Application Bio- and Neurofeedback Clinical use and use in peak …human.kyst.com.tw/upload/Workshop Taipei 26 - BFK NFK.pdf · 2015. 6. 4. · Mind Media BV - Vision 3 Biofeedback,

Application Bio- and Neurofeedback –Clinical use and use in peak performance

Tim Keren

Mind Media BV - Mission

To empower researchers, clinicians and health professional with innovative systems for measuring, training and optimizing human neurophysiology, health and performance

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Biofeedback, Neurofeedback, Stress and Psychophysiological monitoring

Mind Media BV - Vision3


Focus on Health, not on Disease.

(mens sana in copere sano)

Biofeedback

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Development of Biofeedback

• Instrumental conditioning of the autonomic nervous system (1967-1969 Miller)

• Psychophysiology (Shapira 1965)

• 1969 – Biofeedback Research Society

• 1988 – Association of Applied Psychophysiology and Biofeedback –www.aapb.org

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http://www.aapb.org/

Biofeedback is a technique that enables an individual to learn how to change

physiological activity for the purposes of improving health and performance

(Gilbert & Moss, 2003; Schwartz & Andrasik, 2003)

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Physiological activity7

• Muscle Tension – ElektroMyoGram/EMG

• Heart Rate – EKG/Pulse

• Respiration (rate)

• Sweating – Skin Conductance

• Peripheral Temperature

• Brain Waves – EEG

• And more: Force, HEG, Oxygen, etc.


Biofeedback8

• Important:

– Motivated Client

– High quality instruments thatreliably measure what you would like to measure (validity)

– Good therapist.


Active involvement of client = Training!

Biofeedback Instruments

Biofeedback instruments are used to visualize physiological processes, increase awareness of them and to gain voluntary control over

body and mind.

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Learning principle:• Operant conditioning: creating new habits by (positive) reinforcement (Skinner)


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Set-up 12


Therapist Client

General indications for Biofeedback

• Showing psychophysiological interaction and increasing knowledge of biopsychosocial model

• Stressmanagement/relaxation

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Specific indications for Biofeedback

• Tension Headache, Migraine• Chronic pain, back pain• Essential hypertension • ADHD• Anxiety• Insomnia • PTSD• Performance enhancement – sports/management • Constipation• Substance abuse – drugs/alcohol• Rehabilitation• Incontinence• …….

“Evidence-Based Practic in Biofeedback and Neurofeedback”. Carolyn Yucha Ph.D; Doil Montgomery, Ph. D. American Association of Apllied Psychophysiology & Biofeedback (AAPB. www.aapb.org)”

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http://www.aapb.org/

Goals of Biofeedback

• Improvement of perception of physiological processes (Interoception)

• Improvement of controlling these processes and improvement of believe of control.

• Identification of factors that influence physiological processes

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Steps in Biofeedback

• Awareness of physiological processes

• Control – changing Behaviour

• Generalization - Transfer to daily life.

Generally about 10 sessions in Biofeedback/30-40 in Neurofeedback

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Stress - Biopsychosocial model17

Stress Stress

Stress

WHO 1948: “Health is a state of complete

physical, mental and social well-being and

not merely the absence of disease or infirmity”


Environment18


Stress and our brain19

Stress/Thoughts can lead to physical/physiologicaleffects that can be similar to physical excercise

(body/mind interaction)

Psychosomatic Romans about 2000 years ago “Mens sana in corpero sano” – A healthy mind in a healthy body.


(Autonomic) Nervous System 20

The nervous system

Central nervous system (CNS)

Brain Spinal cord

Peripheral nervous system (PNS)

Somatic nervous system

Controls voluntary movement

Peripheral nervous system

Controls involuntary responses

Sympathic

Fight or flight

Parasympathic

Rest and digest


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Sympathetic (Gas – Fight/Flight) Parasympathetic (Brake - Relaxation)


Stress - Survival mechanism22


Chronic Stress 23

Effect stress fully normal, chronic stress can lead to disbalances which in its turn can lead to different (or have effect on) conditions like chronic tension

headache, anxiety, hypertension, etc.


