currentmedical and psychiatric treatment practice doesnot
rest on as much sound scientific evidenceas is commonly
assumed.
ADVERSE EFFECTS, SIDE EFFECTS, ANDHOME TRAINING
Mild side effects can sometimes occur duringneurofeedback
training. For example, occasion-ally someone may feel fatigued,
spacey, oranxious; experience a headache; have difficultyfalling
asleep; or feel agitated or irritable. Some-times such side effects
may occur because thetraining session is too long (Matthews,
2007,
2011; Ochs, 2007). Many of these feelings passwithin a short
time after a training session. Ifclients make their therapists
aware of suchfeelings, they can alter training protocols andusually
quickly eliminate such mild side effects.
Selecting a Qualified Practitioner
It is possible, however, for more significantnegative effects to
occur (Hammond & Kirk,2008; Hammond, Stockdale, Hoffman,
Ayres,& Nash et al., 2001; Todder, Levine, Dwolatzky,&
Kaplan, 2010), particularly if training is notbeing conducted or
supervised by a knowl-edgeable, certified (http://www.bcia.org)
pro-fessional who will individualize the training.
A‘‘one-size-fits-all’’ approach that is not tailoredto the
individual will undoubtedly pose a greaterrisk of either being
ineffective or of producing anadverse reaction. Due to the
heterogeneity inthe brainwave activity (e.g., Clarke et al.,2001;
Hammond, 2010b; Prichep et al.,1993) within broad diagnostic
categories (e.g.,ADD=ADHD, head injuries, depression, autism,or
obsessive-compulsive disorder) the treatmentrequires
individualization, and research isincreasingly showing that
different treatmentprotocols have differential effects
(e.g.,Angelakis et al., 2007; Egner & Gruzelier,2004;
Gevensleben et al., 2009a, 2009b;Gruzelier & Egner, 2005;
Hauri, 1981; Hauriet al., 1982; Heinrich et al., 2004; Ros et
al.,2010; Wrangler et al., 2010) on the brain.
Thus, it is emphasized once again thateveryone does not need the
same treatmentand that if training is not tailored to the
person,the risk is greater of it being ineffective or
veryinfrequently even detrimental. For instance,Lubar et al. (1981)
published a reversal double-blind controlled study with epilepsy
whichdocumented that problems with seizure dis-order could be
improved with neurofeedback,but they could also be made worse if
the wrongkind of training was done. Similarly, Lubar andShouse
(1976, 1977) documented that ADD=ADHD symptoms could improve but
also beworsened if inappropriate training was done.As yet another
example in the treatment ofADD=ADHD, it was found that when a
nonin-dividualized approach was used (Steiner,
320 D. C. HAMMOND
-
Sheldrick, Gotthelf, & Perrin, 2011) with oneelectrode
embedded in a helmet comparedwith computerized attention training,
onlymodest equivalent results were found. In con-trast, when
individualized neurofeedback wascompared with computerized
attention train-ing (Gevensleben et al., 2010; Gevenslebenet al.,
2009a, 2009b; Holtmann et al., 2009),neurofeedback was
significantly more effectivethan the skills training.
Therefore, seeking out a qualified and cer-tified professional
who will do a comprehen-sive assessment of brain function (e.g.,
with aQEEG or careful assessment of the raw EEGactivity) is deemed
to be vitally important. Ifthe practitioner indicates that they do
a ‘‘brainscan’’ or QEEG, it is important to determinewhether the
EEG data are actually beingstatistically compared to a normative
databaserather than simply being roughly measured.
If you are seeking help for a psychological,psychiatric, or
medical problem like those dis-cussed in this article, the ISNR
(Hammondet al., 2011) has recommended that you deter-mine that the
practitioner you select is not onlycertified but also licensed or
certified for inde-pendent practice in your state or province asa
mental health or health care professional.An increasing number of
unqualified andunlicensed persons are managing to
obtainneurofeedback equipment and seeking to basi-cally practice
psychology and medicine withouta license. It has unfortunately
become a ‘‘buyerbeware’’ marketplace.
In this regard, some individuals are nowrenting and leasing home
training equipment.It is strongly recommended that training
withequipment at home should be done onlyunder the regular
consultation and supervisionof a legitimately trained and certified
pro-fessional, and preferably home training shouldoccur only
following closely supervised trainingthat has taken place in the
office for a period oftime (Hammond et al., 2011). It is important
tocaution the public that if this is not done, somenegative effects
(and a higher probability ofineffective results) could occur from
such unsu-pervised self-training. It is important to remem-ber that
the impressive success documented in
most of the research on neurofeedback isbased on work conducted
by qualified profes-sionals, following individualized
assessment,and with training sessions that are supervisedby a
knowledgeable therapist rather than withunsupervised sessions
taking place in an officeor at home. Supervised training sessions
wherethe patient is coached have been found toproduce significantly
better outcomes thanunsupervised sessions (Hammond, 2000).
REFERRAL SOURCES
Readers may identify certified practitionerswho are doing
neurofeedback training byconsulting the website for the
BiofeedbackCertification International Alliance
(http://www.bcia.org) and by examining persons who arelicensed and
listed in the membership directoryfor ISNR (http://www.isnr.org).
In addition tothe references included in this article, the
ISNRwebsite also includes a comprehensive bibli-ography of outcome
literature on neurofeed-back, which is periodically updated.
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