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What is Neurofeedback: An Update

Article in Journal of Neurotherapy · October 2011 DOI: 10.1080/10874208.2011.623090

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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 update and overview of the field of neurofeedback (EEG ). The process of assessment and neurofeedback training is explained. Then, areas in which neurofeedback is being used as 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 process and bind together information from different areas of the brain. Beta brainwaves In the late 1960s and 1970s it was learned that are small, relatively fast brainwaves (above it was possible to recondition and retrain 13–30 Hz) associated with a state of mental, brainwave patterns (Kamiya, 2011; Sterman, intellectual activity and outwardly focused LoPresti, & Fairchild, 2010). Some of this work concentration. This is basically a ‘‘bright-eyed, began with training to increase alpha brainwave bushy-tailed’’ state of alertness. Activity in the activity for the purpose of increasing relaxation, lower end of this frequency band (e.g., the whereas other work originating at University of sensorimotor rhythm, or SMR) is associated California, Los Angeles focused first on animal with relaxed attentiveness. Alpha brainwaves and then human research on assisting uncon- (8–12 Hz) are slower and larger. They are trolled . This brainwave training is generally associated with a state of relaxation. called EEG biofeedback or neurofeedback. Activity in the lower half of this range represents Prior to a more detailed discussion, the author to a considerable degree the brain shifting into will review some preliminary information about an idling gear, relaxed and a bit disengaged, brainwave activity. Brainwaves occur at various waiting to respond when needed. If people frequencies. Some are fast, and some are quite merely close their eyes and begin picturing slow. The classic names of these EEG bands are something peaceful, in less than half a minute delta, theta, alpha, beta, and gamma. They are there begins to be an increase in alpha brain- measured in cycles per second or hertz (Hz). waves. These brainwaves are especially large The following definitions, although lacking in in the back third of the head. Theta (4–8 Hz) scientific rigor, will provide the general reader activity generally represents a more daydream- with some conception of the activity associated like, rather spacey state of mind that is associa- with different frequency bands. ted with mental inefficiency. At very slow Gamma brainwaves are very fast EEG levels, theta brainwave activity is a very relaxed activity above 30 Hz. Although further research state, representing the twilight zone between is required on these frequencies, we know that waking and . Delta brainwaves (.5– some of this activity is associated with intensely 3.5 Hz) are very slow, high-amplitude (magni- focused attention and in assisting the brain to 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]

305 306 D. C. HAMMOND in deep, restorative sleep. In general, different problems present, and not simply ADD=ADHD levels of awareness are associated with domi- alone. Therefore, appropriate assessment is nant brainwave states. important prior to beginning to do neurofeed- It should be noted, however, that each of us back to determine what EEG frequencies are always has some degree of each of these various excessive or deficient, or if there are problems brainwave frequencies present in different parts in processing speed or coherence, and in what of our brain. Delta brainwaves will also occur, parts of the brain. Proper assessment allows the for instance, when areas of the brain go ‘‘off treatment to be individualized and tailored to line’’ to take up nourishment, and delta is also the patient. associated with learning disabilities. If someone Neurofeedback training is EEG (brainwave) is becoming drowsy, there are more delta and biofeedback. During typical training, one or slower theta brainwaves creeping in, and if more electrodes are placed on the scalp and people are somewhat inattentive to external one or two are usually put on the earlobes. things and their minds are wandering, there is Then, high-tech electronic equipment provides more theta present. If someone is exceptionally real-time, instantaneous feedback (usually audi- anxious and tense, an excessively high fre- tory and visual) about your brainwave activity. quency of beta brainwaves may be present in The electrodes allow us to measure the electri- different parts of the brain, but in other cases cal patterns coming from the brain—much like this may be associated with an excess of inef- a physician listens to your heart from the surface ficient alpha activity in frontal areas that are of your skin. No electrical current is put into associated with emotional control. Persons your brain. Your brain’s electrical activity is with Attention-Deficit=Hyperactivity Disorder relayed to the computer and recorded. (ADD, ADHD), head injuries, stroke, epilepsy, Ordinarily, patients cannot reliably influ- developmental disabilities, and often chronic ence their brainwave patterns because they lack fatigue syndrome and fibromyalgia tend to have awareness of them. However, when they can excessive slow waves (usually theta and some- see their brainwaves on a computer screen a times excess alpha) present. When an excessive few thousandths of a second after they occur, amount of slow waves are present in the execu- it gives them the ability to influence and gradu- tive (frontal) parts of the brain, it becomes ally change them. The mechanism of action is difficult to control attention, behavior, and=or generally considered to be operant condition- emotions. Such persons generally have prob- ing. We are literally reconditioning and retrain- lems with concentration, memory, controlling ing the brain. At first, the changes are their impulses and moods, or hyperactivity. short-lived, but the changes gradually become They have problems focusing and exhibit more enduring. With continuing feedback, diminished intellectual efficiency. coaching, and practice, healthier brainwave As the reader can see, there can be com- patterns can usually be retrained in most plexity involved in how the brain is operating. people. As is reviewed later in the article, most Research (Hammond, 2010b) has found that research suggests that significant improvements there is heterogeneity in the EEG patterns seem to occur 75 to 80% of the time. The pro- associated with different diagnostic conditions cess is a little like exercising or doing physical such as ADD=ADHD, anxiety, or obsessive- therapy with the brain, enhancing cognitive compulsive disorder. For example, scientific flexibility and control. Thus, whether symptoms research has identified a minimum of three stem from ADD=ADHD, a learning disability, a major subtypes of ADD=ADHD, none of which stroke, head injury, deficits following neurosur- can be diagnosed from only observing the gery, uncontrolled epilepsy, cognitive dysfunc- person’s behavior and each of which requires tion associated with aging, depression, a different treatment protocol. The picture anxiety, obsessive-compulsive disorder, , can become even more complicated by the or other brain-related conditions, neurofeed- fact that sometimes there are other