Brain biofeedback is neurostimulation therapy. It trains your brain to enhance and/or inhibit selected brainwaves, based on a qEEG assessment, in order to restore damaged function or to correct cognitive issues. The idea is not to change who you are but to heal the damage from brain injury.
“Over time, poorly regulated brain wave patterns become better regulated. As brain circuitry begins to be retrained, behaviors begin to change.”
Donna Jackson Nakazawa. The Angel and The Assassin. The tiny brain cell that changed the course of medicine. Random House. Ballantine Books. 21 Jan 2020.
Principles of Treating the Brain
Three principles guide most techniques of neurostimulation or brain training. Most take time to see results.
The first principle is to reboot, repair, or rewire the brain.
The second principle is to train the brain to the edge of its ability through intensity and frequency of training over time with rest breaks. When training begins to become easier, increase the difficulty so as to continue to train to the edge of ability. Reassess regularly through feedback and progress discussions with the client and by using the same objective tests at the end of the treatment cycle. Exhaustion is a given, and so build in rest in between brain training sessions. Research shows learning works best with breaks in between.
The third principle is to engage in desired activity during or immediately after neurostimulation in order to stimulate rewiring of the neural networks involved in that activity.
Brain Biofeedback and the Principles
The goal of brain biofeedback is to repair and rewire through active training of brainwaves. For brain biofeedback, the number of minutes of biofeedback and the number of biofeedback screens per session reflect the edge of ability as in the second principle. For example, a child may have one minute of biofeedback at a time, whereas an adult will have three minutes, rising to four minutes. And as brain biofeedback takes effect, engaging in activities, feeling emotions again, having greater clarity of thought will happen spontaneously. Supporting activities may be prescribed.
What Is Brain Biofeedback
Brain biofeedback is called “neurofeedback” by the original practitioners, but to differentiate it from a wide variety of therapies using the same term, some all hype, I use brain biofeedback.* Brain biofeedback provides feedback to the brain, muscles, heart via EEG recording of the brainwaves. Feedback on muscle tension, or EMG, keeps tension as low as possible so as to ensure the client is training to the brainwaves and not to the muscle tension artifact. HRV (heart rate variability) training calms the nervous system and improves heart health.
The Procedure
Comprehensive Assessment
Brain biofeedback begins with a complete assessment that must include qEEG. A comprehensive workup will include history taking, IVA a test of visual and auditory continuous attention, maybe TOVA for tests of variable attention if the client can functionally do it, evoke potentials, a computerized neuropsychological test, and a series of questionnaires. qEEG and evoke potentials provide location- and brainwave-specific information to the specialist, and evoke potentials also provides cardiac information important to working on HRV.
Part of the analysis includes comparing your brainwaves and other test results to normative databases, that is, a database comprising EEG readings or test results from healthy people. They also look for busy brain and beta spindles as these interfere with relaxed, focused attention, mood, and functionality. By shrinking busy brain and reducing beta spindles, the treatments reduce anxiety and improve focusing ability and daily life.
The Results Point To What To Treat
The results from the complete assessment provide prognosis and point the way to what to treat first. Usually, the specialists will treat the biggest problems that the qEEG reveals and which are correlated with the client’s own experience. The results determine which brainwave frequencies at which locations require training. These are usually the brainwave frequencies at specific locations or in specific brain networks that are furthest from the norm. For example, the training will enhance SMR 12 to 15 Hz at CZ or increase the network activity correlated to working memory.
The specialist or clinic will draw up an initial schedule of 40 sessions of brain biofeedback, with the possibility of going to 60, twice a week. That’s about four to seven months. However, since each brain injury is unique, the schedule of treatments may extend beyond that. The extent of the injury may require more work in more locations or networks. Or limited funding may result in using the lower-cost but slower method of single-electrode brain biofeedback instead of the 19-point network LORETA-based brain biofeedback. Single-electrode, two-electrode, or LORETA all provide radical improvement if the treatment protocols are based on a comprehensive assessment and followed properly.
The Treatment
Brain biofeedback can be done at a single-electrode location, two-electrode locations, or via a 19-point EEG cap. The latter is LORETA training and works on rewiring the brain’s neural networks. It’s become the more dominant method of neurostimulating the injured brain to heal itself. Two things to keep in mind about brain biofeedback:
- The training is initially very tough then near the end of each protocol it becomes quite easy.
- The effects don’t show up during the first twenty or so sessions. Then a dramatic change usually occurs. However, the change is temporary — at first. Then the change lasts longer and longer until near the end of the treatment protocol, it lasts until the next week’s session. Reassessment by qEEG determines if the change is permanent.
