Frequently Asked Questions

Get answers about neurofeedback’s basic concepts, costs & reimbursements,
field, background, practice, and more on how it works.

Basic Concepts:

What is Neurofeedback?

Neurofeedback is a form of biofeedback that changes the way the brain functions.
It appears to do so more effectively that medication, therapy, exercise or any other form of personal change work.

In a very real sense, Neurofeedback is exercise for the Brain! And not just any exercise…but very specific, focused training that reshapes the way the brain functions.

Neurofeedback, also called EEG Biofeedback is a state-of-the-art, non-invasive method for teaching the brain to function in a more balanced, relaxed and efficient manner. In reality, this creates a healthier brain. The EEG training does this ‘magic’ by giving the brain feedback in very rapid, precise ways.

When the brain isn’t working well, we can experience a wide range of symptoms, from anxiety, distractibility, hyperactivity, depression, brain fog, OCD or worry. Physically, we can get headaches, migraines, seizures, body tension and have sleep problems as well. Rather than talking about issues or problems, or taking medications, Neurofeedback takes a more direct approach (and does so much more effectively).

Here’s a bit of ‘geek’ talk for those of you who might be interested. Electrical impulses in the brain are broken into four major divisions; Delta, Theta, Alpha and Beta (called “Frequency Bands”). These Frequency Bands are measured in 20 locations across the head. Each band is changing continuously, but not randomly. There are clear patterns that quickly emerge, and these tell us which parts of your brain are active, how well parts are communicating together and how efficient the brain is in any particular area. These patterns correlate to various psychological and physical symptoms and point to weaknesses and strengths for each of us.

Certain patterns of these frequency bands should be active for specific activities. For instance, when we are balancing our checkbooks or in a class following directions, certain areas of our brain will need to be active and using the faster frequency called Beta. On the other hand, if after a long day we wish to relax and wind down, a different part of the brain will need to be activated using the slower brainwave frequency called Alpha. When we visualize something in our mind, another specific set of patterns emerge. These are only a few examples.

The goal of Neurofeedback is to improve the brain’s ability to self-regulate, maintain flexibility, and smoothly shift between states of relaxation, focused effort, planning, brainstorming or creating. Since your brain also controls attention, focus, creativity, awareness, attitude, emotions, memory and… well, EVERYTHING…when we bring the brain into smooth harmony with itself, the entire Central Nervous System returns to normal functioning.

How does neurofeedback work?

Neurofeedback Steps
View a step-by-step explanation of how neurofeedback works.
» View Steps

Neurofeedback Head Chart
View an in-depth explanation of the 10-20 head chart complete with diagrams of electrode placement.
» View Chart

Electrode Basics
Everything you need to know about the electrodes used in neurofeedback.
» View Electrode Basics

Understanding an EEG
Learn the implications of EEG changes as they relate to brain function and how neurofeedback can help to “tune up” these functions.
» View EEG Basics

Neurofeedback Clinical Uses?

Types of CNS symptoms that are frequently shown as clinically responsive to neurofeedback training:

  • ADD/ADHD
  • Conduct and Behavior Disorders
  • Depression, Mood Stabilization
  • Affect Regulation Disorders
  • Bipolar Disorder
  • Anxiety Disorders
  • Panic Attacks
  • PTSD
  • Insomnia, Frequent Waking
  • Restless Leg
  • Bruxism
  • Migraines
  • Chronic Pain
  • Seizures
  • Learning Disabilities
  • Pervasive Developmental Disorder
  • Autism, Rumination
  • Obsessive Compulsive, Rumination
  • TBI Traumatic Brain Injury
  • Tourette’s Syndrome
  • Peak Performance
  • Anger, Rage
  • Substance Abuse

Neurofeedback doesn’t hone in on each and every disorder. It is used to change the timing and activation patterns within the brain. It improves brain regulation, which impacts a myriad of symptoms. The numbers have been smaller, but it’s even shown to impact conditions such as Parkinson’s and schizophrenia.

Different symptomology may require different training targets in the brain. As examples, many clinicians report that depression may involve frontal lobe training, and anxiety may involve some parietal training. This is what makes neurofeedback training methods valuable. It can be used to work on specific areas, just like specific exercises work on various muscle groups.

Information on neurofeedback regarding various disorders:

ADD/ADHD
ADD/ADHD in kids and adults are being trained using neurofeedback more than with any other problem. Clinicians feel that at a minimum, it has significant impact with 80-85% of the patients who complete 30-40 training sessions. ADD/ADHD is often made up of many symptoms rolled into a single diagnosis. A few of the reasons that ADD/ADHD is the most common use for neurofeedback are:

  • Parental motivation to help their child be successful.
  • Parents desire for an alternative to medicines.
  • Desire for treatments that offer less adverse side effects that some medications cause.
  • Increased knowledge of the success stories behind neurofeedback.
  • Published research on ADD/ADHD and neurofeedback.
  • Recognition of the role the brain plays in ADHD/ADD

Anxiety
Clinicians tend to agree that generalized anxiety responds well to training. Considerable improvements have been estimated at 80-90% for people undergoing training. Existence of comorbidity does influence results. The more complicated the case, involving many symptoms and difficulties, the more time it takes to respond. Even the most difficult cases are approached with an expectation that response will come with appropriate expertise on the part of the clinician.

Depression
Reduction of symptoms has been noted for those that suffer from long-term and non-responsive depression with neurofeedback training. Reduction of medication is actually a very common outcome. Clinicians frequently use neurofeedback training successfully for depression and dysthymia.

Learning Disabilities
There are professionals that have published data about the new neurofeedback techniques being used to isolate and treat learning disabilities with EEG training. Reading, math and other problems certainly improve with neurofeedback training. This still leaves some clients with learning deficits. By adding in the new technique of coherence training, many well-respected professionals are notingmore consistent improvements in math, dyslexia, and reading deficits, as well as visual and auditory processing problem resolution.

Bipolar
Clinical reports from psychiatrists and psychologists indicate that neurofeedback helps their patients with Bipolar Disorder stabilize and reduce the use of medications.