comorbid back training offers additional opportunities WHAT IS NEUROFEEDBACK 307 for rehabilitation through directly retraining the to doing neurofeedback training, legitimate electrical activity patterns in the brain. The licensed clinicians will want to ask questions exciting thing is that even when a problem is about the clinical history of the client or biological in nature, there is now another treat- patient. Occasionally in more serious cases ment alternative to simply relying on medi- they may suggest doing neuropsychological or cation. Neurofeedback is also being used psychological testing. Competent clinicians increasingly to facilitate peak performance in (Hammond et al., 2011) will also do a careful ‘‘normal’’ individuals, executives, and athletes. assessment and examine brainwave patterns. More than a decade ago, Frank H. Duffy, Some practitioners may do an assessment by MD, a professor and pediatric neurologist at placing one or two electrodes on the scalp Harvard Medical School, stated in the journal and measuring brainwave patterns in a limited Clinical that scholarly number of areas. Other clinicians perform a literature had already suggested that neurofeed- more comprehensive evaluation by doing a back ‘‘should play a major therapeutic role in quantitative electroencephalogram (QEEG) many difficult areas. In my opinion, if any medi- brain map where 19 or more electrodes are cation had demonstrated such a wide spectrum placed on the scalp. of efficacy it would be universally accepted and A QEEG is an assessment tool to objectively widely used’’ (Duffy, 2000, p. v). ‘‘It is a field to and scientifically evaluate a person’s brainwave be taken seriously by all’’ (p. vii). Considerable function. The procedure usually takes about 60 research has been published since that time. to 75 min and consists of placing a snug cap on This article, written to educate both profes- the head, which contains small electrodes to sionals and the general public about the field measure the electrical activity coming from of neurofeedback, provides an overview of this the brain. This is done while the client is resting literature without seeking to cite every publi- quietly with his or her eyes closed, eyes open, cation with all their methodological details. and sometimes during a task. Afterward, a careful process is used to remove as completely as possible artifacts that occurred when the ASSESSMENT PRIOR TO eyes moved or blinked, from body movement, NEUROFEEDBACK TRAINING or tension in the jaw, neck, or forehead. The Some people wish that they could simply buy brainwave data that were gathered are then their own neurofeedback equipment and train statistically compared to a sophisticated and themselves or their children. As is explained large normative database that provides scien- later in this article, this is fraught with potential tifically objective information on how the brain for harm or ineffectiveness. To be done prop- should be functioning at the client’s age. This erly, neurofeedback needs to be conducted assessment procedure allows the professional or supervised by someone with specialized to then determine in a scientific, objective expertise concerning brain function and who manner whether a client’s brainwave patterns is knowledgeable about much more than sim- are significantly different from normal, and if ply how to operate equipment and software. so, how and where they differ. As just mentioned, for training to be successful Since the 1970s and 1980s there has been and side effects avoided, it is vitally important a great deal of research with QEEG for a wide for an assessment to be performed and the range of problems. Abundant evidence, sum- training to be individualized to the distinctive marized in Thatcher (2010), has verified the brainwave patterns and symptoms of each per- reliability of QEEG evaluation, and hundreds son. Everyone does not need the same training of scientific studies have been published using at the same locations, and research has shown QEEG evaluations. These studies have found that a person’s brainwave patterns simply the QEEG to have documented ability to aid cannot be distinguished by only observing the in the evaluation of conditions such as mild person’s behavioral symptoms. Therefore, prior traumatic brain injury (TBI; and sports-related 308 D. C. HAMMOND concussions), ADD=ADHD, learning disabilities, brainwaves in specific areas of the brain, depression, obsessive-compulsive disorder, whereas other individuals need training to anxiety, panic disorder, drug abuse, autism, decrease the speed of and amplitude of their and a variety of other conditions (including brainwaves. Commonly initial improvements schizophrenia, stroke, epilepsy, and dementia; begin to be noticed within the first five to 10 e.g., Alper, Prichep, Kowalik, Rosenthal, & John, sessions. Length of treatment may only be 15 1998; Amen et al., 2011; Barry, Clarke, to 20 sessions for anxiety or , but with Johnstone, McCarthy, & Selikowitz, 2009; other conditions such as ADD=ADHD or learn- Clarke, Barry, McCarthy, & Selikowitz, 2001; ing disabilities it will more often involve 30 to Clarke et al., 2007; Harris et al., 2001; Hoffman 50 sessions, depending on the severity of the et al., 1999; Hughes & John, 1999; Newton problem. Each session usually lasts about 20 et al., 2004; Thatcher, 2010; Thatcher et al., to 25 min once equipment is attached. In treat- 1999). QEEG has even been able to predict ing very complex conditions or when multiple treatment outcomes from interventions with disorders or diagnoses are present, a clinician conditions such as ADD=ADHD (Suffin & cannot always stipulate in advance how many Emory, 1995), and alcoholism and drug abuse treatment sessions may be required. (Bauer, 1993, 2001; Prichep, Alper, Kowalik, John, et al., 1996; Prichep, Alper, Kowalik, & SPECIALIZED TYPES OF Rosenthal, 1996; Winterer et al., 1998). The NEUROFEEDBACK American Psychological Association has also endorsed QEEG as being within the scope of There are also several innovative forms of practice of psychologists who are appropriately neurofeedback that should be explained. They trained, and the International Society for each differ in distinctive ways from the tra- Neurofeedback and Research (ISNR) has simi- ditional neurofeedback methods that have just larly endorsed its use by qualified health care been described, and yet each represents impor- professionals who are appropriately trained tant and fascinating advances in our technology. (Hammond et al., 2004) and created standards for the use of QEEG in neurofeedback. Persons Slow Cortical Potentials Training who are certified in this assessment specialty Speaking very technically for a moment, slow may be identified through either the EEG & cortical potentials are the positive or negative Clinical Neuroscience Society (http://www. polarizations of the EEG in the very slow ecnsweb.com/provider-directory.html) or the frequency range from .3 Hz to usually about Quantitative Electroencephalography Certifi- 1.5 Hz. They may be thought of as the direct cation Board (http://www.qeegboard.org). current baseline on which the alternating cur- rent EEG activity rides. There is generally a negative shift in direct current potentials that NEUROFEEDBACK TRAINING occurs during cognitive processing (to create Once the assessment is complete and treat- excitatory effects) and