Mind over chatter: plastic up-regulation of the fMRI salience network directly after EEG neurofeedback

Effects of one session of theta or high alpha neurofeedback on EEG activity and working memory

Neurofeedback techniques provide participants immediate feedback on neuronal signals, enabling them to modulate their brain activity. This technique holds promise to unveil brain-behavior relationship and offers opportunities for neuroenhancement. Establishing causal relationships between modulated brain activity and behavioral improvements requires rigorous experimental designs, including appropriate control groups and large samples. Our primary objective was to examine whether a single neurofeedback session, designed to enhance working memory through the modulation of theta or high-alpha frequencies, elicits specific changes in electrophysiological and cognitive outcomes. Additionally, we explored predictors of successful neuromodulation. A total of 101 healthy adults were assigned to groups trained to increase frontal theta, parietal high alpha, or random frequencies (active control group). We measured resting-state EEG, working memory performance, and self-reported psychological states before and after one neurofeedback session. Although our analyses revealed improvements in electrophysiological and behavioral outcomes, these gains were not specific to the experimental groups. An increase in the frequency targeted by the training has been observed for the theta and high alpha groups, but training designed to increase randomly selected frequencies appears to induce more generalized neuromodulation compared with targeting a specific frequency. Among all the predictors of neuromodulation examined, resting theta and high alpha amplitudes predicted specifically the increase of those frequencies during the training. These results highlight the challenge of integrating a control group based on enhancing randomly selected frequency bands and suggest potential avenues for optimizing interventions (e.g., by including a control group trained in both up- and down-regulation).

Mindfulness-based Neurofeedback: A Systematic Review of EEG and fMRI studies

Neurofeedback concurrent with mindfulness meditation may reveal meditation effects on the brain and facilitate improved mental health outcomes. Here, we systematically reviewed EEG and fMRI studies of mindfulness meditation with neurofeedback (mbNF) and followed PRISMA guidelines. We identified 10 fMRI reports, consisting of 177 unique participants, and 9 EEG reports, consisting of 242 participants. Studies of fMRI focused primarily on downregulating the default-mode network (DMN). Although studies found decreases in DMN activations during neurofeedback, there is a lack of evidence for transfer effects, and the majority of studies did not employ adequate controls, e.g. sham neurofeedback. Accordingly, DMN decreases may have been confounded by general task-related deactivation. EEG studies typically examined alpha, gamma, and theta frequency bands, with the most robust evidence supporting the modulation of theta band activity. Both EEG and fMRI mbNF have been implemented with high fidelity in clinical populations. However, the mental health benefits of mbNF have not been established. In general, mbNF studies would benefit from sham-controlled RCTs, as well as clear reporting (e.g. CRED-NF).

Adaptive closed-loop modulation of cortical theta oscillations: Insights into the neural dynamics of navigational decision-making

Navigational decision-making tasks, such as spatial working memory (SWM), rely highly on information integration from several cortical and sub-cortical regions. Performance in SWM tasks is associated with theta rhythm, including low-frequency oscillations related to movement and memory. The interaction of the ventral hippocampus (vHPC) and medial prefrontal cortex (mPFC), reflected in theta synchrony, is essential in various steps of information processing during SWM. We used a closed-loop neurofeedback (CLNF) system to upregulate theta power in the mPFC and investigate its effects on circuit dynamics and behavior in animal models. Specifically, we hypothesized that enhancing the power of the theta rhythm in the mPFC might improve SWM performance. Animals were divided into three groups: closed-loop (CL), random-loop (RL), and OFF (without stimulation). We recorded local field potential (LFP) in the mPFC while electrical reward stimulation contingent on cortical theta activity was delivered to the lateral hypothalamus (LH), which is considered one of the central reward-associated regions. We also recorded LFP in the vHPC to evaluate the related subcortical neural changes. Results revealed a sustained increase in the theta power in both mPFC and vHPC for the CL group. Our analysis also revealed an increase in mPFC-vHPC synchronization in the theta range over the stimulation sessions in the CL group, as measured by coherence and cross-correlation in the theta frequency band. The reinforcement of this circuit improved spatial decision-making performance in the subsequent behavioral results. Our findings provide direct evidence of the relationship between specific theta upregulation and SWM performance and suggest that theta oscillations are integral to cognitive processes. Overall, this study highlights the potential of adaptive CLNF systems in investigating neural dynamics in various brain circuits.

The potential of infra-low frequency neurofeedback training in peak performance: The first double-blinded placebo-controlled longitudinal study in healthy adults

Infra-low frequency neurofeedback training (ILF-NFT) has shown promise in addressing cognitive and affective distress symptoms across a range of psychiatric disorders. This study tested ILF-NFT's effects in a double-blinded, placebo-controlled longitudinal context in healthy psychology students. Across five weeks, forty-two healthy psychology students (aged 18-35) were randomly allocated into two groups, receiving ten sessions of 30 minutes of active and sham ILF-NFT. Dependent variables were measured before, following, and two months after the intervention and were comprised of: heartrate variability assessments as a measure of stress resilience; digit span, n-back, trail making and go-no-go task measures of executive functioning performance; and SCL-90-R, WHOQOL-Bref, and peak performance measures of subjective self-report. Statistical analysis was performed using an ANCOVA and compared across groups correcting for baseline differences and multiple comparisons. ANCOVA analyses revealed no significant differences across active and placebo groups in any dependent variables, when correcting for multiple comparisons. Thus, the remaining analyses focused on questionnaire correlations. Here, significant correlations were observed between the novel peak performance questionnaire with the SCL-90-R and WHOQOL-Bref, confirming its construct and retest validity. Despite several methodological limitations, including a potential type-2 error, this study highlights limited effects of ILF-NFT in healthy volunteers. Future research should thus focus on clinically driven experimental designs to explore ILF-NFT's potential in psychiatric contexts. Further research utilization of the novel peak performance questionnaire is recommended for measures of peak performance.

Modulation of human frontal midline theta by neurofeedback: A systematic review and quantitative meta-analysis

Human brain activity consists of different frequency bands associated with varying functions. Oscillatory activity of frontal brain regions in the theta range (4-8 Hz) is linked to cognitive processing and can be modulated by neurofeedback - a technique where participants receive real-time feedback about their brain activity and learn to modulate it. However, criticism of this technique evolved, and high heterogeneity of study designs complicates a valid evaluation of its effectiveness. This meta-analysis provides the first systematic overview over studies attempting to modulate frontal midline theta with neurofeedback in healthy human participants. Out of 1261 articles screened, 14 studies were eligible for systematic review and 11 for quantitative meta-analyses. Studies were evaluated following the DIAD model and the PRISMA guidelines. A significant across-study effect of medium size (Hedges' g = .66; 95%-CI [-0.62, 1.73]) with substantial between-study heterogeneity (Q(16) = 167.43, p < .001) was observed and subanalysis revealed effective frontal midline theta upregulation. We discuss moderators of effect sizes and provide guidelines for future research in this dynamic field.