Stress related parameters

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What happens in stress?25

• Muscle Tension

• Skin Conductance

• Heart Rate

• Temperature

• Respiration rate


What happens in stress?26

• Muscle Tension

• Skin Conductance

• Heart Rate

• Temperature

• Respiration rate


A core principle that Biofeedback uses is physiological activation versus relaxation

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Activation versus relaxation


(Ab-)normal stress responses28

Normal stress response

Abnormal stress response


Stress profiling

• Set-up

– Baseline (reading in silence)

– Stressors

• Alphabet backwards

• Think of as much animals with an “R”

• Deduct 7 from 1081, etc..

– Relaxation

• Offers valuable information for client and therapist (or athlete!)

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Performance enhancement - Sports

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Performance enhancement - Sports

Peak performance does not depend on physical ability alone.

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Where physiology meet psychology

• Difference can be made by mental focus of an athlete, especially under high pressure.

• Athletes have to be able to relax and control their mental state.

Psychology Physiology

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Performance and Bio- Neurofeedback

Biofeedback and Neurofeedback can be helpful for athletes to

detect shift in mental state while resting, practicing, or participating in high stress

and competitive environment.

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Performance and Bio- Neurofeedback

• Getting insight in psychophysiology (biofeedback) in order to:

– Improve emotional self-regulation (biofeedback). More contol over energy levels.

– Improve focus (bio- and neurofeedback)

• Can help facilitate in recovery from injury.

Use and training techniques

• Examples

– Complementary to existing (relaxaton) techniques

– Visualization: reduce stress, sustain focus by directing attention of the athlete to a specific aspect of the performance.

– Simulators: replicate physiological sensations and control them, learning to better anticipate

– Insights in physiology before, during and after performance

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Use and training techniques36


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Training Mind-Body functions

Demo measurement

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Cases

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Case Headache40

• Intake

– Headaches since 1 year, originated from stressfull period.

– Less stress is less complaints, symptoms never completely gone.


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Skin Conductance

Temperature

Breathing

Heart rate

Left shoulder

Right shoulder


42 Left Trapezius1,9 uV

Frontalis –forehead 2,1 uV

Right Trapezius2.2 uV


Case Headache43

• Results– EMG and hand temperature go well– Skin Conductance high and reactive– Breathing rate high (18 times a minute)– Too little interaction between heart rate and

breathing rate

• Client– Also thinks muscle tension is not a problem and

recognizes warm (sweaty) hands– Skin conductance: always busy, sees and hears

everything– Didn’t know about interaction breathing/heart rate


Case Headache44

• Protocol– Headache probably not related to muscle tension.

High skin conductance remarkable. Client continuously reacting which can lead to overload, which results in headache

– Idea to try biofeedback to lower skin conductance and normalize breathing

• Home work– Slower breathing

– Meditation – bodyscan


Case Headache45

• Session 2

– Home work done in car and at home, could not do it a work

– Bodyscan very hard

• New measurement

– With breathing based on feeling

– SC little less and little less reactive


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Skin Conductance

Temperature

Breathing

Heart rate

Left shoulder

Right shoulder


Case Headache47

• Training

– Puzzle: stops when skin

conductance rises

– Bargraph: moves too much


Case Headache48

• Training

– Bargraph removed:

Lowering SC, still quite reactive

– Slow breathing at same time


Case Headache49

• Results

– Learned to control and lower skin conductance within 4 session

– Takes more rest, especially when too many thing are going on

– Strong reduction headache to almost none

– Last appointment cancelled due to absence of complaints


Case Fatigue 50

• Intake

– Mrs B, 46 years old

– Fatigued, agitated and emotionally unstable

– Feeling gest worse at situations she does not feel at ease, feeling of unwelcomeness and no being accepted


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Skin Conductance

Temperature

Breathing

Heart rate

Left shoulder

Right shoulder


Case Fatigue52

• Results

– Fast and shallow breathing

– Cold hands with temperature decreasing during the test.