Neuropsychologists report that improvement with TBI many times occurs several years after the brain injury and that neural plasticity still exists. Emotional and behavioral improvements have been undeniable for these individuals.

Migraines
Therapists and doctors both report that the frequency and intensity of migraines are often reduced and sometimes eliminated.

Chronic Pain
For chronic pain, neurofeedback helps reduce pain, or perhaps how the brain manages and responds to pain. This has proven true in severe cases as well as moderate.

Sleep Disorders
Sleep-related changes seem to be the first thing that clients notice with neurofeedback. This includes improvement for insomnia, bruxism, poor sleep quality, difficulty waking, frequent waking, and nightmares.

Autism, PDD and RAD
Autism, PDD, and RAD are the fastest growing specialties for neurofeedback. The calming effects produce measurable results fast for these individuals.

One published study on neurofeedback compared it with a successful 12-step program for crack, cocaine, methamphetamine, and heroin use. Sustained abstinence was as much as 2 times greater for those that simultaneously received neurofeedback training. Previous published results for alcoholoics were similar. This is supported by the knowledge that substance abuse is simply a poor way of self-regulating and self-medicating.

Epilepsy
Numerous studies point to a reduction in seizures that fail to respond to medication and that these training effects stick. These are provided by respected journals, and the reports almost always show improvement. Lack of education funding to make physicians aware of this is one of the many reasons neurofeedback is not that well known or understood.

How Many Sessions Will I Need?

The success of neurofeedback revolves around how well the training holds. Noticeable results typically occur between the first and tenth session, but this depends on the individual patient. You will enjoy better success by having more training than less. In many cases, therapists recommend a minimum of 30-40 sessions for the results to hold longer term.

The entire goal of neurofeedback is to complete enough training on the brain training to make sure the positive benefits persist.

Are The Sessions Long?

Although some clients may need to start at sessions that are 5-10 minutes long, it’s rare. Total session time is typically 30 minutes.

How Often Do I Have To Have Training Sessions?
Clinicians tend to set session frequency based on the type of problems being tackled, the distance traveled by the client and success rates reported for each type of problem. The clinicians generally tend to start sessions at two or three per week.

Clients can be more hesitant to come in more often than twice a week, especially if they have to drive a long way. Reduction to once a week can sometimes prove to be ineffective and often increases the dropout rate. The goal is to make it as effective as needed with as little inconvenience as possible.

The optimum number of training sessions designated for a specific treatment are a subject of mild debate. Clinicians will run two sessions in one day with 30-45 minutes separation for long-distance clients. Serious addictions and problems might require two sessions a day, 5 days a week. Whatever has a proven track record of success is what the clinician will most likely recommend.

When To Stop Neurofeedback Training?

Can you over-train?

The answer yes, and it is recommended because it is the safest way to approach training. As soon as your symptoms begin to resolve – say you took piano lessons to learn a new song, and after the sixth lesson you quit. You played the song once, but played perfectly with no mistakes. You decide you’ve learned the song, and it’s time to quit. Three years later, you sit down and try to play the song for some friends. Chances are you probably struggled with the song or forgot parts of it. Instead, if you kept taking lessons and practicing the song on your piano until it became a habit, more than likely, you could sit down 10 years from now and play it well.

If you quit neurofeedback immediately after your symptoms have improved, and 11 months from now your symptoms reappear, you will more than likely say that neurofeedback did not work for you. However, neurofeedback is fundamentally learning – do not quit until you have overlearned. If you quit too soon, you may end up feeling as if you have wasted your time and threw away your money. You need repeated practice for the learning permanently to stick

How Soon Could I Notice Change?
Few clients will continue doing neurofeedback month in and month out if they’re not seeing changes, but how soon can you realistically expect to see changes? Often clients report major changes in the first 2-3 sessions. Clinicians like to caution that actual results may not be seen until 3-5 sessions. Other individuals might take up to 10 before anything noticeable happens. It really depends on the client and the changes trying to be made. Progress should be monitored by both the client and the clinician.

With neurfeedback, any changes noticed are a good thing since it means that the brain is responding to training. The changes can be very subtle to start with, so most clinicians will hone in on sleep as a first sign since it’s what most clients first notice. This can include getting to sleep easier, having more dreams, easier to wake or more sound sleep. Early changes can also involve increased calm, reduced anxiety, less reactive to stress or being more alert.

What changes as a result of training varies greatly by individual. Some people may start to notice changes in mood, attention, anger, or pain relatively fast, often within the first 5-10 sessions. For others, it could take more time. It usually takes longer for obsessive thinking, impulsivity, and oppositional behavior to respond to this type of training. Pre-existing neurological issues or brain injury will create a longer period of time before results are seen.

Is it deemed a failure if no changes have been noticed in 10 sessions? Absolutely not. It would make sense to reassess the situation and maybe even take note of any subtle changes from the training that aren’t easily noticed. Delayed response may simply mean the client is slow to change or it may require a very different training approach. It’s motivational if the therapist can show the client any changes they are making in EEG behavior before other visible signs of change occur.

Since this is basically brain exercise, anyone can benefit from neurofeedback. The speed in which full benefit is reached varies as greatly as an individual that exercises their body at a gym. The more regularly and consistently you exercise, the better and faster the results will be.

Is It Possible For My Symptoms To Worsen?
Neurofeedbackhas been reported to produce a positive effect relatively rapidly in many clients. The fact is that no clinicians have reported the worsening of symptoms over long-term use of neurofeedback. When training the brain, the movement is always towards homeostasis. This means that the brain tries to move symptoms towards normal.

Understanding brain training response is very important to the success of neurofeedback. If a person can be made calmer and trained to fall asleep quickly, they can conversely be activated to be less calm. Most results are positive, but like any therapy, until the brain gets used to what is being done, there is a period of time that the brain needs to adjust to the training.

Clinicians value client feedback about training response. It makes it easier to make adjustments when they are necessary. Clinicians usually make adjustments based on a lack of noticeable change from the training. The changes have become very subtle or non-existent.

Experienced clinicians need to be able to differentiate between the brain adapting to training, or when to make an adjustment to reverse a training effect. Since the brain is having to adjust to a new exercise, it develops adaptation techniques that may require the training to be ramped up or changed in some way. A good clinician will recognize this.