Successful learning of alpha up-regulation through neurofeedback training modulates sustained attention

As a fundamental attention function, sustained attention plays a critical role in general cognitive abilities and is closely linked to EEG alpha oscillations. Neurofeedback training (NFT) of alpha activity on different aspects of attention has been studied previously. However, it remains unclear how NFT with up- or down-regulation directions modulates sustained attention. Here we employed a counterbalanced single-blind sham-controlled crossover design, in which healthy young adults underwent one NFT session of alpha up-regulation, one NFT session of alpha down-regulation, and one sham-control NFT session over the posterior area. The session order was counterbalanced with a 7-day interval between each session. After each NFT session, the participants completed a visual continuous temporal expectancy task (vCTET) to assess their sustained attention performance. The results showed that compared to sham-control NFT, successful learning of alpha up-regulation resulted in increased reaction time at the beginning of the attention task but a slower increase over vCTET blocks. On the other hand, successful learning of alpha down-regulation had no impact on attention performance compared to sham-control NFT. These findings suggest that successful learning of alpha up-regulation through NFT could impair initial attention performance but slow down visual attention deterioration over time, i.e., alpha enhancement by NFT stabilizing visual attention.

Decoding the Debate: A Comparative Study of Brain-Computer Interface and Neurofeedback

Brain-Computer Interface (BCI) and Neurofeedback (NF) both rely on the technology to capture brain activity. However, the literature lacks a clear distinction between the two, with some scholars categorizing NF as a special case of BCI while others view BCI as a natural extension of NF, or classify them as fundamentally different entities. This ambiguity hinders the flow of information and expertise among scholars and can cause confusion. To address this issue, we conducted a study comparing BCI and NF from two perspectives: the background and context within which BCI and NF developed, and their system design. We utilized Functional Flow Block Diagram (FFBD) as a system modelling approach to visualize inputs, functions, and outputs to compare BCI and NF at a conceptual level. Our analysis revealed that while NF is a subset of the biofeedback method that requires data from the brain to be extracted and processed, the device performing these tasks is a BCI system by definition. Therefore, we conclude that NF should be considered a specific application of BCI technology. By clarifying the relationship between BCI and NF, we hope to facilitate better communication and collaboration among scholars in these fields.

Theta EEG neurofeedback promotes early consolidation of real life-like episodic memory

Theta oscillations are believed to coordinate neuronal activity related to human cognition, especially for memory functions. Theta power during learning and retrieval has been found to correlate with memory performance success. Additionally, up-regulating theta oscillations during a post-encoding epoch crucial for memory consolidation was previously shown to benefit long-term memory for acquired motor sequences, pictures, and object-location associations. However, it remains to be determined whether such effects would be found for more ecological aspects of long-term episodic memory. Therefore, the current study assessed neurofeedback-based theta upregulation effects on movie memory. After viewing a 15-minute silent, narrative movie, participants engaged in neurofeedback-based theta/beta up-regulation, neurofeedback beta/theta up-regulation as an active control condition, or an unrelated passive control task. Memory was tested three times: once immediately after watching the movie (as baseline); 24 hours thereafter; and once again 1 week later. Memory performance 1 week after encoding was significantly enhanced in the theta/beta up-regulation group compared with the other groups. Additionally, changes in neurofeedback theta/beta ratio from baseline EEG recordings correlated with long-term memory gains in retrieving the movie's content. These findings highlight the relationship between post-learning theta oscillations and the consolidation of episodic memory for a naturalistic event.

Neurofeedback for post-traumatic stress disorder: systematic review and meta-analysis of clinical and neurophysiological outcomes

Background: Posttraumatic stress disorder (PTSD) is a debilitating condition affecting millions of people worldwide. Existing treatments often fail to address the complexity of its symptoms and functional impairments resulting from severe and prolonged trauma. Electroencephalographic Neurofeedback (NFB) has emerged as a promising treatment that aims to reduce the symptoms of PTSD by modulating brain activity.Objective: We conducted a systematic review and meta-analysis of ten clinical trials to answer the question: how effective is NFB in addressing PTSD and other associated symptoms across different trauma populations, and are these improvements related to neurophysiological changes?Method: The review followed the Preferred Reporting Items for Systematic Reviews and Meta analyses guidelines. We considered all published and unpublished randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) involving adults with PTSD as a primary diagnosis without exclusion by type of trauma, co-morbid diagnosis, locality, or sex. Ten controlled studies were included; seven RCTs and three NRSIs with a total number of participants n = 293 (128 male). Only RCTs were included in the meta-analysis (215 participants; 88 male).Results: All included studies showed an advantage of NFB over control conditions in reducing symptoms of PTSD, with indications of improvement in symptoms of anxiety and depression and related neurophysiological changes. Meta-analysis of the pooled data shows a significant reduction in PTSD symptoms post-treatment SMD of -1.76 (95% CI -2.69, -0.83), and the mean remission rate was higher in the NFB group (79.3%) compared to the control group (24.4%). However, the studies reviewed were mostly small, with heterogeneous populations and varied quality.Conclusions: The effect of NFB on the symptoms of PTSD was moderate and mechanistic evidence suggested that NFB leads to therapeutic changes in brain functioning. Future research should focus on more rigorous methodological designs, expanded sample size and longer follow-up.

Neurofeedback Effect on Symptoms of Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis

Posttraumatic stress disorder (PTSD) encompasses various psychological symptoms and a high early dropout rate due to treatment unresponsiveness. In recent years, neurofeedback has been implemented to control PTSD's psychological symptoms through physiological brain regulation. However, a comprehensive analysis concerning its efficacy is lacking. Therefore, we conducted a systematic review and meta-analysis to determine neurofeedback's effect on reducing PTSD symptoms. We analyzed randomized and non-randomized controlled trials (RCTs) from 1990 to July 2020, evaluating neurofeedback treatments for those diagnosed with PTSD and their symptoms. In addition, we calculated the standardized mean difference (SMD)using random-effects models to estimate effect sizes. We assessed ten articles comprising 276 participants, with a - 0.74 SMD (95% confidence interval = - 0.9230, - 0.5567), 42% I2, moderate effect size, and - 1.40 to -0.08 prediction intervals (PI). Neurofeedback was more effective for complex trauma PTSD patients than single trauma. Increasing and lengthening sessions are more effective than fewer, condensed ones. Neurofeedback positively affected arousal, anxiety, depression, and intrusive, numbing, and suicidal thoughts. Therefore, neurofeedback is a promising and effective treatment for complex PTSD.