positive slow cortical ment goals have been established, most com- potentials occur during inhibition of cortical monly one or more electrodes are placed on networks. During and prior to an epileptic seiz- the scalp and one or more on the earlobes for ure, for example, the cortex is electronegative, neurofeedback training sessions. The trainee and this same kind of hyperexcitability tends then usually watches a display on the computer to be seen before many migraines. After a screen and listens to audio tones, sometimes seizure, when the cortex is fatigued, it tends while doing a task such as reading. These train- to be electro-positive. Slow cortical potential ing sessions are designed assist the person to neurofeedback training has been done (e.g., gradually change and retrain their brainwave Kotchoubey, Blankenhorn, Froscher, Strehl, & patterns. For example, some persons may Birbaumer, 1997; Kotchoubey et al., 2001; need to learn to increase the speed or size of Strehl et al., 2006), particularly in Europe, with WHAT IS NEUROFEEDBACK 309 epilepsy and ADHD. This type of neurofeed- Hemoencephalography back may also hold strong potential in the There are two different hemoencephalography treatment of migraine (Kropp, Siniatchkin, & (HEG) systems that provide feedback, which is Gerber, 2002). In this training, one electrode believed to influence cerebral blood flow is placed in the center of the top of the head (Toomim & Carmen, 2009). Preliminary and one behind each ear, while the client research consisting of case series reports on focuses on changing a visual display on the the HEG applications appears encouraging computer (Strehl, 2009). (Carmen, 2004; Coben & Pudolsky, 2007b; Duschek, Schuepbach, Doll, Werner, & Reyes THE LOW ENERGY Del Paso, 2010; Friedes & Aberbach, 2003; NEUROFEEDBACK SYSTEM Mize, 2004; Sherrill, 2004; Toomim et al., 2004), perhaps especially with migraine. The Low Energy Neurofeedback System (LENS; Hammond, 2007b; Larsen, 2006; Ochs, 2006) Live Z-Score Neurofeedback Training is a unique and passive form of neurofeedback that produces its effects through feedback that Live Z-score training is a more recent innovation involves a very tiny electromagnetic field, which that usually utilizes two, four, or more electrodes only has a field strength of 1018 watts=cm2. on the head. Continuous calculations are being This feedback is so small that it is the equivalent computed comparing the way that the brain is 1 functioning on different variables (e.g., power, of only 400 th of the strength of the input we receive from simply holding an ordinary cell asymmetries, phase-lag, coherence) to a scien- phone to the ear and only about the intensity tifically developed normative database. Feed- of the output coming from a watch battery. It back is then based on these moment-to- is delivered in 1-s intervals down electrode wires moment statistical comparisons to norms for while the patient remains relatively motionless, the patient’s approximate age group. As with usually eyes closed. This feedback is adjusted other methods of neurofeedback, the feedback 16 times a second to remain a certain number that is provided is designed to guide the brain of cycles per second faster than the dominant toward normalized function. This feedback brainwave frequency. Most preliminary often consists of observing a DVD where the pic- research and clinical experience are encour- ture dims and flickers when the person is not aging with articles published on LENS treatment doing as well and becomes more clear and of conditions such as TBI (Hammond, 2010c; bright when his or her brain is functioning closer Schoenberger, Shiflett, Esdy, Ochs, & Matheis, to norms. At this point, most of what has been 2001), fibromyalgia (C. C. S. Donaldson, Sella, published on this approach are case series data & Mueller, 1998; Mueller, Donaldson, Nelson, (Collura, 2008a, 2008b, 2009; Collura, Guan, & Layman, 2001), anger (Hammond, 2010a), Tarrant, Bailey, & Starr, 2010; Collura, Thatcher, restless legs syndrome (Hammond, in press), Smith, Lambos, & Stark, 2009), with the excep- ADD=ADHD, anxiety, depression, insomnia tion of a new controlled study showing positive and other conditions (Larsen, 2006; Larsen, results with insomnia (Hammer, Colbert, Brown, Harrington, & Hicks, 2006). LENS has even & Ilioi, 2011), but these preliminary results, been used to modify behavioral problems in ani- which include pre- and posttreatment QEEGs, mals (Larsen, Larsen, et al., 2006). Advantages of are very encouraging. As this is being written, the LENS approach include that it commonly an expansion of this approach has become avail- seems to produce results faster than traditional able wherein an entire electrode cap with 19 neurofeedback, and it can be used with very electrodes can also be used for training. young children and with individuals who are less motivated and who do not have the impulse LORETA Neurofeedback Training control or stamina required with other neuro- LORETA refers to low resolution electromag- feedback approaches. netic tomography. This is a kind of QEEG 310 D. C. HAMMOND analysis that provides an estimation of the ADHD and learning disabilities. Clinical work location of the underlying brain generators by Dr. Joel Lubar and his colleagues (e.g., Lubar, (e.g., the anterior cingulate, insula, fusiform 1995) at the University of Tennessee as well as gyrus) of the patient’s EEG activity within a many others has repeatedly demonstrated that frequency band. Very preliminary research it is possible to retrain the brain. In fact, one (Cannon & Lubar, 2007; Cannon et al., randomized controlled study (Levesque, 2007; Cannon et al., 2006; Congedo, Lubar, Beauregard, & Mensour, 2006) documented & Joffe, 2004) has been published about this with fMRI neuroimaging the positive changes approach. It does require more labor-intensive in brain function in ADHD children that mir- preparation where an entire electrode cap with rored their behavioral changes following neuro- 19 electrodes must be applied in every session. feedback treatment. This and the research cited It is believed that this approach may have next all provide strong support that demon- potential to improve outcomes in difficult cases strate the effectiveness of neurofeedback in and=or shorten the length of treatment, and a treating ADD=ADHD. Whereas the average preliminary report (Cannon & Lubar, 2011) stimulant medication treatment study follow-up suggests that changes may be enduring. is only 3 weeks long, with only four long-term follow-up medication studies that lasted 14 Functional MRI Neurofeedback months or longer, Lubar (1995) published Functional magnetic resonance imaging (fMRI) 10-year follow-ups on cases and found that in is a very sophisticated type of neuroimaging about 80% of clients, neurofeedback can sub- that examines brain activation to evaluate stantially improve the symptoms of ADD and brain functioning (unlike the MRI, which exam- ADHD and that these changes are maintained. ines brain structure). A fascinating scientific Rossiter and LaVaque (1995) found that 20 advancement in the last several years has been sessions of neurofeedback produced compara- utilization of the fMRI for neurofeedback (Caria ble improvements in attention and concen- et al., 2007; deCharms, 2007; deCharms et al., tration to taking Ritalin. Fuchs, Birbaumer, 2004; deCharms et al., 