Most changes that are reported by clients are positive. Any change that is noticed is good and tells the clinician that the person is responding to training. The most difficult clients and cases are the ones that report no change at all. Reported changes are an important tool that helps the clinician determine when adjustments need to be made.

Clinicians are tasked with the challenge of determining if the changes reported have anything to do with the neurofeedback. Some clients are bad about reporting changes and some are more sensitive to the training than others. The optimal time period of 24-48 hours for reporting changes helps determine actual progress.

Are The Effects of Neurofeedback Long-lasting?
For neurofeedback training effects to last, therapists have report there has been “enough training” which usually means enough overtraining. In simple terms, you should train up to 5 to 10 sessions after you’ve seen the major symptoms improve. If you quit before symptoms have stabilized, it’s more likely that the effects won’t stick.

Certain individuals may experience a relapse of symptoms. The triggers could be an injury, trauma, extreme stress, or any other major life event. Underlying neurological issues or genetic vulnerabilities may also be a factor. Many clients’ results hold and tend to not need “maintenance” sessions. For others, ongoing brain training may be appropriate. Once someone has had intensive training, those needing “maintenance” often require only a few sessions to get them back on track. Once the brain has established new patterns from the training, it usually doesn’t take many neurofeedback maintenance sessions to recover.

Certain situations involving brain injury, autism, Tourette’s, cerebral palsy, or other neurological problems may require long-term, ongoing treatment to maintain improvements. For degenerative problems, including Multiple Sclerosis, Parkinson’s, or Alzheimer’s, reports suggest neurofeedback helps stabilize function, slow the progression, or may help optimize brain function with whatever resources still exist. It’s more of a “quality of life” training than an attempt to remediate the problem. Improved quality-of-life can significantly benefit any client in any situation.

What If I Take Medication?
A completed survey of over 150 clinicians demonstrated that more than half of their neurofeedback clients started training while taking one or more medications. This is a common practice among neurofeedback clinicians. Reduction in the amount of medications and frequency of dosage is the norm after a number of neurofeedback sessions.

A psychiatric practice in North Carolina reported using neurofeedback with over 30 people with bipolar disorder diagnosis. The patients met the DSM-IV criteria for bipolar disorder, most had been on medications for several years, and had been hospitalized up to several times within a given year. It was reported that all but one patient that had received more than 20 neurofeedback sessions were able to reduce medications and became stabilized.

Medications have to be closely monitored when using neurofeedback. The earliest signs of overmedication need to be reported to the client’s physician right away. The theory about reducing dosages is that as the brain becomes more activated during training, it works more efficiently. The same dosage seems to have a stronger effect on a more efficient brain, and thus reduction may be required.

Not every patient’s medications are affected. For some, neurofeedback seems to act together with medications, allowing them to produce a better result. Neurofeedback works in unison with other treatments and helps overall effectiveness.

Some Reasons Neurofeedback May Not Work!

Neurofeedback response can be likened to medicinal response in patients. Some respond quickly and others take more time. It may require training in different areas of the brain at different frequencies. There are a lot of variables that factor in to how quickly and efficiently a client responds. Thankfully, most people respond well 75 percent of the time. The percentage of clients that do not respond over extended periods is very low. In fact, it’s in the range of 5 percent or less.

Clinician Technique and Experience

An experienced or well-trained clinician will begin by using recommended areas and frequencies that have a proven track record for working with certain conditions. If the “tried and true” protocol doesn’t work, then adjustments might need to be made, or a client should be referred to a clinician with more experience in certain symptoms. The more experiences or skilled clinicians are aware of ways to boost the responses quicker.

Client Consistency

Drop off in sessions tend to happen on a frequent basis if results aren’t seen within a reasonable period of time. They will declare it something that doesn’t work and give up. This is why it’s important for the clinician to touch base with the client on what results are being experienced and give the client motivation to continue, even if progress seems slow. Remember that neurofeedback is learning. If you come once a week or less, it’s much harder to learn.

There are many sites to train on the brain and many different frequencies to choose from. Training each can have a different effect on the client. Choosing the right site and frequency, like choosing the right medication, can require a mix of skill, knowledge, and patience to identify responsiveness. For some clients, it can take a while to figure out what really works.

Therapists also report that doing neurofeedback without addressing other existing problems, such as family or relationship difficulties, can reduce the effectiveness of neurofeedback.

What Is Success?

Defining “success” can be a challenge. What does the client view as success? It’s important to set realistic expectations with clients before training starts. Discuss these on an ongoing basis. Some clients may view it as a failure if complete remediation is not reached, even if symptoms have been dramatically reduced. Impatience is the number one reason a client may stop training. Some clients fail to recognize or report changes when they happen. It may require a better balance of neurofeedback, medications and therapy.

Daily Situations and Training
Content here . . .

Costs and Reimbursement:

Will My Insurance Company Reimburse Me For Neurofeedback Training?
The most successful insurance code to use for payment on insurance plans for neurofeedback uses the same CPT billing code as biofeedback , which is 90901. Insurance companies can be restrictive about which diagnostic codes are used with 90901 and may not reimburse well for this code. Other billing codes have also been used. Certain plans make it hard to get reimbursement. Biofeedback is not covered by Medicare or Medicaid, except for a few chronic pain or neurological problems.

Psychotherapy billing code is frequently used for mental health professionals. Others call the insurance provider and use the codes specified. 90875 and 90876 are new psychotherapy codes combined with biofeedback, but since they are still fairly new codes they’re not widely covered. Some neuropsychologists bill neurofeedback as part of a cognitive rehabilitation program. Physicians tend to get better insurance reimbursement than other providers, but decisions about insurance billing codes are the responsibility of the clinician.

Many clinicians have chosen to not accept insurance for neurofeedback and are still doing a lot of business. Clients who are looking for alternative therapy are often more willing to pay for this training versus other methods. Clinicians taking cash will usually provide the billing for the client to file with their own insurance.