Mental strategies and resting state EEG: Effect on high alpha amplitude modulation by neurofeedback in healthy young adults

Neurofeedback (NFB) is a brain-computer interface which allows individuals to modulate their brain activity. Despite the self-regulatory nature of NFB, the effectiveness of strategies used during NFB training has been little investigated. In a single session of NFB training (6*3 min training blocks) with healthy young participants, we experimentally tested if providing a list of mental strategies (list group, N = 46), compared with a group receiving no strategies (no list group, N = 39), affected participants' neuromodulation ability of high alpha (10-12 Hz) amplitude. We additionally asked participants to verbally report the mental strategies used to enhance high alpha amplitude. The verbatim was then classified in pre-established categories in order to examine the effect of type of mental strategy on high alpha amplitude. First, we found that giving a list to the participants did not promote the ability to neuromodulate high alpha activity. However, our analysis of the specific strategies reported by learners during training blocks revealed that cognitive effort and recalling memories were associated with higher high alpha amplitude. Furthermore, the resting amplitude of trained high alpha frequency predicted an amplitude increase during training, a factor that may optimize inclusion in NFB protocols. The present results also corroborate the interrelation with other frequency bands during NFB training. Although these findings are based on a single NFB session, our study represents a further step towards developing effective protocols for high alpha neuromodulation by NFB.

Exploring the Effects of EEG-Based Alpha Neurofeedback on Working Memory Capacity in Healthy Participants

Neurofeedback, an operant conditioning neuromodulation technique, uses information from brain activities in real-time via brain-computer interface (BCI) technology. This technique has been utilized to enhance the cognitive abilities, including working memory performance, of human beings. The aims of this study are to investigate how alpha neurofeedback can improve working memory performance in healthy participants and to explore the underlying neural mechanisms in a working memory task before and after neurofeedback. Thirty-six participants divided into the NFT group and the control group participated in this study. This study was not blinded, and both the participants and the researcher were aware of their group assignments. Increasing power in the alpha EEG band was used as a neurofeedback in the eyes-open condition only in the NFT group. The data were collected before and after neurofeedback while they were performing the N-back memory task (N = 1 and N = 2). Both groups showed improvement in their working memory performance. There was an enhancement in the power of their frontal alpha and beta activities with increased working memory load (i.e., 2-back). The experimental group showed improvements in their functional connections between different brain regions at the theta level. This effect was absent in the control group. Furthermore, brain hemispheric lateralization was found during the N-back task, and there were more intra-hemisphere connections than inter-hemisphere connections of the brain. These results suggest that healthy participants can benefit from neurofeedback and from having their brain networks changed after the training.

Probing fMRI brain connectivity and activity changes during emotion regulation by EEG neurofeedback

Despite the existence of several emotion regulation studies using neurofeedback, interactions among a small number of regions were evaluated, and therefore, further investigation is needed to understand the interactions of the brain regions involved in emotion regulation. We implemented electroencephalography (EEG) neurofeedback with simultaneous functional magnetic resonance imaging (fMRI) using a modified happiness-inducing task through autobiographical memories to upregulate positive emotion. Then, an explorative analysis of whole brain regions was done to understand the effect of neurofeedback on brain activity and the interaction of whole brain regions involved in emotion regulation. The participants in the control and experimental groups were asked to do emotion regulation while viewing positive images of autobiographical memories and getting sham or real (based on alpha asymmetry) EEG neurofeedback, respectively. The proposed multimodal approach quantified the effects of EEG neurofeedback in changing EEG alpha power, fMRI blood oxygenation level-dependent (BOLD) activity of prefrontal, occipital, parietal, and limbic regions (up to 1.9% increase), and functional connectivity in/between prefrontal, parietal, limbic system, and insula in the experimental group. New connectivity links were identified by comparing the brain functional connectivity between experimental conditions (Upregulation and View blocks) and also by comparing the brain connectivity of the experimental and control groups. Psychometric assessments confirmed significant changes in positive and negative mood states in the experimental group by neurofeedback. Based on the exploratory analysis of activity and connectivity among all brain regions involved in emotion regions, we found significant BOLD and functional connectivity increases due to EEG neurofeedback in the experimental group, but no learning effect was observed in the control group. The results reveal several new connections among brain regions as a result of EEG neurofeedback which can be justified according to emotion regulation models and the role of those regions in emotion regulation and recalling positive autobiographical memories.

Increased top-down control of emotions during symptom provocation working memory tasks following a RCT of alpha-down neurofeedback in PTSD

BACKGROUND

Posttraumatic stress disorder (PTSD) has been found to be associated with emotion under-modulation from the prefrontal cortex and a breakdown of the top-down control of cognition and emotion. Novel adjunct therapies such as neurofeedback (NFB) have been shown to normalize aberrant neural circuits that underlie PTSD psychopathology at rest. However, little evidence exists for NFB-linked neural improvements under emotionally relevant cognitive load. The current study sought to address this gap by examining the effects of alpha-down NFB in the context of an emotional n-back task.

METHODS

We conducted a 20-week double-blind randomized, sham-controlled trial of alpha-down NFB and collected neuroimaging data before and after the NFB protocol. Participants performed an emotional 1-back and 2-back working memory task, with interleaved trauma-neutral and trauma-relevant cues in the fMRI scanner. Data from 35 participants with a primary diagnosis of PTSD were analyzed in this study (n = 18 in the experimental group undergoing alpha-down NFB, n = 17 in the sham-control group).

RESULTS

Firstly, within-group analyses showed clinically significant reductions in PTSD symptom severity scores at the post-intervention timepoint and 3-month follow-up for the experimental group, and not for the sham-control group. The neuroimaging analyses revealed that alpha-down NFB enhanced engagement of top-down cognitive and emotional control centers, such as the dorsolateral prefrontal cortex (dlPFC), and improved integration of the anterior and posterior parts of the default mode network (DMN). Finally, our results also indicate that increased alpha-down NFB performance correlated with increased activity in brain regions involved in top-down control and bodily consciousness/embodied processing of self (TPJ and posterior insula).

CONCLUSION

This is the first study to provide mechanistic insights into how NFB may normalize dysfunctional brain activity and connectivity in PTSD under cognitive load with simultaneous symptom provocation, adding to a growing body of evidence supporting the therapeutic neuromodulatory effects of NFB. This preliminary study highlights the benefits of alpha-down NFB training as an adjunctive therapy for PTSD and warrants further investigation into its therapeutic effects on cognitive and emotion control in those with PTSD.