– Unconcious tensing shoulder.

– Cold hands may indicate that client approaches the world with suspision, which is indeed the case. (insecurity, anxious). Shallow breathing may be explained by this as well (pattern associated with anxiety)


Case Fatigue53

• Protocol– Breathing training with pacer

– Home excercises.

• Results– Noticed that other accepted her, being herself.

– Comfortable in groups

– Another job, which suited better

– After a while fatigue diminished

– Last stress stress warm hand and normal responses


Case Sleeping disorder #254

• Intake

– Woman, 38 years, mother of 3, volunteer at school

– Sleeping problems, wakes up regularly, since 15th

– Other problems: tense, especially in the evening. Feels unsafe at times. Legs and arms painful during sleep.

– Since 15th year medication; feels like this helps, but very tired in the morning, more and more concentration problems which could be side effect

– Stopped with medication since a week, tried to stop several times


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Skin Conductance

Temperature

Breathing

Heart rate

Left shoulder

Right shoulder



• Results

– Fast breathing with sighing

– Reactive skin conductance without relaxation

– Temperature drops

– Shoulders helping during breathing excercise

– Client want to learn to be less alert, doesn’t know how. Wants to be there any time for her children

– Temperature drops: fits feeling unsafe

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• Protocol

– Doesn’t like slow breathing

– Advice:

• Sleep diary

• Temperature training, create feeling of being safe



• Training

– Lowering SkinConductance and raising temperature by visualizing lying on a warm beach

• Homework

– Hand thermometer

– Visualisation


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Skin Conductance

Temperature

Breathing

Heart rate

Left shoulder

Right shoulder



• Results

– Learned to lower skin Conductance and warm hand, muscles relax as well.

– Sleeping improved, deeper sleep, less waking up and felt more rested


Case High Blood Pressure61

• Intake

– 47 old woman, high blood pressure since first pregnancy 13 years ago.

– Medicine: beta blocker.

– Self reported BP 85-95 systolic and 135-150 systolic

– Busy job (coach) but able to relax through Meditation.

– Personality: activ, enthusiastic! Motivated to work on her health and to try to lower blood pressure!


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• Assesment

– Biofeedback measurement in rest (reading magazin), 3 stressors and 3 relaxations.


Case High Blood Pressure

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Skin Conductance

Temperature

Breathing

Heart rate

Left shoulder

Right shoulder


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Baseline Stressor Relaxation

• Assesment first session

– No slower breathing during relaxation, HRV drops.



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• Second session - training

– Paced breathing 7; 6,5 and 6 times for 3 minutes


Skin Conductance

Temperature

Breathing

Heart rate


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• Second session


Pulse

Breathing

Heart rate


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• Second session

– Heart skips beat: client doesn’t feel or know this. Has been extensively tested, skipping beat harmless but taken in to consideration.

– Temperature drops

– Conclusion: pacer not best way, better to breath based on feeling. Client comes with the idea to practice this while walking her dog.



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• Third session

– Breathing on feeling, 6 times a minute.


Skin Conductance

Temperature

Breathing

Heart rate


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• Results

– Perfect stress profile

– Now practices 3 times a day during walk with dog

– Reduction in medication, discussing with physician to lower even more.

– Lower blood plessure

– Feels more vital and can sleep better



Case Hyperventilation70

• Intake

– 37 year old woman

– Hyerventilation

• Assesment stress test


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Skin Conductance

Temperature

Breathing


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• Results stress test

– Breathing rate baseline 16 when not paying attention to breathing

– Breath rate relax: 6, during awareness of breathing

– Pacer breathing: drop in temperature, increase in skin conductance.

– Breathing pacer not the way

Case Hyperventilation


Case Hyperventilation73

• Training protocol

– Relaxed breathing while being measured

– Homework

– Awareness of breathing by using Resperate

– Tone says when to breath in and breath out

• Results– Within 5 session less anxious, less frequent and

intense hyperventilation episodes


Case Sleeping disorder74

• Intake

– Male, 31 years, teacher

– Since 4 month sleeping issues, sleeping in after 1,5hours and wakes up during the night

– Low energy, headache, feeling exhausted. Sleeps during weekend to recover.