About The Field Of Neurofeedback:

What Is The Correct Term – EEG Biofeedback, Neurtherapy or Neurofeedback?
All of these can be used to state that neurofeedback services are offered. There is no one name that is permanently tagged for the process of neurofeedback training. It will depend greatly on the training the clinician has obtained and personal preference. As long as tried and true training protocol is followed, they are all considered correct.
Is There Only One Way To Do Neurofeedback?

You can talk to 100 experienced clinicians and hear of 100 varieties of options and methods regarding neurofeedback. Most tell you no one approach works for everyone. Every brain is different and responds differently to training. It can be a hot topic of debate within the field and there are some that claim to know the “best ways” to do neurofeedback.

The first model for neurofeedback back in the 1960?s was training alpha occipitally. Then Dr. Barry Sterman introduced training the Sensory Motor Rhythm along the sensory motor strip back in the 1970’s.

Here are even more models since then:

  • The arousal model
  • The instability model
  • The chaos theory non-linear dynamic model
  • The train to the EEG model (which is actually multiple models)
  • Squash, training down all amplitudes across multiple frequencies
  • Alpha-synchrony model
  • Interhemispheric training
  • “Sweet spot” training
  • The use of ratio training
  • The “mini-map” model

Reducing theta for ADD Then there are the mixed models issues, ones that combine other types of systems into the process that are feedback, but aren’t EEG Biofeedback. Are some better than others? The truth is some work for certain clients and others work better for different clients. The best clinicians work with more than one method for that very reason. You need to start with one that is solid, basic, successful, and build on it.

There are recommendations about how to choose models and systems. They all have benefits, and there are colleagues who are proponents of each model. You need to develop a sense of what is a good fit for a variety of situations and goals. Good training, no matter what model, is important. There are no perfect answers, but there are good reasons why one model might be recommended over another one.

Is Neurofeedback Training Considered Experimental?
Neurofeedbackis not approved by the FDA for use in the treatment of depression, anxiety, or ADD, which are the three most common clinical uses. Many insurance companies and health professionals label any treatment that does not have specific approval by the FDA as experimental. Similarly, many things are used successfully for what is called “off-label” use.

EEG neurofeedback equipment is regulated by the FDA. If a manufacturer registers it with the FDA, it’s registered as a medical device. Under FDA guidelines, these devices can be used to reduce stress by licensed healthcare providers. This means any licensed clinician can use that tool as they see fit, in what is called “off-label” use. Physicians prescribe a large number of medications based on “off-label” use. A simple example is how medicines not approved for one use are still granted use for another ailment.

Clinician activity isn’t regulated by the FDA. They allow clinicians to use whatever they need and feel is helpful and safe for their clients, as long as it falls under their scope of practice, licensing standards, and is ethical.

“Off-label” use isn’t simply an issue with neurofeedback. It enters into all modalities. Acupuncture was used for chronic pain for years in the United States, even though it was experimental because the FDA had not approved it. Doctors were being trained in acupuncture at UCLA long before it ever received FDA approval. It took multi-million dollar studies and huge amounts of lobbying to gain FDA approval. That’s not likely to happen for something like neurofeedback.

FDA Guidelines For Neurofeedback!

Continuous efforts within the field of neurofeedback to clarify the FDA requirements for EEG biofeedback equipment and software are yielding some results. Included is all current information that we believe to be correct and we will continue to update this section with any new clarifications that are made.

Any and allneurofeedback equipment registered with the FDA is considered a medical device. There are some companies that follow these guidelines. All medical devices are supposed to be sold only to licensed providers, but there are a few companies that sell neurofeedback instruments to anyone with money. Some of them never register the devices with the FDA. That’s because the FDA guidelines, until recently, are really ambiguous regarding neurofeedback equipment. The FDA hasn’t been very diligent in worrying about it.

Some FDA registered companies sell the equipment to dealers that then sell the equipment directly to the public. The FDA guidelines don’t specify whether this is allowed or not. It’s debated to this day within the industry.

The better equipment and software vendors are registered with the FDA and have received their 510 certifications. They are deemed qualified to manufacture and sell these items. It doesn’t assess quality, but ability of the vendor.

There are some manufacturers who are in violation of FDA requirements since they have never registered. Although the companies may end up inviting FDA scrutiny because of this, the ambiguity in the guidelines has invited the confusion. Certain manufacturers chose to interpret the guidelines to their own advantage.

What the FDA Says

All biofeedback equipment that is promoted as medical devices to help relaxation have been “grandfathered” by the FDA. No further claims are allowed since the FDA Medical Device Act was approved in 1976. FDA approval for a company on the relaxation end means that they do not have to go through with expensive approval processes with each individual condition or problem.

Actual Uses

The equipment is widely used to treat all types of conditions and problems. Manufacturers are generic in terms and don’t endorse any particular treatments. The FDA would not approve of anything specific.

Clinicians, on the other hand, can use devices and medications “off-label” for patients however they wish. Clinicians avoid making curative claims about neurofeedback with conditions like ADHD or anxiety. Licensing boards would take issue with that. Instead, neurofeedbackis touted as a helpful tool in treating these conditions. Neurofeedback helps with self-regulation, so it’s not necessary to make additional claims.

Getting FDA approval for a device to treat a specific condition like ADD would cost millions of dollars. No one is willing to fund this due to the language of the FDA. Approval for one would, in effect, gain approval for all. The market would be wide open for every competitor. It’s not financially feasible or desired.

Manufacturers and the FDA

Manufacturers of neurofeedback equipment with 510K FDA registration are only allowed to sell these as a medical device to licensed healthcare providers. There might be a loop hole in some areas that don’t license mental health providers, but they still require the appropriate credentials. Manufacturers are never allowed to sell the equipment to general consumers. Licensed healthcare clinicians may provide the equipment to a client, but the ultimate responsibility for it comes under their licensure.

Manufacturers of equipment that have not registered with the FDA can, and do, sell directly to non-licensed providers without oversight. Hopefully there will be additional clarification soon as to whether they are in violation of the FDA guidelines.

The neurofeedback community is beginning to take a close look at the manufacturers that have 510K approval and still sell directly to consumers or distributors that end up marketing them to anyone. The concern revolves mainly around the fact that this equipment is being used without proper training or monitoring.