Can neurofeedback provide evidence of direct brain-behavior causality?

Neurofeedback is a procedure that measures brain activity in real-time and presents it as feedback to an individual, thus allowing them to self-regulate brain activity with effects on cognitive processes inferred from behavior. One common argument is that neurofeedback studies can reveal how the measured brain activity causes a particular cognitive process. The causal claim is often made regarding the measured brain activity being manipulated as an independent variable, similar to brain stimulation studies. However, this causal inference is vulnerable to the argument that other upstream brain activities change concurrently and cause changes in the brain activity from which feedback is derived. In this paper, we outline the inference that neurofeedback may causally affect cognition by indirect means. We further argue that researchers should remain open to the idea that the trained brain activity could be part of a "causal network" that collectively affects cognition rather than being necessarily causally primary. This particular inference may provide a better translation of evidence from neurofeedback studies to the rest of neuroscience. We argue that the recent advent of multivariate pattern analysis, when combined with implicit neurofeedback, currently comprises the strongest case for causality. Our perspective is that although the burden of inferring direct causality is difficult, it may be triangulated using a collection of various methods in neuroscience. Finally, we argue that the neurofeedback methodology provides unique advantages compared to other methods for revealing changes in the brain and cognitive processes but that researchers should remain mindful of indirect causal effects.

Combined Aerobic Exercise and Neurofeedback Lead to Improved Task-Relevant Intrinsic Network Synchrony

Lifestyle interventions such as exercise and mindfulness training have the potential to ameliorate mental health symptoms and restore dysregulated intrinsic connectivity network (ICN) dynamics, seen in many psychopathologies. Multiple lifestyle interventions, in combination, may interact synergistically for enhanced benefits. While the impacts of lifestyle interventions on subjective measures of mood are well-documented, their impacts on ICN dynamics are not well-established. In this study, we assessed the validity of EEG-derived measures of ICN dynamics as potential markers of mood disorders, by tracking ICN dynamics and mood symptoms through the course of a longitudinal exercise intervention. Specifically, we investigated the separate and combined effects of aerobic exercise and mindfulness-like neurofeedback training on task-linked ICN dynamics of the default mode network (DMN), central executive network (CEN), and salience network (SN). Participants were assigned pseudo-randomly into four experimental conditions—Control, Running, Neurofeedback, and Combined, performing the corresponding intervention for 16 sessions across 8 weeks. Intervention-linked changes in ICN dynamics were studied using EEG-based neuroimaging scans before and after the 8-week intervention, during which participants performed multiple blocks of autobiographical memory recall (AM) and working memory (WM) trials, designed to activate the DMN and CEN, respectively, and to activate the SN in conjunction with the task-appropriate network. The EEG-based features for classification of the three core networks had been identified in our prior research from simultaneously recorded EEG and fMRI during the same AM and WM tasks. We categorized participants as “responders” or “non-responders” based on whether the exercise intervention increased their aerobic capacity (VO2-max) (Running/Combined group), and/or neurofeedback increased the percentage time spent in the calm mindfulness state (Neurofeedback/Combined group). In responders, compared to each intervention alone, the combined exercise-neurofeedback intervention resulted in a more healthy CEN-SN synchrony pattern. Interestingly, non-responders to neurofeedback exhibited a maladaptive pattern of persistent, task-inappropriate DMN-SN synchrony which we speculate could be linked to depressive rumination. Furthermore, the CEN-SN synchrony at baseline predicted NFB response with up to 80% accuracy, demonstrating the potential utility of such network-based biomarkers in personalizing intervention plans.

Enhancing Brain Connectivity With Infra-Low Frequency Neurofeedback During Aging: A Pilot Study

Aging is associated with decreased functional connectivity in the main brain networks, which can underlie changes in cognitive and emotional processing. Neurofeedback is a promising non-pharmacological approach for the enhancement of brain connectivity. Previously, we showed that a single session of infra-low frequency neurofeedback results in increased connectivity between sensory processing networks in healthy young adults. In the current pilot study, we aimed to evaluate the possibility of enhancing brain connectivity during aging with the use of infra-low frequency neurofeedback. Nine females aged 52 ± 7 years with subclinical signs of emotional dysregulation, including anxiety, mild depression, and somatoform symptoms, underwent 15 sessions of training. A resting-state functional MRI scan was acquired before and after the training. A hypothesis-free intrinsic connectivity analysis showed increased connectivity in regions in the bilateral temporal fusiform cortex, right supplementary motor area, left amygdala, left temporal pole, and cerebellum. Next, a seed-to-voxel analysis for the revealed regions was performed using the post- vs. pre-neurofeedback contrast. Finally, to explore the whole network of neurofeedback-related connectivity changes, the regions revealed by the intrinsic connectivity and seed-to-voxel analyses were entered into a network-based statistical analysis. An extended network was revealed, including the temporal and occipital fusiform cortex, multiple areas from the visual cortex, the right posterior superior temporal sulcus, the amygdala, the temporal poles, the superior parietal lobule, and the supplementary motor cortex. Clinically, decreases in alexithymia, depression, and anxiety levels were observed. Thus, infra-low frequency neurofeedback appears to be a promising method for enhancing brain connectivity during aging, and subsequent sham-controlled studies utilizing larger samples are feasible.

Infra-Low Frequency Neurofeedback in Tension-Type Headache: A Cross-Over Sham-Controlled Study

Primary headaches are highly prevalent and represent a major cause of disability in young adults. Neurofeedback is increasingly used in the treatment of chronic pain; however, there are few studies investigating its efficacy in patients with headaches. We report the results of a cross-over sham-controlled study on the efficacy of neurofeedback in the prophylactic treatment of tension-type headache (TTH). Participants received ten sessions of infra-low frequency electroencephalographic neurofeedback and ten sessions of sham-neurofeedback, with the order of treatments being randomized. The study also included a basic psychotherapeutic intervention — a psychoeducational session performed before the main study phases and emotional support provided throughout the study period. The headache probability was modeled as a function of the neurofeedback and sham-neurofeedback sessions performed to date. As a result, we revealed a strong beneficial effect of neurofeedback and no influence of the sham sessions. The study supports the prophylactic use of infra-low frequency neurofeedback in patients with TTH. From a methodological point of view, we advocate for the explicit inclusion of psychotherapeutic components in neurofeedback study protocols.

Sharpening Working Memory With Real-Time Electrophysiological Brain Signals: Which Neurofeedback Paradigms Work?