2005; Haller, Birbau- Lutzenberger, Gruzelier, and Kaiser (2003) mer, & Veit, 2010; Johnston, Boehm, Healy, and Rossiter (2005) likewise demonstrated that Goebel, & Linden, 2010; Rota et al., 2009; neurofeedback produced comparable improve- Weiskopf et al., 2004; Weiskopf et al., 2003; ments to Ritalin. Drechsler et al. (2007) found Yoo et al., 2006). An advantage of fMRI neuro- slow cortical potentials training superior to feedback is that it can examine functioning at group therapy with ADHD children. Neuro- deep subcortical areas of the brain. However, feedback has also been found in randomized the serious practical disadvantage of fMRI controlled studies to be superior to EMG neurofeedback is that it would be incredibly biofeedback (Bakhshayesh, 2007). In a 1-year expensive and with equipment that costs follow-up, control group study, Monastra, approximately $1 million or more, as well as Monastra, and George (2002) found that neuro- extreme expenses associated with the day-to- feedback produced superior improvements day operation of such equipment, this approach compared to Ritalin, not requiring continuation does not appear to be something that will hold of the medication. In a randomized controlled realistic clinical promise as a treatment option study, Leins et al. (2007) demonstrated that in the foreseeable future. 30 sessions of slow cortical potentials training or of traditional neurofeedback were both effective in producing cognitive, attentional, AREAS OF APPLICATION FOR behavioral, and IQ improvements, which NEUROFEEDBACK TREATMENT remained stable 6 months after treatment. ADD/ADHD Gevensleben et al. (2009b) in a randomized Since the late 1970s, neurofeedback has been controlled study documented the superiority of researched, refined, and tested with ADD= neurofeedback training (effect size ¼ .60) WHAT IS NEUROFEEDBACK 311 compared with computerized attention skills efficacious and specific treatment—the highest training (which would have placebo control level of scientific validation (La Vaque et al., characteristics). Behavioral and attentional 2002). In comparison to neurofeedback, improvements were found to be stable on a meta-analysis (Schachter, Pham, King, 6-month follow-up in research studies reported Langford, & Hoher, 2001) of randomized con- by Strehl et al. (2006) and Gevensleben et al. trolled studies of medication treatment for (2010), and the latter found that neurofeedback ADD=ADHD concluded that the studies were training produced superior results to computer- of poor quality, had a strong publication bias ized attention skills training, as did Holtmann (meaning that drug company funded studies et al. (2009). that failed to support the effectiveness of their Two randomized, double-blind placebo product tended to never be submitted for pub- controlled studies (deBeus & Kaiser, 2011; lication), and often produced side effects. They deNiet, 2011) have documented the effective- further indicated that long-term effects (beyond ness of neurofeedback with ADHD. Other placebo effects) for longer than a 4-week recent, large randomized controlled studies follow-up period were not demonstrated. (Gevensleben et al., 2009a; Wrangler et al., A recent comprehensive review (Drug 2010) should also do much to dispel concerns Effectiveness Review Project, 2005) of medi- that improvements from neurofeedback training cation treatment for ADD=ADHD concluded simply reflect nonspecific placebo factors. These that there was no evidence on the long-term studies demonstrated protocol-specific changes safety of the medications used in ADD=ADHD in electrophysiological brain function using treatment and that good quality evidence is EEG and sophisticated event-related potential lacking that drug treatment improves academic measures, replicating some earlier findings performance or risky behaviors on a long-term (Heinrich, Gevensleben, Freisleder, Moll, & basis, or in adolescents or adults. The latter con- Rothenberger, 2004) and showing distinct clusions were also reached by Joughin and Zwi neuronal mechanisms involved with different (1999). The largest randomized controlled mul- training techniques. A 2-year follow-up (Gani, tisite study compared medication treatment, Birbaumer, & Strehl, 2008) of the Heinrich ‘‘routine community care,’’ and behavior ther- research found that not only were improve- apy. Outcome raters were not blinded, introdu- ments in attention and behavior stable but that cing a bias, and most subjects in community some parent ratings had shown continued care were also on medications. At 14-month improvement during the 2 years. Continuing follow-up (MTA Cooperative Group, 1999), all improvement on 6-week and 12-week follow- groups showed improvements, and medication ups were also found after the completion of produced better improvements in attention LENS treatment of adult ADD=ADHD by deNiet and hyperactivity (the latter only on parent rat- (2011) in a randomized, double-blind placebo ings), but not in aggression, social skills, grades, controlled study. Thus follow-up evaluations or parent–child relations. The ratings provided ranging from 3 months to 10 years after treat- by the only blinded rater (a classroom observer), ment (Gani et al., 2008; Heinrich et al., 2004; however, showed no difference between Lubar, 1995; Monastra et al., 2002; Strehl groups, and on 3-year follow-up (Swanson et al., 2006) provide strong support that et al., 2007) there was no difference on any improvements from neurofeedback with ADD= outcome measures between groups, findings ADHD should be enduring, unless of course that were confirmed on 8 year follow-up something such as a head injury or drug abuse (Molina et al., 2009). Studies (e.g., Swanson were to occur to negative alter brain function. et al., 2007) have confirmed loss of appetite A recent meta-analysis (Arns, de Ridder, and growth suppression as a side effect of medi- Strehl, Breteler, & Coenen, 2009) concluded cation treatment, along with other side effects that neurofeedback treatment of ADD=ADHD such as increased heart rate and blood pressure, meets criteria for being classified as an insomnia, loss of emotional responsiveness, 312 D. C. HAMMOND dizziness, headache, and stomachache. In the of 9 IQ points improvement in one study MTA study, 64% of children reported side (Linden, Habib, & Radojevic, 1996), to an effects, 11% of them moderately severe and average improvement of 12 IQ points in a 3% severe. Side effects associated with ADD= study by L. Thompson and Thompson (1998), ADHD medications are also so common that a mean of 19 IQ points in another study less than 50% of children maintain prescribed (Tansey, 1991b), and even up to an average dosages for more than 6 months (Hoagwood, increase of 23 IQ points in a study by Othmer, Jensen, Feil, Vitiello, & Blatara, 2000). Othmer, and Kaiser (1999). In light of these findings, neurofeedback seems well validated as providing a noninvasive Learning and Developmental and relatively side effect free treatment alterna- Disabilities tive for ADD=ADHD. In the long run it is also With regard to learning disabilities, Fernandez very cost effective. Some individuals express et al. (2003) demonstrated in a placebo- concern about the cost of neurofeedback being controlled study that neurofeedback was an greater than the expense involved in drug treat- effective treatment, and the improvements ment. Research has