Is A License Required To Do Neurofeedback?
There are obviously ways that anyone can get ahold of the equipment for neurofeedback, but is it a wise investment? Getting the necessary training may not be as easy as you think. Without the training you’ll have no way to know if the process is even working.

Most providers of neurofeedback are licensed and trained clinicians. There are people that started in the field prior to the year 2000 that are trained and experienced, yet not licensed. They offer high quality neurofeedback service, but there are lesser quality individuals that are operating without a license as well. Even if a licensed provider has no experience, there is recourse with the licensing board if problems arise. There is limited recourse with an unlicensed provider.

There is continuing debate surrounding what can happen if an unlicensed and inexperienced person offers neurofeedback training. Offering it for the reduction of stress isn’t necessarily a bad deal. Neurofeedback is all about self-regulation training. Some feel it is so powerful, that used incorrectly can do actual damage.

One thing is certain, if a person offers the training for autism, bipolar disorder or depression it’s generally considered “treating without a license” in most cases. You have to be licensed to treat actual conditions. There have been some cases in which legal actions were taken against the individuals.

Background Of Neurofeedback Training:

Is There Enough Research?

How Much Research Is Involved?

There has been a significant amount of research devoted to neurofeedback. Back in January 2005, a medical journal that specializes in child and adolescent psychiatry published an issue that focused mainly on neurofeedback research. The contributing editors for that issue were: an associate professor at Brown Medical School and psychiatrists from Harvard Medical School and the University of California – Davis. It’s an intriguing issue and can be accessed by clicking this link: Click Here

This is just one example of the research that has been conducted in this field. There have been over 1,000 studies published throughout the years; showing significant attention given to this subject. Early research involved experiments using animals. This type of research started in the 1970s and lead to the discovery of: 1) the use of operant conditioning to change the EEG, and 2) a reduction in the amount of seizures when using EEG training.

Animal research during this period was performed mostly on cats. The use of cats as testing subjects eliminated the argument of a placebo effect and further research was done in human studies to verify the animal research results. The research was thorough, well-documented, and lead to a number of outcome studies. In addition to all of this research, nothing has been published showing significant studies done to refute that neurofeedback works.

As stated earlier, a number of outcome studies have arisen from the research performed in the 1970s. The three areas that have been studied are: 1) epilepsy, 2) attention deficit disorder (ADD), and 3) substance abuse. Other basic research has been conducted as well (i.e. obsessive compulsive disorder (OCD), autism, and anxiety studies), but listed areas above are the most recognizable.

As in any field, research on neurofeedback is not over. More studies are needed. In the meantime, there is a substantial amount of literature that can be referenced on the subject. Your best literature options are specialized journals, but you may need to obtain a basic understanding in neurophysiology of cognitive behavioral function, EEG (see Intergrative Neuroscience for reference), arousal, the functions of the thalamus, and knowledge of the brainstem. The collective knowledge of these areas will give you a good foundation in furthering your research in neurofeedback. If you feel you need to catch up, there is a good introductory course that covers information in all of these categories in a comprehensive, understandable manner. For information on this course, please contact us.

A Brief History

A Short Synopsis On Neurofeedback

The research and history of neurofeedbackwere stumbled upon inadvertently. In fact, it was research done on cats using operant conditioning that lead to the development of the field of neurofeedback.

The year was 1968 and a UCLA neuroscientist named Dr. Barry Sterman was conducted experiments using cats to prove that they can be trained, using operant conditioning, to make EEG activity at frequencies of 12-15 Hz. He labeled this activity as SMR, or Sensory Motor Rhythm.

Dr. Sterman than brought his research to NASA and developed a contract with the organization to investigate whether there was a connection between seizures and rocket fuel exposure. Sterman took cats that were not used in the EEG activity study and exposed them to the volatile fuel hydrazine. These cats displayed signs of seizures, but the cats that were a part of the EEG activity study that were exposed to the same amount of hydrazine had a dramatic reduction in seizure thresholds. The results amazed NASA and the beginning of neurofeedback studies was born.

Eventually animal research turned to human research and EEG training methods were used on a woman that had uncontrolled seizures. She worked in Dr. Sterman’s lab and was the perfect subject for his research. The experiment used operant conditioning and consisted of 12-15 frequency trainings along the sensory motor strip. To Dr. Sterman’s delight, the training showed the same effect results as it did with the cats using the same methods.

Conducting research using humans helped launch the field of neurofeedback and lead to studies in brain dysregulation; which includes epilepsy. Epilepsy research is by far the most extensive of these studies.

Are There Differences in Neurofeedback and Biofeedback?

Neurofeedback vs Biofeedback

You may be surprised to learn that neurofeedback and biofeedback are almost one in the same. How can that be, you ask? It’s because neurofeedback IS biofeedback, it is just a specialized form of EEG biofeedback. Does that help clear it up a little? Let’s discuss both areas a little further.

Biofeedback, which is also referred to as peripheral biofeedback, deals with the areas of: relaxation, stress disorders, migraines, headaches, and incontinence. The number of applications used in biofeedback is diverse. These applications are: EMG/muscle relaxation; GSR/galvanic skin response, which can also help indicate stress; heart rate variability, temperature, and breathing training. More recently, applications have been found to be highly effective in handling problems with incontinence.

Neurofeedback, or EEG biofeedback, is used to target specialized areas surrounding: behavior; attention; mood regulation and affect; cognition; and learning, memory, and neurological issues. Neurofeedback looks at ways to train the brain into changing certain functions, hence the reason this method is used more in the psychiatric, psychological, and neurological fields. As an example, clinicians who started out using peripheral feedback to handle stress-related issues, pain, and addiction problems quickly moved to neurofeedback procedures like hand temperatiure and EMG training when they discovered faster progress using this method. Using neurofeedback helps the individual change their EEG which is believed to directly affect the central nervous system by impacting EEG activation and timing. Since neurofeedback provides a direct impact on brain regulation it requires additional education in order to deliver the process safely and correctly.

