258

NOVAAddress

grat

Notes From Clinical Practice: An MD’s Perspective on9 Years of Neurofeedback PracticeDoreen E. McMahon, MD

eurofeedback is a form of biofeedback in which electro- receive referrals and that benefit from neurofeedback in my

Nencephalogram (EEG) activity is made apparent to apatient, who is “persuaded” to alter that activity via rewardsand inhibitions that are manipulated by the EEG feedbacktherapist. The most popular forms of feedback presentation toa patient are via videos or simple video games. The operatingparameters of the chosen feedback are altered according toselected EEG frequencies. The closer the EEG activity comes tooptimal, the more the patient is rewarded by feedback thatruns well. When the EEG deviates from the desired objectives,the feedback runs poorly in several ways that inform the brainhow it has changed (eg, an increase in delta or theta causes thepicture on the computer screen to fog over, and an increase inbeta causes the sound volume to decrease). Conversely, as thepatient's EEGbecomesmore optimal, the video or game beginsto run better. Some neurofeedback systems also include atactile object that vibrates with greater intensity as the patientproduces more EEG in the desirable frequency range.Neurofeedback appeals to the innate desire to earn rewards,

and the brain's ability to detect liminal events and to relatethese changes to its own internal state. The brain's activity ismade obvious to itself just as one can monitor facial expres-sions in a mirror. Via trial and error, the brain is operantlyconditioned to manipulate feedback and change the relativequantity of EEG produced in various frequency bands.In a typical 30-minute session, a patient may receive up to2000 discrete data points about the function of his or herbrain. With repeated practice, the patient slips easily andnaturally into prescribed EEG patterns. It appears thatimproved brain functioning becomes self-reinforcing as thepatient applies their newly learned EEG patterns in theireveryday life and meets with positive consequences. At acertain point, usually in 40-60 sessions, the patient is able toreliably replicate the desired EEG without the use of neuro-feedback equipment. The neurofeedback-trained EEG istranslated into better-regulated brain states that are in turnreflected in improved brain functioning and patient symp-toms.2 The most frequent medical diagnoses for which I

1071-9091/13/$-see front matter & 2013 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.spen.2013.10.007

NeuroIntegrative Medicine, McLean, VA.reprint requests to Doreen E. McMahon, MD, NOVA NeuroInte-

ive Medicine, McLean, VA. E-mail: novaneuro@hotmail.com

practice are listed in Table 1.In the last few years, neurofeedback systems have been

developed that can train very slow or infra-low EEG frequen-cies down to 0.0001 Hz. It is thought that these frequenciescorrespond to ultradian cycles in the brain and thus representthe level of overall cortical excitability and activity of corticalnetworks. It is postulated that neurofeedback systems that traininfra-low EEG are training neuromodulator glial cells in thebrain Legarda et al1 and Kaiser.3 The advent of these systemshas made neurofeedback training easier from a clinical stand-point. The optimal reward frequency for nearly all patients is inthe infra-low region, and clinical results seem to happen evenmore reliably and quickly.Neurofeedback is not well recognized in the allopathic

medical community even though the American Academy ofPediatrics rates it as Level 1 “Best Support” Intervention forADHD.4 For instance, I am the only physician in theWashington, DC area, who uses neurofeedback as a majortool in their practice. There is also ongoing resistance inmedical insurance companies in recognizing neurofeedback asanything but “experimental” and therefore not covering underinsurance. In some instances, medical insurance companieshave been persuaded to reimburse patients for neurofeedbacksessions in lieu of other more drastic or expensive treatments.Obtaining “preauthorization” in writing from an insurer isimportant in this circumstance. Because a typical course oftherapy involves approximately 2 sessions of 45-60 minutesa week for 40-60 sessions, affordability can be an issue forprivate payment patients. Some patients use funds fromflexible health spending accounts that are administered bytheir employers.The push toward having physicians practice in the most

efficient manner also plays against neurofeedback. Not onlymust the neurofeedback practitioner take time to carefullyinteract with their patients to ascertain treatment efficacyand address their ongoing issues, but they should also beobserving, and optimally, running neurofeedback sessions. Asa routine patient interaction in a neurofeedback session takesapproximately 45-60 minutes, it is difficult to practicallyhandle more than approximately 10 patients a day. Someproviders use well-trained “extender” personnel to administer