Brain biofeedback works by connecting you to a computer via electrodes pasted to the head. For single-electrode biofeedback, the trainer will paste one electrode at the location determined from the assessment, for example, CZ. For LORETA, it’s a stretchy cap with 19 electrodes. For all types, the trainer will clip electrodes on the ears to act as a ground. To provide feedback for the HRV training and to monitor cardiac and breathing during brain training, the brain trainer will attach various sensors:
- A sensor strapped to the thumb reads your pulse.
- A sensor placed over the stomach records breathing.
- A sensor on the pinky monitors body temperature.
Heart Rate Variability (HRV) Training
HRV reflects the function of the vagus nerve, which often atrophies after brain injury. The brain trainer will start HRV training after checking the connections between electrodes and the computer. HRV and brain training require the ability to deep breathe.
If you don’t know how to deep breathe, you will be trained. The brain trainer will set the breathing rate as represented by a moving ball on a line (see image below). Optimal is six breaths per minute.
The specialist or clinic will also give you a goal for HRV training. The goal is a number on the Low Frequency (LF) bar chart that you’ll see on the HRV screen.
The HRV screen shows the heart rate rising and falling (in pink), breathing rising and falling (in blue), and indicators of sympathetic and parasympathetic nervous system activity on rising and falling bar charts underneath the heart and breathing waves. The goal is to synchronize the ups and downs of heart rate with the breathing. How good the synchronization and balance between sympathetic and parasympathetic activity is will be reflected on the LF amplitude bar chart.
Brain Training: Single Electrode
After HRV training, brain training commences. The client will choose what kind of visuals and music they prefer to provide the feedback. The brain trainer will explain the goals. For example, for single-electrode brain biofeedback, they’ll ask you to enhance a brainwave frequency such as SMR at 12 to 15 Hz while reducing delta at 2 to 3 Hz. The idea is to raise the desired frequency above a threshold set by the trainer and to drop the undesired frequency below its threshold. Thresholds are measured in microvolts. You’ll know you’ve achieved this when the chosen video/graphic loop, such as a triplane flying around an island, begins to move and music, such as ragtime, begins to play. The graphic and music will stop when the desired brainwave frequency drops below a threshold and/or the undesired one rises above its threshold.
Each screen lasts about three minutes. For single-electrode training, the brain trainer will change the graphic to the next screen you’ve chosen. Same with the music. In between screens, the brain trainer will chat or perhaps have you play a game such as Rush Hour. Afterwards it’s a good idea to eat something and have a place to relax or nap.
Brain Training: LORETA
For LORETA network brain biofeedback, the brain trainer will have the client choose a movie to play. They will explain the goal is to enhance the target neural network activity. As with single-electrode brain biofeedback, the trainer sets a threshold. In this case, the threshold is measured in standard deviations from the norm. The goal is to reduce the number of standard deviations away from the norm as measured by the z-score. The movie will play in full screen mode when the network drops below the threshold. The movie will disappear otherwise.
How you do this with your brain is a bit of a mystery. You can see from the video above that it looks like the person is simply staring at a screen doing nothing. Internally, at first that may be true. But as the brain awakens and you become used to the training, there’s much conscious thought or imagining going on. I’ve sometimes consciously thought to the plane, “fly!” or to the movie, “play!” and it will. Other times, I imagine the plane flying or the movie playing when nothing’s happening on the screen. And they begin moving. Then neither method works, and I have to devise another method. This is why the brain trainer won’t say, “If you do x, then the plane will move” because it’s different each time or for each person.
Reassessment
The clinic will reassess you with qEEG at the end of the initial 40 sessions. The qEEG provides an objective marker of progress. But you’ll already have experienced progress in alleviation of the targetted symptoms, improved energy, better function, and so on. At the end of the entire treatment, you may have a complete reassessment. Or if stressors in your life or complicating factors such as PTSD are interfering with treatment, you may have a complete reassessment in order to determine how the interfering factors have changed your brain for the worse so as to switch treatment to target those brainwaves or networks.
Discussion
Brain biofeedback was initially developed decades ago for epilepsy. It’s a proven method with well-established brain biofeedback protocols to permanently improve epilepsy and ADD.
Brain biofeedback has been used for brain injury since I was a test case at the ADD Centre that proved its efficacy in 2005 to 2007. But brain injury is individual and each individual will have unique challenges. Someone with diffuse axonal injury may require years of treatment at different locations for different brainwaves, while another may find the initial prescribed protocol sufficient.