Even though clinicians have seen faster progress using neurofeedback alone, there is an emerging trend with certain clinicians who add heart rate variability training, GSR, and breathing rate training. Therefore; the combination is being considered as additional methods for clients who are learning self-regulation in balancing the sympathetic and parasympathetic systems.

The use of either of these methods provides an individual with physiological data; however, peripheral biofeedback is used more often by health professionals than neurofeedback. In fact, the term neurofeedback is used so rarely that physicians and other health professionals may assume that you are referring to biofeedback instead of the specialized study. However, neurofeedback is becoming more common and is now the fastest-growing segment of the biofeedback field.

Hopefully this article helps in determining the differences between neurofeedback and biofeedback. Although clinicians may favor one over the other, there is nothing that points towards one working better. The suggestion is that methods from both areas be implemented according to the needs of the client.

About The Practice Of Neurofeedback:

Which Professionals Use Neurofeedback?

Neurofeedback And The Professionals That Use It

Most professionals that use neurofeedback these days are in private practice. In fact, it is estimated to be between 2,500 to 3,500 health professionals using neurofeedback with the majority practicing in psychology, neuropsychology, therapy, marriage and family counseling, and social work. Neurofeedback has expanded into psychiatry and is also being used by some physicians and registered nurses. In fact, there have been a number of organizations for professionals created worldwide to support the increased need for education in this field. For those professionals that have a large number of clients using neurofeedback, technicians are hired on to perform client sessions. This allows these professionals to serve more people while supervising their treatment.

A workshop on the subject of neurofeedbackwas presented by a group of psychologists and psychiatrists at the annual meeting of the American Psychiatric Association and was received quite well. This may lead to more use of this modality in the fields of psychology and psychiatry in the future.

As for institutions, there is very little use or involvement in neurofeedback. In fact, there has been very little incorporation of neurofeedback in schools, hospitals, psychiatric units, and large mental health centers as well as neurology and pediatric practices. However, there is evidence that neurofeedback is being widely used in many mental health and addiction programs in Mexico. There are some theories on why there is low incorporation of this field in institutions. These theories involve four areas: 1) committees, 2) marketing, 3) doctor support, and 4) and funding.

Here are the reasons that these areas are considered vital in making neurofeedback more mainstream in institutions:

1) Committees
Committees are used in institutions to overlook the performance of the organization. In small practices, the use of a committee is not needed because the individual clinician decides what happens in their clinic.

Information has to be shared with each member of the committee and voted on whether it is a service that should be provided. The education of each and every member takes time and requires a certain level of knowledge in order to understand the research that has been conducted in the field. Since all committee members may not hold the knowledge needed to make an educated decision on neurofeedback, it doesn’t pass. This is why individual clinicians that have no need for committee votes have an easier time incorporating this modality.

Seeing that committees can interfere in accessing neurofeedback procedures, a major addiction center in the United States decided to try a new approach. They offered their own onsite, in-service training for their staff. The Medical Director was in strong support of this approach and it has shown significant results in their addiction program. There is speculation that their success in this program will lead to other institutions following in their footsteps.

2) Marketing
Currently there is no marketing done surrounding neurofeedback. With a lack in marketing, there is a lack of knowledge of its benefits and features.

3) Doctor Support
With the lack of marketing in this area, doctors are not aware of the success and impact of neurofeedback. The professionals that are more likely to be attracted to neurofeedback are in the mental health field. These would include psychologists and social workers. Unfortunately, these professionals aren’t always the ones helping committees make final decisions.

4) Funding
As with any new business or process, it takes time before it generates income. This is the same with neurofeedback. It isn’t an instant moneymaker and can take two to three years before showing any return on the investment. It’s unfortunate that the patient’s needs are put ahead of the financial aspects of a treatment, but that is what institutions concentrate on. There are investors involved and they focus on the bottom line. If a procedure inhibits profit, then it isn’t considered important.

Health Professionals Report What Neurofeedback Does for Their Clients?
Several hundred clinicians such as psychologist, doctors, therapists, etc. reported three common findings during an informal survey:

1.) The training does extremely well with a psychotherapy and medication combination. Professionally, everyone reported that their patients got better faster, and made more progress when psychotherapy and medications were combined compared to when they were used alone.

2.) Medications are commonly reduced. A survey that was conducted using over 150 licensed clinicians who use neurofeedback with their patients reported that 50% to 70% of their clients ended up reducing their medication (under medical supervision) after sufficient training. It needs to be noted that most of these clinicians reported that their goal was not to reduce the medications but to stabilize and improve their clients. Reports of reduced medications are commonly discussed during many presentations at professional conferences.

3.) Neurofeedback is extremely helpful with a large percentage of mood disorders, such as a society disorders, affect regulation, depression, impulse activity, and ADD/ADHD. Several other central nervous system-related symptoms are also improved with neurofeedback; however, these are the most common.

What Do Patients Say About Their Experiences With Neurofeebback?
Clinicians that offer neurofeedback hear a lot of comments about changes. Some are noticed sooner than others, but some clients have to nearly have them pointed out to them. Here’s a typical example. A woman that struggled with migraines for 20 years was asked to assess any changes after the 20th neurofeedback session. She agreed it helped “a little.” The original complaint had been 2 or 3 migraines every week that lasted up to 6-hours. They were now down to one per week of 2-3 hours. She then realized that she had made more progress than she thought.

Seeing self-change can be hard. It’s like the woman having migraines. She still suffered with some, so it didn’t feel better to her. Missing symptoms are harder to recognize than new ones. Clients don’t always like to give credit to neurofeedback for changes. It seems difficult for people to place the blame for improved behavior on a few sessions of neurofeedback. They will pawn it off to maturing, better weather or good food. Anything but what it might really be due to. Even though clients have a hard time connecting the realities to the therapy, clinicians are able to spot these things immediately.

One of the harder tasks for any clinician is trying to show the client that one of the most important events causing change is the addition of neurofeedback. A good client-clinician relationship cultivates trust in the process and the client can feel confident that they are truly making positive strides.

Why Isn’t Neurofeedback Offered More Often?

The field of neurofeedback is simply not very well known. There is a big void when it comes to education about and training amongst mental healthcare professionals and other medical personnel. A closer look shows that there is plenty of solid research and publications about the science behind neurofeedback, yet the mystery persists.