Table 1 Common Diagnoses Referred for Treatment WithNeurofeedback

� Sleep disorders� Headache disorders, including migraines� Seizure disorders� Traumatic brain injury, including concussions� CVA� Autism spectrum disorders� Attention disorders, including ADD and ADHD� Tic disorders� Tourette syndrome� Chronic pain� Restless legs syndrome� Asthma� Gastrointestinal issues, includingmotility problems, irritablebowel syndrome, GERD, inflammatory bowel syndrome

� Premenstrual syndrome� Menopausal disorders� Fibromyalgia� Sensory integration disorders (including misophonia)� Fatigue/chronic fatigue syndrome� Anxiety� Mood disorders

Notes from clinical practice 259

some aspects of neurofeedback treatment. This practice modelmust be carefully managed by the supervising provider tomaintain high standards of care and patient satisfaction.Learning to administer neurofeedback involves a change

from usual neurologic and psychiatric practice. As neurofeed-back is based on functional status, a careful and thoroughhistory must be taken. Especially if physical findings would bepertinent to monitoring a patient's progress and well-being, acareful physical examination should be performed. A workingknowledge of functional neuroanatomy is essential in design-ing individualized training protocols. Some neurofeedbacktrainers provide algorithms to aid in the planning of a neuro-feedback program for each patient.5 The best preparation forlearning to administer neurofeedback is to get training from areputable provider. Once neurofeedback equipment isobtained, begin by practicing on oneself and volunteers whocan give reliable feedback on how neurofeedback isaffecting them.Actual neurotherapy uses EEG in a quantitative way that

most physicians, including neurologists, are unaccustomed.Usually only 1-2 channels of EEG in either a monopolar orbipolar montage are used. The EEG signal is Fourier trans-formed and quantified. In monopolar training, the patient isthen asked to produce more or less of various types of EEG atthe site of the active electrode(s) when compared with areferential electrode on a neutral nonscalp site. Bipolar traininginvolves asking the patient to make the EEG quantity (netamplitude) and coherence (phase) either more alike (inhibit-ing) ormore different (rewarding) between 2 equally importantelectrode positions. In other words, the patient is asked tomake the difference between the electrodes either smaller orlarger, thus acquiring a degree of control over the activity of thesites being recorded. The bipolarmontage has the advantage of

reinforcing coordination between connected electrode place-ments. Theoretically, this strengthens networks within thebrain. Although there are often obvious quantitative andqualitative changes in the EEG during neurofeedback, themain therapeutic effect seems to be in the realm of performingsmall corrections in EEG repeatedly. A weight-lifting analogywould be that the patient is asked to perform “reps” and notnecessarily to lift large amounts of weight. Moving theelectrode positions to various carefully selected 10-20 sites iseventually extended to get a well-rounded “work out.” Thepatientmay need coaching to reduce EMGor to relaxmentally.Environmental factors can affect neurofeedback efficacy.