shown, however, that the were sustained on 2-year follow-up (Becerra costs associated with medication treatment et al., 2006). An additional report by Fernandez are actually quite sizable. For instance, a study (Fernandez et al., 2007) on 16 children with (Marchetti et al., 2001) of six different medica- learning disabilities documented significant tions for ADD=ADHD treatment found that the EEG changes 2 months after neurofeedback average cost per school-aged patient was compared to a placebo-control group where $1,678 each year. Another study (Swensen there were no EEG changes, and 10 of 11 chil- et al., 2003) examined the health care costs in dren in the neurofeedback treatment group more than 100,000 families where ADHD showed objective changes in academic perfor- was either present or not present. They found mance compared with one in five children in that in families where a member had ADHD, the placebo group. Other articles have also the direct costs of health care expenditures plus been published on the value of neurofeedback indirect costs (such as work loss) averaged with learning disabilities (Orlando & Rivera, $1,288 per year higher for the other family 2004; Tansey, 1991a; Thornton & Carmody, members (who had not been diagnosed as hav- 2005). A randomized controlled study with ing ADD=ADHD) in comparison with members children with dyslexia (Breteler, Arns, Peters, of families where ADHD was not present. This Giepmans, & Verhoeven, 2010) documented would mean that the cost of medication just significant improvement in spelling, and Walker cited, combined with indirect costs each year (2010a; Walker & Norman, 2006) found signifi- for a family with two children, one of whom cant improvements in reading ability in 41 had ADHD, would be $5,542. dyslexia cases. In the first 12 cases reported Neurofeedback training for ADD=ADHD by Walker (Walker & Norman, 2006) after 30 is commonly found to be associated to 35 sessions, all the children had improved with decreased impulsiveness=hyperactivity, at least two grade levels in reading ability. increased mood stability, improved sleep pat- Barnea, Rassis, and Zaidel (2005) identified terns, increased attention span and concen- improvements in reading ability in learning tration, improved academic performance, and disability children after 20 sessions. increased retention and memory, and with a Although controlled research has not been much lower rate of side effects. It is fascinating done, Surmeli and Ertem (2007) evaluated to note that ADD=ADHD or learning disability whether QEEG-guided neurofeedback could studies that have evaluated IQ pre- and be helpful with Down Syndrome children. All posttreatment have commonly found IQ eight children who completed up to 60 treat- increases following neurofeedback training. ment sessions (one child dropped out after only These improvements ranged from an average eight sessions) showed significant improvement WHAT IS NEUROFEEDBACK 313 in attention, concentration, impulsivity, of seizures, neurofeedback can offer an behavior problems, speech and vocabulary, additional modality that can be added to treat- and on QEEG measures. Surmeli and Ertem ment, which has the potential to assist in bring- (2010) treated 23 children diagnosed with mild ing seizures under control, allowing dosage to moderate mental retardation with 80 to levels of medications to be reduced, and help- 160 QEEG-guided neurofeedback sessions. ing to avoid invasive brain surgery. Twenty-two of 23 showed clinical improve- Research in this area began in the early ment on the Developmental Behaviour 1970s and is extensive and rigorous, including Checklist, and 19 of 23 showed improvement blinded, placebo-controlled, cross-over studies on the Wechsler Intelligence Scale for Children (reviewed in Sterman, 2000, and in a meta- and a computerized test of attention. analysis by Tan et al., 2009). The samples in the studies that have been done typically Cognitive and Memory Enhancement consist of the most severe, out-of-control, Neurofeedback also has documented results for medication-treatment-resistant patients. How- cognitive and memory enhancement in normal ever, even in this most severe group of individuals (Angelakis et al., 2007; Boulay, patients, research found that neurofeedback Sarnacki, Wolpaw, & McFarland, 2011; training on average produces a 70% reduction Egner & Gruzelier, 2003; Egner, Strawson, & in seizures. In these harsh cases of medically Gruzelier, 2002; Fritson, Wadkins, Gerdes, & intractable epilepsy, neurofeedback has been Hof, 2007; Gruzelier, Egner, & Vernon, 2006; able to facilitate greater control of seizures in Hanslmayer, Sauseng, Doppelmayr, Schabus, 82% of patients, often reducing the level of & Klimesch, 2005; Hoedlmoser et al., 2008; medication required, which can be very posi- Keizer, Verment, & Hommel, 2010; Rasey, tive given the long-term negative effects of Lubar, McIntyre, Zoffuto & Abbott, 1996; some medications. Many patients, however, Vernon et al., 2003; Zoefel, Huster, & may still need to remain on some level of Herrmann, 2010). Neurofeedback to enhance medication following neurofeedback. cognitive functioning and to counter the effects More recently Walker and Kozlowski of aging has been referred to as ‘‘brain brighten- (2005) reported on 10 consecutive cases, and ing’’ (Budzynski, 1996). Ros, Munneke, Ruge, 90% were seizure free after neurofeedback, Gruzelier, and Rothwell (2010) produced although only 20% were able to cease taking evidence that neurofeedback training with medication. In another group of 25 uncon- normal persons may enhance neuroplasticity. trolled epilepsy patients (Walker, 2008), 100% became seizure free following QEEG- Uncontrolled Epilepsy guided neurofeedback, with 76% no longer Medication treatment of epilepsy is successful requiring an anticonvulsant for seizure control only in completely controlling seizures in two on follow-up, which averaged 5.1 years. thirds of patients (Iasemidis, 2003), and the Walker (2010b) reported on still an additional long-term use of many antiseizure medications 20 patients with intractable seizures, 18 of can have health risks. When medication treat- which were seizure free following neurofeed- ment is not successful, neurosurgery is often back training, whereas two continued to report recommended, but it has limited success occasional seizures. Two of the 18 patients (Witte, Iasemidis, & Litt, 2003). In addition, remained on a single anticonvulsant medi- many epilepsy patients are also women of cation. The average length of follow-up in child-bearing age who wish to have children these cases was 4 years. In this same report, but fear the effects of medications on the fetus. Walker indicated that he had seen nine Therefore, a treatment option other than or in women who wished to stop taking anticonvul- addition to medication and surgery would be sants to become pregnant, and all nine desired. Research has shown that when medi- have remained seizure free for an average of cation is insufficient to control the occurrence 6 years. 314 D. C. HAMMOND