Growing evidence supports the idea that the ultimate biofeedback is to reward sensory pleasure (e.g., enhanced visual clarity) in real-time to neural circuits that are associated with a desired performance, such as excellent memory retrieval. Neurofeedback is biofeedback that uses real-time sensory reward to brain activity associated with a certain performance (e.g., accurate and fast recall). Working memory is a key component of human intelligence. The challenges are in our current limited understanding of neurocognitive dysfunctions as well as in technical difficulties for closed-loop feedback in true real-time. Here we review recent advancements of real time neurofeedback to improve memory training in healthy young and older adults. With new advancements in neuromarkers of specific neurophysiological functions, neurofeedback training should be better targeted beyond a single frequency approach to include frequency interactions and event-related potentials. Our review confirms the positive trend that neurofeedback training mostly works to improve memory and cognition to some extent in most studies. Yet, the training typically takes multiple weeks with 2-3 sessions per week. We review various neurofeedback reward strategies and outcome measures. A well-known issue in such training is that some people simply do not respond to neurofeedback. Thus, we also review the literature of individual differences in psychological factors e.g., placebo effects and so-called "BCI illiteracy" (Brain Computer Interface illiteracy). We recommend the use of Neural modulation sensitivity or BCI insensitivity in the neurofeedback literature. Future directions include much needed research in mild cognitive impairment, in non-Alzheimer's dementia populations, and neurofeedback using EEG features during resting and sleep for memory enhancement and as sensitive outcome measures.

Moral wounds run deep: exaggerated midbrain functional network connectivity across the default mode network in posttraumatic stress disorder

BACKGROUND

A moral injury occurs when a deeply held moral code has been violated, and it can lead to the development of symptoms of posttraumatic stress disorder (PTSD). However, the neural correlates that differentiate moral injury and PTSD remain largely unknown. Intrinsic connectivity networks such as the default mode network (DMN) appear to be altered in people with PTSD who have experienced moral injury. However, brainstem, midbrain and cerebellar systems are rarely integrated into the intrinsic connectivity networks; this is a critical oversight, because these systems display marked differences in people with PTSD and are thought to underlie strong moral emotions such as shame, guilt and betrayal.

METHODS

We conducted an independent component analysis on data generated during script-driven memory recall of moral injury in participants with military- or law enforcement-related PTSD (n = 28), participants with civilian-related PTSD (n = 28) and healthy controls exposed to a potentially morally injurious event (n = 18). We conducted group-wise comparisons of functional network connectivity differences across a DMN-correlated independent component, with a particular focus on brainstem, midbrain and cerebellar systems.

RESULTS

We found stronger functional network connectivity in the midbrain periaqueductal grey (t ₇₁ = 4.95, p _FDR = 0.028, k = 39) and cerebellar lobule IX (t ₇₁ = 4.44, p _FDR = 0.046, k = 49) in participants with civilian-related PTSD as compared to healthy controls. We also found a trend toward stronger functional network connectivity in the midbrain periaqueductal grey (t ₇₁ = 4.22, p _FDR = 0.076, k = 60) in participants with military- or law enforcement-related PTSD as compared to healthy controls.

LIMITATIONS

The significant clusters were large, but resolution is generally lower for subcortical structures.

CONCLUSION

In PTSD, the DMN appears to be biased toward lower-level, midbrain systems, which may drive toxic shame and related moral emotions that are common in PTSD, highlighting the depth at which moral injuries are represented neurobiologically.

EEG-heart rate connectivity changes after sensorimotor rhythm neurofeedback training: Ancillary study

OBJECTIVES

Neurofeedback can induce long-term changes in brain functional connectivity, but its influence on the connectivity between different physiological systems is unknown. The present paper is an ancillary study of a previous paper that confirmed the effect of neurofeedback on brain connectivity associated with chronic pain. We analysed the influence of neurofeedback on the connectivity between the electroencephalograph (EEG) and heart rate (HR).

METHODS

Seventeen patients diagnosed with fibromyalgia were divided into three groups: good sensorimotor rhythm (SMR) training responders (n = 4), bad SMR responders (n = 5) and fake training (SHAM, n = 8). Training consisted of six sessions in which participants learned to synchronize and desynchronize SMR power. Before the first training (pre-resting state) and sixth training (post-resting state) session, open-eye resting-state EEG and electrocardiograph signals were recorded.

RESULTS

Good responders reduced pain ratings after SMR neurofeedback training. This improvement in fibromyalgia symptoms was associated with a reduction of the connectivity between the central area and HR, between central and frontal areas, within the central area itself, and between central and occipital areas. The sham group and poor responders experienced no changes in their fibromyalgia symptoms.

CONCLUSIONS

Our results provide new evidence that neurofeedback is a promising tool that can be used to treat of chronic pain syndromes and to obtain a better understanding of the interactions between physiological networks. These findings are preliminary, but they may pave the way for future studies that are more methodologically robust. In addition, new research questions are raised: what is the role of the central-peripheral network in chronic pain and what is the effect of neurofeedback on this network.

Closed-loop Modulation of the Self-regulating Brain: A Review on Approaches, Emerging Paradigms, and Experimental Designs

Closed-loop approaches, setups, and experimental designs have been applied within the field of neuroscience to enhance the understanding of basic neurophysiology principles (closed-loop neuroscience; CLNS) and to develop improved procedures for modulating brain circuits and networks for clinical purposes (closed-loop neuromodulation; CLNM). The contents of this review are thus arranged into the following sections. First, we describe basic research findings that have been made using CLNS. Next, we provide an overview of the application, rationale, and therapeutic aspects of CLNM for clinical purposes. Finally, we summarize methodological concerns and critics in clinical practice of neurofeedback and novel applications of closed-loop perspective and techniques to improve and optimize its experiments. Moreover, we outline the theoretical explanations and experimental ideas to test animal models of neurofeedback and discuss technical issues and challenges associated with implementing closed-loop systems. We hope this review is helpful for both basic neuroscientists and clinical/ translationally-oriented scientists interested in applying closed-loop methods to improve mental health and well-being.

Neurofeedback with low-cost, wearable electroencephalography (EEG) reduces symptoms in chronic Post-Traumatic Stress Disorder

BACKGROUND

The study examines the effectiveness of both neurofeedback and motor-imagery brain-computer interface (BCI) training, which promotes self-regulation of brain activity, using low-cost electroencephalography (EEG)-based wearable neurotechnology outside a clinical setting, as a potential treatment for post-traumatic stress disorder (PTSD) in Rwanda.

METHODS

Participants received training/treatment sessions along with a pre- and post- intervention clinical assessment, (N = 29; control n = 9, neurofeedback (NF, 7 sessions) n = 10, and motor-imagery (MI, 6 sessions) n = 10). Feedback was presented visually via a videogame. Participants were asked to regulate (NF) or intentionally modulate (MI) brain activity to affect/control the game.