– Cause is combination work and study less free time. Feel like being active all the time. Tries not to check mails in the evening and not work when at home


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Skin Conductance

Temperature

Breathing

Heart rate

Left shoulder

Right shoulder



• Results

– Fast breathing

– No recovery after stressor (skin conductance)

– High rise in heart rate with stressor

– Tense shoulders, especially during stressors



• Protocol

– Lower Skin Conductance

– Practice slow breathing

– Awareness muscle tension

– Home work

• Mini breaks during the day

• Apps slow breathing/Resperate

• PIP skin conductance



• Results

– After about 8 session increase sleep efficiency to 75-80% . Client already satisfied with this

– Less tense, will keep on using homework to improve even more.


Neurofeedback

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Neurofeedback is a speciality field within Biofeedback where the goal is to training

people to gain control over electro-physiological activity in the human brain (EEG

– ElectroEncephalogram)

(Gilbert & Moss, 2003; Schwartz & Andrasik, 2003)

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Development of EEG/Neurofeedback81

- First EEG – Hans Berger 1929

-Digital EEG 1960

-QEEG 1960-1970 ULCA Brain Research Institute (Ross Adey).

-Neurofeedback 1960’s (Joe Kamiya, Barry Sterman)


Neurofeedback applications

• #1: ADHD, very well investigated

• Well investigated

– Epilepsy

– Sleep disorder/insomnia

• Experimental

– Traumatic brain injury

– Autism

• Peak Performance (John Gruzelier)

• Improvement attention and memory

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EEG - Neurofeedback83


EEG – physiological basis84


EEG Physiological basis85






Addition of electrical activity of billions of pyramid cells

Locations – Ten20 system88


Neurofeedback training approaches

- Frequency band training

* Standard protocol (Cz, C3, C4)

* QEEG guided Neurofeedback

- Z-score training

- Slow Cortical Potentials neurofeedback

- HEG neurofeedback

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Neurofeedback sessions

• 30/40 session 1-2 times a week

– Often combined with BFB to reduce # sessions

– Different phases:

• Learning/Automisation;– 1-10 sessions; client feels tired in beginning, after around 10

sessions getting feeling of control and keeping the desired state

• Stabilising: – 11-20: learned condition is stabilised and can be controlled for

longer periods. Often more feeling of focus. Often feeling ofbteer sleeps, faster recovery.

• Performance enhacement phase– 21-30: Increasing learned control even more.

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Therapist screen91


Client screen92


Client screen93


Client screen94


Client screen95


Client screen96


Neurofeedback session

Duration video: 3 minutes

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Spontaneous EEG98


Beta: 13 – 30 Hz

Alpha: 8-12 Hz

Theta: 4-8 Hz

Delta: 1-4 Hz

Mental awareness

Cerebral activity

Neurofeedback –Frequency bands99


Neurofeedback –Frequency amplitudes100


Theta (4-8 Hz)101


• Theta: distractability/inattention/daydreaming

• ADHD/Learning disabilities: reduction of Theta

• Used in Theta/Beta ratio reduction theta and increase beta reduction of Theta/Beta ratio.

SMR (12-15 Hz) 102


• SMR: Sensomothoric Rhytm, mental alertness, physical relaxation.

• ADHD: increase

• Sensomotoric cortex (Cz, C3, C4)

(Low) Beta (13-21 Hz) 103


• Low Beta: attentive wakefullness

• ADHD: increase. Used in Theta/Beta ratio reduction theta and increase beta reduction of Theta/Beta ratio.