Cost is a factor. But like all neurostimulation therapies, brain biofeedback works out cheaper than a lifetime of medication, tackles a broader scope of problems not just concentration, has no side effects, and results in permanent improvement. For details on what the experience is like and the research, see Concussion Is Brain Injury: Treating the Neurons and Me.
When choosing a specialist or clinic, check that they can provide proof of training through certification and are a member of organizations like ISNR.
The International Society for Neuroregulation and Research, ISNR, supports education and excellence in this field.
“comprises people from many countries and various professional disciplines working on neurotherapy, neurofeedback training and neurofeedback research. ISNR supports education and excellence in the field of neurofeedback training and neurotherapy and seeks the validation and acceptance of this discipline by a broad spectrum of society. Both the society and its members gladly cooperate with other like-minded organizations and individuals.”
https://isnr.org/
Biofeedback Certification International Alliance (BCIA) “certifies individuals who meet education and training standards in biofeedback and progressively recertifies those who advance their knowledge through continuing education.”
“Professional certification is the voluntary process by which a non-governmental entity grants a time-limited recognition to an individual after verifying that predetermined and standardized criteria have been met. Because biofeedback is an unregulated field, certification is crucial for providing standards of care. To be viable as a professional service, standards of competence and clinical practice must be defined and measured. Since 1981, BCIA has taken on this task and offers certification programs in Biofeedback, Neurofeedback (also called EEG biofeedback), HRV Biofeedback, and Pelvic Muscle Dysfunction Biofeedback. Through the BCIA recertification program, each certificant is held accountable to a code of ethics, obtains specified continuing education, and maintains proper credentialing appropriate for clinical practice. Additionally, BCIA offers a certificate of completion in Heart Rate Variability.”
https://www.bcia.org/i4a/pages/index.cfm?pageid=3351
References
J Thompson, W Sebastianelli, S Slobounov. EEG and postural correlates of mild traumatic brain injury in athletes. Neuroscience Letters. (3), 158-163. 2005
IJ Baguley, RE Heriseanu, KL Felmingham, ID Cameron, I.D. Dysautonomia and heart rate variability following severe traumatic brain injury. Brain Injury. 20(4),437–444. 2006.
J Thompson, D Hagedorn. Multimodal Analysis: New Approaches to the Concussion Conundrum. Journal of Clinical Sport Psychology. (6) 22-46. 2012
Michael Thompson, Lynda Thompson, Andrea Reid-Chung, James Thompson. Managing Traumatic Brain Injury: Appropriate Assessment and a Rationale for Using Neurofeedback and Biofeedback to Enhance Recovery in Postconcussion Syndrome. Biofeedback. 41 (4): 158–173. 2013 https://doi.org/10.5298/1081-5937-41.4.07
Michael Thompson, Lynda Thompson, Andrea Reid-Chung. Treating Postconcussion Syndrome with LORETA Z-Score Neurofeedback and Heart Rate Variability Biofeedback: Neuroanatomical/Neurophysiological Rationale, Methods, and Case Examples. Biofeedback. 43 (1): 15–26. 2015 https://doi.org/10.5298/1081-5937-43.1.07
Marquise Bonn. The Effectiveness of Neurofeedback and Heart Rate Variability Biofeedback for Individuals with Long-Term Post-Concussive Biofeedback for Individuals with Long-Term Post-Concussive Symptoms Thesis. Western University. 2018. https://ir.lib.uwo.ca/cgi/viewcontent.cgi?article=7698&context=etd
Shireen Jeejeebhoy. Concussion Is Brain Injury: Treating the Neurons and Me. Chapter R, Gamma. Page 303. 2017.
Norman Doidge. The Brain’s Way of Healing. Appendix 3. Neurofeedback for ADD, ADHD, Epilepsy, Anxiety, and TBI. Page 377. 2015.
John Carmichael. Multi-Component Treatment For PTSD, Including Strategies From Clinical Psycho-Physiology And Applied Science. ISNR Research Foundation. 2011
Online list of references in PDF: http://www.addcentre.com/Pages/references/references.pdf
*This neurostimulation method is usually called “neurofeedback.” But I found that confusing because my original introduction to the term “neurofeedback” was as the name for alpha-TENS. “Neurofeedback” is also used for audiovisual entrainment and other modalities. Since neurofeedback is widely used for completely different kinds of treatments, some not effective, people with brain injury can be deceived into thinking they’re going to get brain biofeedback when they’re not. An alternative term EEG biofeedback may be even better as it’s precise.