RESULTS

The NF group demonstrated an increase in resting-state alpha 8-12 Hz bandpower following individual training sessions, termed alpha 'rebound' (Pz channel, p = 0.025, all channels, p = 0.024), consistent with previous research findings. This alpha 'rebound', unobserved in the MI group, produced a clinically relevant reduction in symptom severity in NF group, as revealed in three of seven clinical outcome measures: PCL-5 (p = 0.005), PTSD screen (p = 0.005), and HTQ (p = 0.005).

LIMITATIONS

Data collection took place in environments that posed difficulties in controlling environmental factors. Nevertheless, this limitation improves ecological validity, as neurotechnology treatments must be deployable outside controlled environments, to be a feasible technological treatment.

CONCLUSIONS

The study produced the first evidence to support a low-cost, neurotechnological solution for neurofeedback as an effective treatment of PTSD for victims of acute trauma in conflict zones in a developing country.

Neurofeedback Modulation of the Sound-induced Flash Illusion Using Parietal Cortex Alpha Oscillations Reveals Dependency on Prior Multisensory Congruency

Spontaneous neural oscillations are key predictors of perceptual decisions to bind multisensory signals into a unified percept. Research links decreased alpha power in the posterior cortices to attention and audiovisual binding in the sound-induced flash illusion (SIFI) paradigm. This suggests that controlling alpha oscillations would be a way of controlling audiovisual binding. In the present feasibility study we used MEG-neurofeedback to train one group of subjects to increase left/right and another to increase right/left alpha power ratios in the parietal cortex. We tested for changes in audiovisual binding in a SIFI paradigm where flashes appeared in both hemifields. Results showed that the neurofeedback induced a significant asymmetry in alpha power for the left/right group, not seen for the right/left group. Corresponding asymmetry changes in audiovisual binding in illusion trials (with 2, 3, and 4 beeps paired with 1 flash) were not apparent. Exploratory analyses showed that neurofeedback training effects were present for illusion trials with the lowest numeric disparity (i.e., 2 beeps and 1 flash trials) only if the previous trial had high congruency (2 beeps and 2 flashes). Our data suggest that the relation between parietal alpha power (an index of attention) and its effect on audiovisual binding is dependent on the learned causal structure in the previous stimulus. The present results suggests that low alpha power biases observers towards audiovisual binding when they have learned that audiovisual signals originate from a common origin, consistent with a Bayesian causal inference account of multisensory perception.

Using Neurofeedback to Restore Inter-Hemispheric Imbalance: A Study Protocol for Adults With Dyslexia

Neurofunctional models of developmental dyslexia (DD) point out disruption of the left-lateralized reading network. In individuals with DD, the left temporo-parietal (TP) regions are underactivated during reading tasks and a dysfunctional activation of the contralateral regions is reported. After a successful reading intervention, left TP lateralization was found to be increased in children with DD. Previous studies measured the effect of modulating the excitability of the left TP cortex using non-invasive brain stimulation (NIBS) in individuals with reading difficulties, showing significant reading improvements. NIBS exclusion criteria and safety guidelines may limit its application in settings without medical supervision and in younger populations. Neurofeedback (NF) training could be an alternative intervention method for modulating the inter-hemispheric balance of the temporal–parietal regions in DD. To date, the effect of NF on reading has been scarcely investigated. Few protocols increasing beta activity in underactivated areas showed improved reading outcomes. However, none of the previous studies designed the NF intervention based on a neurofunctional model of DD. We aim to propose a study protocol for testing the efficacy of a NF training specifically designed for inducing a functional hemispheric imbalance of the tempo-parietal regions in adults with DD. A randomized clinical trial aimed at comparing two experimental conditions is described: (a) Enhancing left beta/theta power ratio NF training in combination with reducing right beta/theta power ratio NF training and (b) sham NF training.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier [NCT04989088].

Motor Preparation and Execution for Performance Difficulty: Centroparietal Beta Activation during the Effort Expenditure for Rewards Task as a Function of Motivation

Debate exists as to the effects of anxiety in performance-based studies. However, no studies have examined the influence of motivation both in preparation of a motor movement and during movement performance. The present study measured beta activation in preparation for and during execution of the effort expenditure for rewards task (EEfRT), a button-pressing task consisting of easy and hard trials. Results indicated that motor preparation (i.e., reduced beta activation) was greater in preparation for hard trials than for easy trials. Additionally, motor preparation decreased (i.e., beta activation increased) over the course of hard trial execution. These results suggest that motor preparation is enhanced prior to more challenging tasks but that motor preparation declines as participants become closer to completing their goal in each challenging trial. These results provide insight into how beta activation facilitates effort expenditure for motor tasks varying in difficulty and motivation. The impact of these results on models of anxiety and performance is discussed.

EEG Neurofeedback for Anxiety Disorders and Post-Traumatic Stress Disorders: A Blueprint for a Promising Brain-Based Therapy

PURPOSE OF REVIEW

This review provides an overview of current knowledge and understanding of EEG neurofeedback for anxiety disorders and post-traumatic stress disorders.

RECENT FINDINGS

The manifestations of anxiety disorders and post-traumatic stress disorders (PTSD) are associated with dysfunctions of neurophysiological stress axes and brain arousal circuits, which are important dimensions of the research domain criteria (RDoC). Even if the pathophysiology of these disorders is complex, one of its defining signatures is behavioral and physiological over-arousal. Interestingly, arousal-related brain activity can be modulated by electroencephalogram-based neurofeedback (EEG NF), a non-pharmacological and non-invasive method that involves neurocognitive training through a brain-computer interface (BCI). EEG NF is characterized by a simultaneous learning process where both patient and computer are involved in modifying neuronal activity or connectivity, thereby improving associated symptoms of anxiety and/or over-arousal. Positive effects of EEG NF have been described for both anxiety disorders and PTSD, yet due to a number of methodological issues, it remains unclear whether symptom improvement is the direct result of neurophysiological changes targeted by EEG NF. Thus, in this work we sought to bridge current knowledge on brain mechanisms of arousal with past and present EEG NF therapies for anxiety and PTSD. In a nutshell, we discuss the neurophysiological mechanisms underlying the effects of EEG NF in anxiety disorder and PTSD, the methodological strengths/weaknesses of existing EEG NF randomized controlled trials for these disorders, and the neuropsychological factors that may impact NF training success.