TBI and Stroke many years after a head injury. The accumulat- Concussions and head injuries that cause ing evidence indicates that neurofeedback emotional, cognitive, and behavioral problems offers a valuable additional treatment in the occur as a result of many things such as motor rehabilitation of head injuries and with athletes vehicle accidents, war (Trudeau et al., 1998), who have suffered concussions. and sports (McCrea, Prichep, Powell, Chabor, & Barr, 2010; McKee et al., 2009), including Alcoholism and Substance Abuse football (Amen et al., 2011), doing headers in EEG investigations of alcoholics (and the chil- soccer (Tysvaer, Stroll, & Bachen, 1989), and dren of alcoholics) have documented that even boxing (Ross, Cole, Thompson, & Kim, 1983). after prolonged periods of abstinence, they fre- Neurofeedback treatment outcome studies quently have lower levels of alpha and theta of closed and open head injuries have been brainwaves and an excess of fast beta activity. published (Ayers, 1987, 1991, 1999; Bounias, This suggests that alcoholics and their children Laibow, Bonaly, & Stubbelbine, 2001; Bounais, tend to be hardwired differently from other Laibow, Stubbelbine, Sandground, & Bonaly, people, making it difficult for them to relax. 2002; Byers, 1995; Hammond, 2007a, Following the intake of alcohol, however, the 2007b, 2010c; Hoffman, Stockdale, Hicks, & levels of alpha and theta brainwaves increase. Schwaninger, 1995; Hoffman, Stockdale, & Thus individuals with a biological predis- Van Egren, 1996a, 1996b; Keller, 2001; position to develop alcoholism (and their chil- Laibow, Stubbelbine, Sandground, & Bounais, dren) are particularly vulnerable to the effects 2001; Schoenberger et al., 2001; Thornton, of alcohol because, without realizing it, alco- 2000; Tinius & Tinius, 2001), as well as with holics seem to be trying to self-medicate in an stroke (Ayers, 1981, 1995a, 1995b, 1999; effort to treat their own brain pathology. The Bearden, Cassisi, & Pineda, 2003; Cannon, relaxing mental state that occurs following alco- Sherlin, & Lyle, 2010; Doppelmayr, Nosko, hol use is highly reinforcing to them because of Pecherstorfer, & Fink, 2007; Putnam, 2001; their underlying brain activity pattern. Several Rozelle & Budzynski, 1995; Walker, 2007; research studies now show that the best predic- Wing, 2001), but further high-quality research tor of relapse is the amount of excessive beta needs to be done. One article (Hammond, brainwave activity that is present in both 2007b) reported a case of moderate severity alcoholics and cocaine addicts (Bauer, 1993, TBI treated with the LENS, which resulted in 2001; Prichep, Alper, Kowalik, John, et al., the complete reversal of posttraumatic anosmia 1996; Prichep, Alper, Kowalik, & Rosenthal, 1 (complete loss of sense of smell) of 92 years’ 1996; Winterer et al., 1998). duration, which was previously unheard of, Recently, neurofeedback training to teach as well as significant clinical improvement in alcoholics how to achieve stress reduction and postconcussion symptoms. profoundly relaxed states through increasing A recent research review (Thornton & alpha and theta brainwaves and reducing fast Carmody, 2008) particularly suggests that beta brainwaves has demonstrated promising QEEG-guided neurofeedback is superior to neu- potential as an adjunct to alcoholism treatment. rocognitive rehabilitation strategies and medi- Peniston and Kulkosky (1989) used such training cation treatment in the rehabilitation of TBI. in a study with chronic alcoholics compared to a Traditionally physical medicine and rehabili- nonalcoholic control group and a control group tation physicians tell head injury patients that of alcoholics receiving traditional treatment. 1 12 years after a TBI they cannot expect further Alcoholics receiving 30 sessions of neurofeed- improvement and must simply adjust to their back training demonstrated significant increases deficits. Clinical experience and research thus in the percentages of their EEG that was in the far clearly indicate that neurofeedback may alpha and theta frequencies, and increased often produce significant improvements even alpha rhythm amplitudes. The neurofeedback WHAT IS NEUROFEEDBACK 315 treatment group also demonstrated sharp more than tripled the length of stay in the reductions in depression when compared to recovery center. On 1-year follow-up of the controls. Alcoholics in standard (traditional) 94 patients who completed treatment, 95.7% treatment showed a significant elevation in were now maintaining a residence, 93.6% were serum beta-endorphin levels (an index of stress employed or in schooling, 88.3% had no and a stimulant of caloric [e.g., ethanol] intake), further arrests, and 53.2% had been alcohol whereas those with neurofeedback training and drug free 1 year, whereas another 23.4% added to their treatment did not demonstrate had used alcohol or dugs only one to three this increase in beta-endorphin levels. On times, corroborated by urinalysis. 4-year follow-up checks (Peniston & Kulkosky, Arani, Rostami, and Nostratabadi (2010) 1990), only 20% of the traditionally treated compared results from 30 sessions of neuro- group of alcoholics remained sober, compared feedback being provided to opioid dependent with 80% of the experimental group who had patients undergoing outpatient treatment received neurofeedback training. Furthermore, (methadone or Buprenorpine maintenance), the experimental group showed improvement compared with a control group that received in psychological adjustment on 13 scales of the outpatient treatment alone. Patients receiving Millon Clinical Multiaxial Inventory compared neurofeedback showed significantly more to the traditionally treated alcoholics who improvements in outcome measures (e.g., of improved on only two scales and became worse hypochondriasis, obsessing, interpersonal sensi- on one scale. On the 16-PF personality inven- tivity, aggression, psychosis, anticipation of posi- tory, the neurofeedback training group demon- tive outcome, and desire to use drugs) and on strated improvement on seven scales, compared QEEGs. Preliminary research (Horrell et al., to only one scale among the traditional treat- 2010) has suggested that neurofeedback may ment group. Similar positive results with 92% also have potential to reduce drug cravings in sobriety on 21-month follow-ups were reported cocaine abusers. by Saxby and Peniston (1995) in 14 depressed The evidence reviewed validates the alcoholics, and encouraging results were immense potential that neurofeedback treatment reported on 3-year follow-ups in a treatment has to likely double if not triple the outcome rates program with native Americans (Kelley, 1997). in alcoholism and substance abuse treatment Scott, Kaiser, Othmer, and Sideroff (2005) when it is added as an additional component to conducted a randomized controlled study with a comprehensive treatment program (Sokhadze, 121 individuals undergoing an inpatient sub- Cannon, & Trudeau, 2008). It may have real stance abuse program. The patients received potential in not only treating but also remediating 40 to 50 treatment sessions. Persons who had some of the serious damage to the brain that neurofeedback added to their treatment occurs through drug abuse (e.g., Alper et al., remained in therapy significantly longer—an 1998;Prichep,Alper,Kowalik,&Rosenthal, important factor in the treatment of substance 1996; Struve, Straumanis, & Patrick, 1994). abuse. On 1-year follow-up, 77% of patients receiving neurofeedback remained sober ver- Antisocial Personality sus only 44% of traditional treatment patients. and Criminal Justice Significant differences were found in measures Quirk (1995) reported reduced recidivism using of attention and in seven scales on the Minne- a combination of neurofeedback and galvanic sota Multiphasic Personality Inventory–2 com- skin response biofeedback. Smith and Sams pared with improvement on only one scale in (2005) showed improvements in attention and those receiving traditional treatment. Reports behavior in a group of juvenile offenders, and from a similar treatment program (Burkett, a study in a Boys Totem Town project with Cummins, Dickson, & Skolnick, 2005) with seven juvenile felons (Martin & Johnson, 270 homeless crack cocaine addicts showed 2005) improvements were noted on a variety that the addition of neurofeedback to treatment of measures. Most recently, Surmeli and Ertem 316 D. C. HAMMOND