High Beta (21-35 Hz) 104


• High Beta: very active, busy head, impulsiveness

• ADHD: decrease

Z-score training105

• Training to normalize (0 standard deviations)

– EEG data is compared while measuring with database

– Neuroguide database

0Biofeedback, Neurofeedback, Stress and Psychophysiological monitoring

Z-score training106

• Screenshot nieuwe software


Slow cortical potentials (SCP)107

SCP Frequency bandsBiofeedback, Neurofeedback, Stress and Psychophysiological monitoring



• Phenomenons in the EEG that last for a couple of hundred milliseconds up to several seconds. In other words slower than regular EEG

• Show the cortical activation

• Distinction between positive and negative potentials

• Close relationship SCP to attention, memory, reaction time Negative SCP Positive SCP



• Phenomenons in the EEG that last for a couple of hundred milliseconds up to several seconds. In other words slower than regular EEG

• Show the cortical activation

• Distinction between positive and negative potentials

• Close relationship SCP to attention, memory, reaction time Negative SCP Positive SCP

SCP training110


• Set-up:

– SCP Sensor (TP connection)

– Ground TP sensor

– Sintered Electrodes + Accesories

– Red on Cz, 2x Black on A1/A2, ground anywhere

SCP training111


• Protocol

– Baseline (1-2 sec)

– Negativity/Positivity at random (8 second)

– Reward/No reward (2 sec)

– +- 50 times/trials (1 run)

– Several runs possible

SCP training112


• Goal: Voluntary Negativity and Positivity

Therapist screen SCP113


Client screens114


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• Regional Cerebral Blood Flow (rCBF):

– Measurement of relative cortical blood flow

– Experimental

HEG Neurofeedback


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HEG Neurofeedback


QEEG117

QEEG is Quantified EEG. Nuwer, 1997: The mathematical processing of digitally recorded EEG in order to highlight specific waveform components, transform the EEG into a format or domain that provides relevant information, or associate numerical results with the EEG data for subsequent review or comparison.” (Nuwer, 1997)

One of the simplest forms is spectral analysis 1 channel quantified EEG


QEEG118

- Often linked to 21 channel full cap EEG.

- Clinically: comparing (standard deviations) to a QEEG database like:

• Neuroguide• Loreta

-Prognostic tool.


Demo measurement

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Cases ADHD

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Case ADHD #1

• Intake

– 56 years, male

– Recently diagnosed with ADHD

– Problem with concentration, busy head, problem with planning, forgetfullness.

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• QEEG screening (21 channels)

– High beta relatively high associated with busy head

– Protocol Cz downtraining 20-24 Hz

– Start with HRV training

Case ADHD #1

Case ADHD #1

• After 8 sessions– Self-reported increased focus

– Better organized, less chaotic

• EEG data shows reduction Beta amplitude (20-24)

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Case ADHD #2

• Intake

– Male 58

– Presenting diagnosis ADD

– Planning and execution issues

– Distractible

– Task completion issue

– Also:

• Episodic migraine

• Eleveated blood pressure 140-160/80-100

• Generalized anxiety disorder

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Case ADHD #2

• Assesment

– Excess 9-10 Hz in

central, temporal, parietal

• Protocol

– 2 channel z-score training

• Fz and Pz (13 sessions)

• F3 and F4 (4 sessions)

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Case ADHD #2

• Improvements– Better focus

– Able to complete tasks

– Faster responses to cognitive challeng

– Less volatile emotional responses

– Fewer migraine episoded and reduced intensitiy.

• Unchanged– Blood Pressure

– Anxiety

– Continued migraine episodes

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Case ADHD #2

• Extra training (5 sessions)

– HRV training office

– Home (Resperate for Blood pressure control)

• Improvements

– Reduced blood pressure 10-15 points systolic and diastolic

– Reduced migraine

– Mess anxiety, less need for control

– Memory and cognitive improvement

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Case ADHD #2

• Assesment

– Reduction 9-10 Hz

– Also elimination of 18-19 Hz in parietal

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Case: Elle – 10 year old girl

• Diagnosed with (DSM-IV):

– ADHD

• Main symptoms:

– Easily distracted

– Hard to keep her attention for some time

– Moves around

– Stares

– Dreamy

– School problems: mainly inability to automate:

math, reading, days of week, tell time

• Main impression:

– Sweet, cheerful and energetic child

– Passionate about animals, can be completely wrapped up into this subject

– Appears to be dreamy, in her own world, but makes adequate contact

– Seems to need some time to process information coming from her environment

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Intake: QEEG130


– QEEG:

• Over aroused: excess of high beta activity (20-30 Hz), mainly in the parietal cortex area.