Neurofeedback for cognitive enhancement and intervention and brain plasticity

In recent years, neurofeedback has been used as a cognitive training tool to improve brain functions for clinical or recreational purposes. It is based on providing participants with feedback about their brain activity and training them to control it, initiating directional changes. The overarching hypothesis behind this method is that this control results in an enhancement of the cognitive abilities associated with this brain activity, and triggers specific structural and functional changes in the brain, promoted by learning and neuronal plasticity effects. Here, we review the general methodological principles behind neurofeedback and we describe its behavioural benefits in clinical and experimental contexts. We review the non-specific effects of neurofeedback on the reinforcement learning striato-frontal networks as well as the more specific changes in the cortical networks on which the neurofeedback control is exerted. Last, we analyse the current challenges faces by neurofeedback studies, including the quantification of the temporal dynamics of neurofeedback effects, the generalisation of its behavioural outcomes to everyday life situations, the design of appropriate controls to disambiguate placebo from true neurofeedback effects and the development of more advanced cortical signal processing to achieve a finer-grained real-time modelling of cognitive functions.

Effectiveness, Cost-Utility, and Safety of Neurofeedback Self-Regulating Training in Patients with Post-Traumatic Stress Disorder: A Randomized Controlled Trial

Post-traumatic stress disorder (PTSD) is characterized by neurophysiological and psycho-emotional problems after exposure to trauma. Several pharmacological and psychotherapy limitations, such as adverse events and low adherence, increase the need for alternative therapeutic options. Neurofeedback is widely used for PTSD management. However, evidence of its clinical efficacy is lacking. We conducted a randomized, waitlist-controlled, assessor-blinded clinical trial to assess the effectiveness, cost-utility, and safety of 16 sessions of neurofeedback on people with PTSD for eight weeks. Eleven participants were allocated to each group. One and two subjects dropped out from the neurofeedback and control groups, respectively. The primary outcome was PTSD symptom change evaluated using the PTSD Checklist-5 (PCL-5-K). The PCL-5-K levels improved more in the neurofeedback group (44.3 ± 10.8 to 19.4 ± 7.75) than in the control group (35.1 ± 18.5 to 31.0 ± 14.92). The change value was significantly improved in the neurofeedback group (24.90 ± 13.13 vs. 4.11 ± 9.03). Secondary outcomes such as anxiety, depression, insomnia, and quality of life were also improved. In an economic analysis using EuroQol-5D, the incremental cost-per-quality-adjusted life-year was approximately $15,600, indicating acceptable cost-utility. There were no adverse events in either group. In conclusion, neurofeedback might be a useful, cost-effective, and safe intervention for PTSD management.

Validation of eyes-closed resting alpha amplitude predicting neurofeedback learning of upregulation alpha activity

Neurofeedback training (NFT) enables users to learn self-control of EEG activity of interest and then to create many benefits on cognitive function. A considerable number of nonresponders who fail to achieve successful NFT have often been reported in the within-session prediction. This study aimed to investigate successful EEG NFT of upregulation alpha activity in terms of trainability, independence, and between-session predictability validation. Forty-six participants completed 12 training sessions. Spectrotemporal analysis revealed the upregulation success on brain activity of 8-12 Hz exclusively to demonstrate trainability and independence of alpha NFT. Three learning indices of between-session changes exhibited significant correlations with eyes-closed resting state (ECRS) alpha amplitude before the training exclusively. Through a stepwise linear discriminant analysis, the prediction model of ECRS's alpha frequency band amplitude exhibited the best accuracy (89.1%) validation regarding the learning index of increased alpha amplitude on average. This study performed a systematic analysis on NFT success, the performance of the 3 between-session learning indices, and the validation of ECRS alpha activity for responder prediction. The findings would assist researchers in obtaining insight into the training efficacy of individuals and then attempting to adapt an efficient strategy in NFT success.

The Effects of Theta EEG Neurofeedback on the Consolidation of Spatial Memory

How can the stability of a recently acquired memory be improved? Recent findings regarding the importance of theta frequency EEG activity in the hippocampus suggest that entraining neural activity in that frequency band might increase post-encoding waking replay, reinforcing learning-related plasticity. Our previous studies revealed that upregulating postlearning theta power using EEG neurofeedback (NFB) significantly benefitted procedural and episodic memory performance (both immediate and delayed), and may provide optimal conditions for stabilization of new memories. We have now explored whether memory benefits of theta NFB generalize to delayed spatial memory, an additional hippocampus-dependent process. Participants learned to associate object images with locations on a computer screen. NFB was used to enable participants to selectively increase scalp EEG theta power for 30 minutes. Visuo-spatial memory was tested one week later, with the theta NFB participants compared with 2 control groups (beta-augmentation NFB as an active control group, and an additional passive control group that did not engage in NFB). Theta upregulation was found to improve visuo-spatial memory, as reflected in reduced error distances in location marking and faster reaction time for correct answers by the theta group. This supports the contention that theta upregulation immediately after learning strengthens early consolidation of visuo-spatial memory. This intervention could potentially benefit various memory-challenged populations, as well as healthy individuals.

A Multivariate Randomized Controlled Experiment about the Effects of Mindfulness Priming on EEG Neurofeedback Self-Regulation Serious Games

Neurofeedback training (NFT) is a technique often proposed to train brain activity SR with promising results. However, some criticism has been raised due to the lack of evaluation, reliability, and validation of its learning effects. The current work evaluates the hypothesis that SR learning may be improved by priming the subject before NFT with guided mindfulness meditation (MM). The proposed framework was tested in a two-way parallel-group randomized controlled intervention with a single session alpha NFT, in a simplistic serious game design. Sixty-two healthy naïve subjects, aged between 18 and 43 years, were divided into MM priming and no-priming groups. Although both the EG and CG successfully attained the up-regulation of alpha rhythms (F(1,59) = 20.67, p < 0.001, ηp2 = 0.26), the EG showed a significantly enhanced ability (t(29) = 4.38, p < 0.001) to control brain activity, compared to the CG (t(29) = 1.18, p > 0.1). Furthermore, EG superior performance on NFT seems to be explained by the subject’s lack of awareness at pre-intervention, less vigour at post-intervention, increased task engagement, and a relaxed non-judgemental attitude towards the NFT tasks. This study is a preliminary validation of the proposed assisted priming framework, advancing some implicit and explicit metrics about its efficacy on NFT performance, and a promising tool for improving naïve “users” self-regulation ability.