(2009) presented a case series of 13 patients improvements in 20 adopted children with who received from 80 to 100 neurofeedback histories of abuse and=or neglect. Improve- treatment sessions guided by QEEG findings. ments were noted in externalizing and interna- Outcomes were measured with the Minnesota lizing problems, social problems, aggressive and Multiphasic Personality Inventory, a test of delinquent behavior, anxiety=depression, attention, QEEG results, and interviews with thought problems, and attentional problems. family members. Twelve of the 13 patients Neurofeedback seems very promising with showed significant improvement, which was posttraumatic stress disorder, but further corro- maintained on 2-year follow-up. The abnormal borating research is needed. representation of learning disabilities, ADHD, head injuries, childhood abuse, alcoholism, Autism and Aspberger’s Syndrome and substance abuse in an incarcerated There is a quite significant body of research that offender population (Wekerle & Wall, 2002; has now appeared on the neurofeedback Wilson & Cumming, 2009) and of alcoholism treatment of autism and Asperger’s Syndrome and drug abuse in domestic violence (Lin (Coben & Myers, 2010; Coben & Pudolsky, et al., 2009) would suggest considerable poten- 2007a; Jarusiuwicz, 2002; Knezevic, Thompson, tial for the use of neurofeedback, particularly & Thompson, 2010; Kouijzer, de Moor, Gerrits, given the high recidivism rates that attest to Buitelaar, & van Schie, 2009; Kouijzer, de Moor, the limited effectiveness of traditional psy- Gerrits, Congedo, & van Schie, 2009; Kouijzer, chotherapies and pharmacology treatment. This van Schie, de Moor, Gerrits, & Buitelaar, 2010; will be another fruitful area for further research. Pineda et al., 2007; Pineda et al., 2008; Scolnick, 2005; Sichel, Fehmi, & Goldstein, Posttraumatic Stress Disorder 1995). Peniston and Kulkosky (1991) added thirty L. Thompson, Thompson, and Reid (2010) 30-minute sessions of alpha=theta neurofeed- reported on a case series of 150 Asperger’s Syn- back training to the traditional VA hospital drome patients and nine autism spectrum dis- treatment provided to a group of posttraumatic order patients who received 40 to 60 sessions, stress disorder Vietnam combat veterans, and commonly with some supplementary peripheral then compared them at 30-months posttreat- biofeedback. They found very statistically sig- ment with a contrast group who received only nificant improvements in measures of attention, traditional treatment. On follow-up, all 14 tra- impulsivity, auditory and visual attention, read- ditional treatment patients had relapsed and ing, spelling, arithmetic, EEG measures, and an been rehospitalized, whereas only three of 15 average full scale IQ score gain of 9 points. neurofeedback training patients had relapsed. Some of the studies just cited were control Although all 14 patients who were on medi- group studies. There has also been a placebo- cation and were treated with neurofeedback controlled study (Pineda et al., 2008), and there had decreased their medication requirements have been 6-month (Kouijzer et al., 2010) and by follow-up, among the patients receiving tra- 1-year follow-ups (Kouijzer et al., 2009) docu- ditional treatment, only one patient decreased menting maintenance of positive results. A medication needs, two reported no change, review of neurofeedback with autism spectrum and 10 required an increase in psychiatric med- problems, which includes a review of unpub- ications. On the Minnesota Multiphasic Person- lished papers presented as scientific meetings, ality Inventory, neurofeedback training patients has been published by Coben, Linden, and improved significantly on all 10 clinical scales— Myers (2010). In an as-yet-unpublished study dramatically on many of them—whereas there cited by those authors using neurofeedback were no significant improvements on any scales and HEG training, Coben found a 42% in the traditional treatment group. One study reduction in overall autistic symptoms, including (Huang-Storms, Bodenhamer-Davis, Davis, & a55% decrease in social interaction deficits and Dunn, 2006) has also reported positive improvements in communication and social WHAT IS NEUROFEEDBACK 317 interaction deficits of 55% and 52%,respect- Holmes, Hirst, & Gruzelier, 2008). In a rando- ively. Overall, neurofeedback has positive mized, placebo-controlled study with medical research support as a beneficial treatment with students (Raymond, Varney, Parkinson, & Gru- autism spectrum problems, with findings of zelier, 2005) neurofeedback enhanced mood, positive changes in brain function, attention, confidence, feeling energetic and composed. IQ, impulsivity, and parental assessments of Neurofeedback has also been shown with other problem behaviors such as communi- objective measures to improve depression cation, stereotyped and repetitive behavior, (Baehr, Rosenfeld, & Baehr, 2001; Hammond, reciprocal social interactions, and sociability. 2001a, 2005b; Hammond & Baehr, 2009). The Although neurofeedback is certainly not a cure degree to which depressed patients were able for these conditions, it appears to usually pro- to normalize their EEG activity during neuro- duce significant improvements in these chronic feedback has been found to significantly corre- conditions. late with improvement in depressive symptoms (Paquette, Beauregard, & Beaulieu-Prevost, Anxiety and Depression 2009). A blinded, placebo-controlled study Encouraging preliminary research has been (Choi et al., 2011) demonstrated the superiority published for the effectiveness of neurofeed- of neurofeedback over a placebo treatment in back in treating anxiety with 10 controlled stu- reducing depression while improving executive dies that have been identified (Hammond, function. However, more research is needed 2005c; Moore, 2000). Of the eight studies of on the use of neurofeedback with depression. anxiety that were reviewed, seven found posi- tive changes. Another study (Passini, Watson, Insomnia Dehnel, Herder, & Watkins, 1977) used only A randomized, controlled study (Hoedlmoser 10 hr of neurofeedback with anxious alcoholics et al., 2008) demonstrated that only 10 neuro- and found very significant improvements in feedback sessions focused on reinforcing the state and trait anxiety compared to a control SMR resulted in an increase in sleep spindles group, with results sustained on 18-month and reduced sleep latency. Because memory follow-up. A randomized, blinded, controlled consolidation occurs during sleep, this study study (Egner & Gruzelier, 2003) was done with also documented improved memory in the sub- performance anxiety at London’s Royal College