Since it is a very specialized practice, even those that have heard of neurofeedback are not always aware of just how much the training can impact patients when it comes to true clinical results. The research tends to be published in journals that most other healthcare professionals don’t read very often, if it all. Busy personal schedules tend to limit their reading time to their immediate profession only.

Education will take a lot of money and continued efforts to make sure that physicians are properly exposed to the benefits and track record of neurofeedback training. Pharmaceutical companies know that they are looking at spending at least $20 million dollars anytime they introduce new drugs. The resources simply don’t exist for neurofeedback.

Lack of Monetary Gains to Back Neurofeedback
Neurofeedback is a technique that can’t be patented. This means that large amounts of invested funds have no way to be “protected” and recouped. Neurofeedback training is based on software and hardware that can’t be “owned” by any one company or individual for any length of time. Major capital investors have so far refused to dump huge sums of money into a venture that it sees no way to make money from.

Without a lot of monetary resource, there’s no way to afford to mount an educational campaign, including the ability to pay for speakers, educational material, offering copies of journal articles, or for experts representation at medical conferences. All efforts to educate the physicians to date has taken place simply out of the personal interest in expanding knowledge by neurofeedback professionals themselves.

Insurance reimbursement is an obstacle to neurofeedback with both potential clients and clinicians. Reimbursement denials and low rates act to discourage the expansion of utilizing this type of service. Medicaid and Medicare clients are normally avoided since the reimbursement rates are abysmal. Neurofeedback is being paid for out-of-pocket by an increasing number of clients.

People are still willing to seek out viable alternatives when current medications and therapies don’t work well. Even if this means they have to pay for the treatment themselves. The bottom line for most is the fact that it’s still cheaper than additional doctor visits, medicine or missing days of work.

Unfamiliarity Breeds Distrust
Not having a lot of peers who have adopted and accepted neurofeedback and concern about being the new kid on the block holds many professionals back. “It’s not in my journals”. The fact that the studies and research materials appear in smaller specialty journals rather than “my journal” is the excuse heard most often.

It’s true that Clinicians and MD’s are incredibly busy and expecting them to keep up with every offspring branch of healthcare is unrealistic. There’s a high comfort level in dealing with pharmaceuticals or traditional psychotherapy. It may not work well all the time, but it’s something that’s comfortable and familiar. Neurofeedback is not something that MD’s and psychologists know much about simply due to lack of exposure. This is no easy hurdle to jump. Innovation is frowned on in the healthcare system. The reward systems are designed and cater to those that cut costs.

Dr. Tom Brod and Mike Cohen have been organizing a presentation for psychiatrists at the American Psychiatric Association since 2003. Psychiatrists, psychologists and neuropsychologists conduct these presentations to peers at their own cost in the interest of bringing neurofeedback into a more mainstream view.

Neurofeedback will need to find ways to fund education and awareness in order to gain a wider appeal. Growth, although slow, will still continue due to the numerous grassroots efforts of those within the field itself. Increased vendor involvement might be the ticket to getting the word out faster. They do currently exert some effort, but not to the level that other traditional types of therapy are given.

Are There Adverse Effects To Neurofeedback Training?
For over 30 years, neurofeedbackhas been used in hundreds of thousands of training sessions. Since its use, there have never been any long-term, adverse effects identified. Not only that, but to the best of our knowledge, neurofeedback training has never caused a lawsuit.

It is important to note that anything that has the power to change something significantly could potentially lead to adverse effects. This is why professional training is crucial and critical. Neurofeedback can help improve sleep, but if someone were to train a site and frequency that is not optimal for a specific individual, it could backfire making sleep worse. In addition, it can also help improve depression, but if done wrongly, it could exacerbate the symptoms.

Commonly, any change that occurs in one session is extremely minor. However, having said this, training effects can quickly be reversed by changing the sites and frequencies (protocols) during a training session. A trained professional needs to monitor the change and shift the training protocols. In medications, short-term side effects can lead to change; this holds true for neurofeedback training as well. A trained professional will adjust the training to the client’s needs.

More On How Neurofeedback Works:

How Neurofeedback Training Changes Sleep Fast?
Can problems falling asleep and waking up be changed fast? What if they are from long-term poor sleeping patterns?Neurofeedback training changes are mostly noted as initial changes in sleep. So the answer is yes. It depends on how sensitive the person, but there are many notations of clients attending one or two 30-minute sessions and sleeping better. A few have actually claimed improvement after one 15-minute session. True and lasting change comes from continued training to ensure the brain learns the new desired pattern.

Activating the brain to wake up quicker is done by simply placing an electrode at the C3 region for 30-minutes at 15-18hz. Client reward happens when the brain begins to maintain this active state on its own. This training helps anyone that has a really hard time waking up in the morning.

Problems falling asleep are handled with right-side training. Training the C4 region at 12-15 hz. calms the brain. Learning the calming pattern helps the brain know how to shut down when it’s appropriate to do so. No more struggling and tossing and turning in bed.

The opposite effects can be achieved if you train the wrong areas at the wrong frequency. Slight problems can arise, but they can be reversed quickly. It doesn’t take any time at all to realize that things are reversed of what they should be. Necessary adjustments can be made and you are then back on the right track.

What EEG Frequencies Are Typically Trained And What?

There are three areas of EEG frequency that training is offered in. This article will go over each frequency area and explain what is covered and the reason it is necessary.

The first area is alpha-theta training. This training is typically used to treat deep, psychological issues: depression, addiction, anxiety, and post-traumatic stress disorder (PTSD). Alpha-theta training runs at a frequency of 8-12 Hz for alpha and 4-8 Hz for theta. The use of the neurofeedback brings an individual to a deep level of consciousness, which is why it is used to treat the psychological issues listed. It also has a couple of positive side effects: enhancing creativity and allowing the person to enjoy deep states of relaxation.