Biomedical issues need to be identified and corrected asindicated by history, physical, and (lack of) response toneurofeedback. For instance, omega-3 fatty acid supplemen-tation is often desirable to facilitate the neuroanatomicalchanges that neurofeedback is theorized to induce. Repeatedcoaching to help patients maintain optimal health habits isusually necessary and may include sleep habits, diet, dietarysupplements, maintaining daily routines, and physical activity.A patient’s social support systemmay also play a vital role in

her or his response to neurofeedback. It is very helpful to havecalm and well-controlled primary social contacts whether theyare parents, siblings, spouses, coworkers, teachers, or friends.In fact, patients with behavioral issues should have an environ-ment that promotes positive and desirable behaviors. Thisoften involves getting other health and mental health profes-sionals involved in their care. For example, a child with aseizure disorder acquires improved control so that socialactivities become a high priority. This child may require socialskills training in addition to having ways to apply improvedskills successfully. Additionally, sometimes offering neurofeed-back to care givers and others providing support to patientscan provide a way for them to regulate their own stresses andissues. Through open and active communication with thepatient and those in their support structure, the neurofeedbackprovider can greatly facilitate a patient's progress in gainingcontrol over their symptoms.Medications must be closely monitored and adjusted in

someone receiving neurofeedback. As the brain becomes betterself-regulated, symptoms that reflect medication overdosingmay appear. For instance, a patient on a seizure medicationmay have an increase in lethargy and fatigue. This effect is notlimited tomedications that are generally considered to be brainspecific. For example, blood pressure medications mightbecome overly effective and symptoms of hypotension mightensue. Careful vigilance throughout the course of therapy isimportant. For many patients, decreasing or eliminatingmedications that have become redundant is a desirable goalof neurofeedback.Measurement of patient response to neurofeedback can be

challenging. Qualitative tracking of symptoms is easy and canbe formally reviewed with the patient at set intervals. Moreformal quantifying of symptoms can be performed via patientself-assessment or health provider–assisted techniques such ascustom-made symptom-tracking charts. There are also com-puterized symptom-tracking tools available. www.epilepsy.com has an online, user-friendly seizure-tracking application.

D.E. McMahon260

The EEG Institute of Woodland Hills, CA offers the EEGExpert online tool specifically for tracking symptoms forneurofeedback practitioners.The EEG Institute also offers a continuous performance test

known as the QIK TEST. This is a handheld device used toquantify certain aspects of signal recognition and responsetime. Similarly, the Test of Variables of Attention is acomputerized test that more exhaustively measures signalrecognition and can be used to establish the diagnosis of anattention issue. Testing can be performed before neurofeed-back is undertaken and then repeated at intervals to helpdocument and guide therapy. Some patients seem to needreassurance of their progress with neurotherapy by seeingquantitative measurements. Clinical research protocols withneurofeedback would require measures such as these.Neurofeedback offers many rewards to its practitioners. As

many of the patients who seek neurofeedback treatmenthave exhausted allopathic medical treatments, they havecomplicated and intransigent issues. Great satisfaction can bederived from ushering these patients toward better symptomcontrol. Often the mental health toll of medical problems can

be markedly eased. Hopeless and difficult patients becomemore optimistic and pleasant. Unexpected benefits can berealized. For instance, control of chronic conditions likeasthma, diabetes, and inflammatory diseases can be markedlyimproved. “Ripple effects” are often seen because of a patientshowing improved functionality when family and other socialsystems around the patient begin to run more smoothly.

References1. Legarda Stells B, McMahon Doreen, Othmer Siegfried, et al: Clinical

neurofeedback: Case studies, proposed mechanism, and implications forpediatric neurology practice. J Child Neurol 26:1045-1051, 2011

2. Othmer Siegfried, Othmer Sue, Legarda Stella B: Clinical neurofeedback:training brain behavior. Treatment strategies. Pediatr Neurol Psychiatry2:67-73, 2011

3. Kaiser, David. Infra-low frequencies and ultradian rhythms, April 10, 2013.4. American Academy of Pediatrics. www.aap.org/en-us/advocacy-and-po

licy/aap-health-initiatives/Mental-Health/Documents/CRPsychosocialinterventions.pdf.

5. Othmer Sue: Optimizing Assessment and Training With Infra-LowFrequency HD and Alpha-Theta Neurofeedback. Protocol guide forneurofeedback practitioners. 4th Edition: July 2013. EEG Instititue.