• Connection with neuropsychology: parietal cortex is involved with automate processes.

– Questionnaire:

• Mother reports a lot of ADD related distractibility and attention problems. Also learning problems.

Intake: QEEG131


Training

– Protocol:

• Inhibit fast brain waves: 20-30 Hz

• Locations: P3 and P4

– Feedback:

• Watching movie (Planet Earth)

• Each time the high beta amplitude stays below threshold, the video continues playing

– Total amount of sessions:

• 40 session (twice a week)

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Results

– Subjective results: • Parents and Elle are very enthusiastic about the results

of the training

• Elle’s concentration is improved, better able to keep her attention

• Less daydreaming

• Better school results, especially math

• Elle is in a better mood

• Elle makes better social contact, seems to got out of her ‘own world’ and makes a better connection with the world around her

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Result - QEEG134


Before: After:

The EEG is more normalized. Reduction of high beta around the parietal cortex.

Case: Elle – 10 year old girl135


Results - Questionairre

– Questionnaire: Strong reduction of reported problems

ADD Distractibility Inattention

Learning problem: linguisticsLearning problem: Reading

Memory problems: visual/reading Notion of social information

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Case ADHD #3

• Intake

– Gregoire, 8 years old

– Happy, spontaneous. Parents: inattentive, forgetfullness, losing things.

• Protocol/Results

– Theta/Beta Ratio training Cz, which was elevated.

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Case ADHD #3138



– First 4 sessions Videos/Animation/Games

– Next sessions more boring animations which was a challenge for Gregory

– 8 Session very hard, motivation talk with Gregory and parents. Rewards after session when doing well.

– After 10th session drop in Theta/Beta ratio

Case ADHD #3139


5

10

15

5

10

15

Session 1

Session 10

Case ADHD #3140



– After 27 sessions 40% drop in Theta/Beta ratio

– Parents/Teacher: better concentration, less impulsive, better social behavior, less chaotic, more independent at home.

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Thank you for your attention!


Brain waves142


Frequency Hz Function (positive and negativ)

Delta 1 – 4 Deep sleepUnconciousnes, TBI, Coma

Theta 4 – 8 Drowsiness; deep relaxation, creativitivity, spontanityDistractible, Inattention, Daydreaming, ADHS, Depression, Anxiety

Alpha 8 – 12 Relax awake, internal restDaydreams, Depression, ADHD

SMR 12– 15 Supressed by motoric activity, increase better sensoric input and cognitive integration (metally awake and physically relax)

Beta

High Beta

13– 21

21 – 38

Attentive wakefullnes; ADHD, Sleep and learning disorders

Cognitive workingTense, Hypervigilant, Anxiety

Gamma 38 – 42 „Binding“ – Integration of Neuronen connection with sensoric and cognitive processes, problem solving. Too little: learning deficit, mental deficits

Case ADHD #2

• Intake

– Concentration issues

– Busy head

• Protocol

– Theta and High Beta down (Fz and Pz)

• Sample session

– Theta en High beta reduction

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Case ADHD #3144


Other applications NFB

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Epilepsy

• Review articles Sterman (2000)

– 1972 – 1996

– 18 peer reviewed studies

– 82% experienced >30% reduction

– EEG changes after neurofeedback

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Sleep

• First publication 1970 Sterman

– Longer periods undisturbed sleep (cats)

– Increased number of sleep spindles

– First “side-effect” most often reported by people submitted to SMR neurofeedback

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Documents

Application Bio- and Neurofeedback Clinical use and use in peak …human.kyst.com.tw/upload/Workshop Taipei 26 - BFK NFK.pdf · 2015. 6. 4. · Mind Media BV - Vision 3 Biofeedback,