Caution must be taken in regards to theta and delta waves. These frequencies can cause negative effects if they are excessively used; therefore, they must be inhibited during sessions. Theta waves (4-7 Hz) are associated with a person’s ability to focus while delta waves (0-3 Hz) deal with sleep states; however, when a person is awake, the delta waves can be associated with brain dysfunction. If theta and delta waves are not properly monitored, the patient may experience problems with concentration among other problems.

Beta frequencies are the next training area. This frequency’s training is used to improve attention, organization, cognition, mood improvement, and task performance. In order to accomplish this, the beta band (12-20 Hz) is increased creating a more alert brain.

In the beginning stages of neurofeedback studies, training in beta frequencies along the sensory motor strip was the main focus. As neuroscience and brain imaging research developed, other functional areas were discovered and added to the treatment. Therefore, neurofeedback training can include frontal, prefrontal, temporal and parietal lobes, as well as the anterior cingulate. An example of how beta frequency can be helpful in these areas, is the anterior cingulate. Increasing beta frequencies in this area will help inhibit ADD, depression, and OCD tendencies.

The last frequency is high beta. Like beta frequencies, this area focuses on improving attention, but like theta and delta frequencies, excessive frequencies can have negative effects. At excessive rates, high beta frequencies can increase anxiety and tension. Training is strongly suggested in order to avoid these negative effects.

When You See The EEG, Is The Brain Actually Changing?
Neurofeedbackis used to train specific sites of the brain. A clinician and patient will see these changes in the form of changes in EEG activity. Correct activity is enhanced by a reward system. These are rewards in the form of a treat or payment, instead, a series of beeps are emitted when the brain is able to keep EEG activity within a specified frequency. This reward system is based on the operant conditioning principle. Read More

Training the brain is a method that is still not understood by all professionals. In fact, there are still points that most professionals are not aware of. These points are:

1. EEG training, over time, can have a significant impact on changing behavior, attention, resilience and stability.

2. Changing EEG is easier than expected.

3. Even though there are 100 billion neurons in the cortex, the electrodes only access a few hundred thousand; however, each and every neuron doesn’t have to be accessed at the same time in order to see a change. If the few thousand neurons show a change in a particular EEG band, it means that the underlying neurons are having the same effect. How is this possible? It is possible because neurons influence each other. In fact, it is estimated that each neuron had the ability to influence up to 1 million neurons. That is why each and every neuron does not have to be accessed directly by an electrode.

4. Since EEGs are the compilation of the electrical potential of neuron activity, any EEG activity is actually showing neuronal shifts, either towards excitability or inhibition.

5. When neurons fire (show activity) they release neurotransmitters. These neurotransmitters can bind the receptor sites and also travel to synapses. The neurons gather information from each other in order to determine if they should continue to fire or if they need to be inhibited.

6. The cortex and the thalamus have a feedback loop between them. This is important due to the fact that EEG training influences neurons which in turn influences feedback loops. Affecting feedback loops can have dramatic effects on maintaining alertness and an awake state.

7. Neurofeedback is effective because neurons have the ability to communicate with each other. It is this communication that helps train the brain.

Will Training Always Change the EEG?
When a person suffers a head injury or has epilepsy, often abnormalities will be seen in the EEG. Of course, there are a variety of other causes that can cause an EEG to have abnormalities. A reduction of abnormalities is often seen when a person trains the EEG. Clients who suffer with depression, anxiety, or ADD may see an extreme reduction as well. This does not happen overnight, but is a direct result of long-term training. By definition, when a person suffers with excessively slow or fast brain activity, timing, or variability, this is not a true abnormality. However, these issues are related to problems associated with cognitive function, behavior, and more.

It is possible that some patients will not see a change in their EEG, because one cannot be measured, but they will see a change in the improvement of their symptoms. When this happens, it may be because the measure of change in an EEG is not recorded due to the complex wave form, as well as the location on the head being recorded. However, the reality is sometimes patients cannot physically see the change on their EEG, but it is changing. There are hundreds of possibilities to measure change, this can happen in a laboratory setting as well. Today, new efforts are being developed to measure relevant change.

Having said this, the goal is not to observe the EEG change, but rather to observe the change in the patient. If a patient is making progress, then many clinicians are not worried when they do not see an EEG change.

Some therapists do not pay attention as to whether a patient’s EEG changes, instead they look for clinical changes in their patients. However, an EEG could be changing because most of the training procedures will at least produce a subtle change in the EEG for many patients. In addition, some clinicians focus more on frequencies, training strategies, and targeting specific parts of the human brain that they want to train. This is the clinical side of neurofeedback, and is commonly referred to as the symptom and training-based model. This model has worked extremely well for many years. Today, there is an extremely good course that is has been developed to target in teach this approach.

Other professionals commonly believe that the primary goal of an EEG is normalization. This means that professionals should be able to identify something in an EEG that needs to be changed, and then be able to change it and see the results.

In reality, the answer is somewhere in-between. There are times when an EEG is extremely dysregulated showing excessively slow or fast activity. Many clinicians have reported that if they observe a reduction in the excessively slow or fast activity on an EEG, it usually is related to improvements found in the patient. You can achieve improvements without watching an EEG, but combining both approaches will help in courage faster learning, which is optimal.

Having said this, more research is needed. However, both approaches work 1) training to improve symptoms, and 2) training to normalize an EEG. Recent research has suggested that the greater the changes that are found in an EEG are directly related to changes in symptom improvement and cognitive function. This leads us to ask the questions: Does one approach work better than the other did, is it more important to watch and EEG or stay tuned to the client, can a clinician do both? As soon as these questions are answered, they produce more questions.

How Is Brain Imaging And Cognitive NeuroScience Impacting?

Neurofeedback: How it has been affected by brain imaging and neurosciene
Studies in the fields of brain imaging and neuroscience have had a direct effect on neurofeedback. Their research has led to better methods in targeting different areas of the brain using neurofeedback. In fact, research in the field of brain imaging may lead to neurofeedback methods that will assist people with learning disabilities and chronic pain.

Neurofeedback is more than just placing electrodes over areas of the cortex. There is more to the mechanics than that since the structure of the cortex is a complex, integrated network system. Extensive training and research can be done through brain imaging and neuroscience to help identify specific areas that can be targeted to make neurofeedback more effective.

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