jects. This study replicated findings some earlier of Music. They evaluated the ability of alpha= studies (Berner, Schabus, Wienerroither, & theta neurofeedback to enhance musical per- Klimesch, 2006; Sterman, Howe, & MacDonald, formance in high-talent-level musicians when 1970). Hammer et al. (2011) published a they were performing under stressful conditions randomized, single-blind controlled study docu- where their performance was being evaluated. menting the effectiveness of 20 sessions of live When compared with alternative treatment Z-score training in the treatment of insomnia. groups (physical exercise, mental skills training, Individualized neurofeedback was also shown Alexander Technique training, and two other in control group studies by Hauri (1981; Hauri, neurofeedback protocols that focused more Percy, Hellekson, Hartmann, & Russ, 1982) to on enhancing concentration), only the alpha= have long-lasting effects with insomnia patients. theta neurofeedback group resulted in enhanc- A recent randomized control group study ement of real-life musical performance under (Cortoos, De Valck, Arns, Breteler, & Cluydts, stress. Similar randomized controlled studies 2010) of primary insomnia patients found an reducing performance anxiety have been average of 18 sessions of home neurofeedback conducted with musical performance (Egner & training administered over the Internet pro- Gruzelier, 2003), ballroom dance performance duced a significant improvement in the time (Raymond, Sajid, Parkinson, & Gruzelier, required to fall asleep and a significant improve- 2005), and performance in singing (Kleber, ment in total sleep time as measured in a sleep Gruzelier, Bensch, & Birbaumer, 2008; Leach, lab compared with a control group. Even three 318 D. C. HAMMOND schizophrenic or schizoaffective patients with improvements in ballroom dance performance. disturbed sleep all showed improvement in Such results have also been reported with golf sleep quality when compared with a control (Arns, Kleinnijenhuis, Fallahpour, & Breteler, group (Cortoos et al., in press). 2007), archery (Landers, 1991; Landers et al., 1994), improving fast reaction time and visuo- Headaches and Migraine spatial abilities (which has relevance to athletic Walker (2011) reported on 71 recurrent performance; Doppelmayr & Weber, 2011; migraine cases who consulted a neurological Egner & Gruzelier, 2004), improving singing practice. Forty-six of the patients consented performance (Kleber et al., 2008; Leach et al., to QEEG-guided neurofeedback treatment, 2008), acting performance (Gruzelier, Inoue, whereas 25 chose drug treatment. Excess higher Smart, Steed, & Steffert, 2010), and improve- frequency beta was present in all cases. At ments in radar-monitoring tasks (Beatty, 1-year follow-up, 54% of the neurofeedback Greenberg, Diebler, & O’Hanlon, 1974). One group experienced complete cessation of fascinating study (Ros et al., 2009) compared migraines compared with no one in the medi- training to either increase SMR or alpha and cation treatment group. In the neurofeedback theta brainwave frequencies in opthalmic group, 39% experienced a reduction of greater microsurgeons in training, compared to a wait- than 50% in migraines (compared with 8% with list (no-treatment) group. In only eight sessions drug treatment), and a reduction of less than of SMR training the physicians demonstrated 50% was found in 4% of patients (compared significant improvements in surgical skill, to 20% with medication treatment). Sixty-eight decreases in anxiety, and a 26% reduction in percent of the medication treatment group surgical task time. Research documenting reported no change in headache frequency, improvements in cognitive and memory perfor- whereas only one patient (2%) receiving neuro- mance has already been reviewed earlier. The feedback reported no reduction in frequency. potential of neurofeedback applications for Siniatchkin, Hierundar, Kropp, Gerber, and optimal performance will be very a fruitful area Stephani (2000) found a significant reduction for further research. in the number of days per month with a migraine in children treated with slow cortical Other Clinical Applications potentials training versus a waitlist control group. of Neurofeedback Training Carmen (2004) reported improvement of more Preliminary reports have also been published than 90% in migraine sufferers who completed on the use of neurofeedback with chronic fati- at least six sessions of HEG training. For Stokes gue syndrome (Hammond, 2001b); Tourette’s and Lappin (2010), 70% of migraine patients (Tansey, 1986); obsessive-compulsive disorder experienced at least a 50% reduction in fre- (Hammond, 2003, 2004; Surmeli, Ertem, quency on more than 1-year follow-up from a Eralp, & Kos, 2011); Parkinson’s tremors (M. combination of 40 neurofeedback sessions com- Thompson & Thompson, 2002); tinnitus bined with HEG training. Tansey (1991a) pub- (Crocetti, Forti, & Bo, 2011; Dohrmann, Elbert, lished four case reports. Although encouraging, Schlee, & Weisz, 2007; Gosepath, Nafe, further controlled research is needed. Ziegler, & Mann, 2001; Schenk, Lamm, Gundel, & Ladwig, 2005; Weiler, Brill, Tachiki, Peak or Optimal Performance Training & Schneider, 2001); pain (Ibric & Dragomirescu, Neurofeedback is also being utilized in peak 2009; Jensen, Grierson, Tracy-Smith, Baciga- performance training (Vernon, 2005). For lupi, & Othmer, 2007; Sime, 2004); physical example, in a randomized, blinded controlled balance, swallowing, gagging, and incontinence study (Egner & Gruzelier, 2003) neurofeedback (Hammond, 2005a); children with histories of significantly enhanced musical performance, abuse and neglect (Huang-Storms et al., 2006) and a similarly designed study (Raymond, or reactive attachment disorder (Fisher, 2009); Sajid, et al., 2005) documented significant cerebral palsy (Ayers, 2004); restless legs and WHAT IS NEUROFEEDBACK 319 periodic limb movement disorder (Hammond, controlled outcome research is still needed in in press); physical and emotional symptoms the application of neurofeedback to various associated with Type I diabetes mellitus problems. Placebo-controlled studies are often (Monjezi & Lyle, 2006); essential tremor; and regarded as the very highest level of scientific for ‘‘chemo fog’’ (Raffa & Tallarida, 2010; validation. It can be assumed that positive Schagen, Hamburger, Muller, Boogerd, & van results from neurofeedback are due to a com- Dam, 2001) following chemotherapy or radi- bination of expectancy (placebo) effects and ation treatments. effects specific to the neurofeedback treatment Mixed results have been found with neuro- (Hammond, 2011; Perreau-Linck, Lessard, feedback treatment of fibromyalgia. An uncon- Levesque, & Beauregard, 2010), because pla- trolled trial (Mueller et al., 2001) with 30 cebo effects appear to be an active ingredient patients with fibromyalgia (using an early version in virtually every therapeutic modality. We of LENS) found significant improvements in know, however, that there are improvements mood,clarity,andsleep.C.C.S.Donaldson very specific to neurofeedback because there et al. (1998) used an earlier version of LENS are several placebo-controlled studies that (and a small amount of EMG biofeedback) and have demonstrated significant efficacious and reported significant improvement in 77% of specific effects beyond placebo influences in patients’ long-te