Neurofeedback Training of the Control Network Improves Children's Performance with an SSVEP-based BCI

In the past 20 years, neural engineering has made unprecedented progress in the interpretation of brain information (e.g., brain-computer interfaces) and in neuromodulation (e.g., electromagnetic stimulation and neurofeedback). However, there has been little research aiming to improve the performance of brain-computer interfaces (BCIs) using neuromodulation. The present study presents a novel design for a neurofeedback training (NFT) method to improve the operation of a steady-state visual evoked potential (SSVEP)-based BCI and further explores its underlying mechanisms. The use of NFT to upregulate alpha-band power in the user's parietal lobe is presented in this study as a new neuromodulation method to improve SSVEP-based BCI in this study. After users completed this NFT intervention, the signal-to-noise ratio (SNR), accuracy, and information transfer rate (ITR) of the SSVEP-based BCI were increased by 5.8%, 4.7%, and 15.6%, respectively. However, no improvement was observed in the control group in which the subjects did not participate in NFT. Moreover, a general reinforcement of the information flow from the parietal lobe to the occipital lobe was observed. Evidence from a network analysis and an attention test further indicates that NFT improves attention by developing the control capacity of the parietal lobe and then enhances the above SSVEP indicators. Upregulating the amplitude of parietal alpha oscillations using NFT significantly improves the SSVEP-based BCI performance by modulating the control network. The study validates an effective neuromodulation method and possibly contributes to explaining the function of the parietal lobe in the control network.

A Sham-Controlled Study of Neurofeedback for Pain Management

Background

Neurofeedback (NFB) attempts to alter the brain’s electrophysiological activity and has shown potential as a pain management technique. Existing studies, however, often lack appropriate control groups or fail to assess whether electrophysiological activity has been successfully regulated. The current study is a randomized controlled trial comparing changes in brain activity and pain during NFB with those of a sham-control group.

Methods

An experimental pain paradigm in healthy participants was used to provide optimal control of pain sensation. Twenty four healthy participants were blind randomized to receive either 10 × NFB (with real EEG feedback) or 10 × sham (with false EEG feedback) sessions during noxious cold stimulation. Prior to actual NFB training, training protocols were individually determined for each participant based on a comparison of an initial 32-channel qEEG assessment administered at both baseline and during an experimental pain task. Each individual protocol was based on the electrode site and frequency band that showed the greatest change in amplitude during pain, with alpha or theta up-regulation at various electrode sites (especially Pz) the most common protocols chosen. During the NFB sessions themselves, pain was assessed at multiple times during each session on a 0–10 rating scale, and ANOVA was used to examine changes in pain ratings and EEG amplitude both across and during sessions for both NFB and sham groups.

Results

For pain, ANOVA trend analysis found a significant general linear decrease in pain across the 10 sessions (p = 0.015). However, no significant main or interaction effects of group were observed suggesting decreases in pain occurred independently of NFB. For EEG, there was a significant During Session X Group interaction (p = 0.004), which indicated that EEG amplitude at the training site was significantly closer to the target amplitude for the NFB compared to the sham group during painful stimulation, but this was only the case at the beginning of the cold task.

Conclusion

While these results must be interpreted within the context of an experimental pain model, they underline the importance of including an appropriate comparison group to avoid attributing naturally occurring changes to therapeutic effects.

Effects of Transcranial Alternating Current Stimulation and Neurofeedback on Alpha (EEG) Dynamics: A Review

Transcranial alternating current stimulation (tACS) and neurofeedback (NFB) are two different types of non-invasive neuromodulation techniques, which can modulate brain activity and improve brain functioning. In this review, we compared the current state of knowledge related to the mechanisms of tACS and NFB and their effects on electroencephalogram (EEG) activity (online period/stimulation period) and on aftereffects (offline period/post/stimulation period), including the duration of their persistence and potential behavioral benefits. Since alpha bandwidth has been broadly studied in NFB and in tACS research, the studies of NFB and tACS in modulating alpha bandwidth were selected for comparing the online and offline effects of these two neuromodulation techniques. The factors responsible for variability in the responsiveness of the modulated EEG activity by tACS and NFB were analyzed and compared too. Based on the current literature related to tACS and NFB, it can be concluded that tACS and NFB differ a lot in the mechanisms responsible for their effects on an online EEG activity but they possibly share the common universal mechanisms responsible for the induction of aftereffects in the targeted stimulated EEG band, namely Hebbian and homeostatic plasticity. Many studies of both neuromodulation techniques report the aftereffects connected to the behavioral benefits. The duration of persistence of aftereffects for NFB and tACS is comparable. In relation to the factors influencing responsiveness to tACS and NFB, significantly more types of factors were analyzed in the NFB studies compared to the tACS studies. Several common factors for both tACS and NFB have been already investigated. Based on these outcomes, we propose several new research directions regarding tACS and NFB.

Electrophysiological correlates of improved executive function following EEG neurofeedback in adult attention deficit hyperactivity disorder

OBJECTIVE

Event-related potentials (ERPs) are reported to be altered in relation to cognitive processing deficits in attention deficit hyperactivity disorder (ADHD). However, this evidence is mostly limited to cross-sectional data. The current study utilized neurofeedback (NFB) as a neuromodulatory tool to examine the ERP correlates of attentional and inhibitory processes in adult ADHD using a single-session, within-subject design.

METHODS

We recorded high-density EEG in 25 adult ADHD patients and 22 neurotypical controls during a Go/NoGo task, before and after a 30-minute NFB session designed to down-regulate the alpha (8-12 Hz) rhythm.

RESULTS

At baseline, ADHD patients demonstrated impaired Go/NoGo performance compared to controls, while Go-P3 amplitude inversely correlated with ADHD-associated symptomatology in childhood. Post NFB, task performance improved in both groups, significantly enhancing stimulus detectability (d-prime) and reducing reaction time variability, while increasing N1 and P3 ERP component amplitudes. Specifically for ADHD patients, the pre-to-post enhancement in Go-P3 amplitude correlated with measures of improved executive function, i.e., enhanced d-prime, reduced omission errors and reduced reaction time variability.

CONCLUSIONS

A single-session of alpha down-regulation NFB was able to reverse the abnormal neurocognitive signatures of adult ADHD during a Go/NoGo task.

SIGNIFICANCE

The study demonstrates for the first time the beneficial neurobehavioral effect of a single NFB session in adult ADHD, and reinforces the notion that ERPs could serve as useful diagnostic/prognostic markers of executive dysfunction.

Interacting brains coming in sync through their minds: an interbrain neurofeedback study

Neurophysiological evidence shows that interpersonal action coordination is accompanied by interbrain synchronization (IBS). However, the functional significance of this association remains unclear. Using two experimental designs, we explored whether IBS is amenable to neurofeedback (NFB). Feedback was provided either as two balls approaching each other (so-called ball design), or as two pendula, each reflecting the oscillatory activity of one of the two participants (so-called pendulum design). The NFB was provided at delta (i.e., 2.5 Hz) and theta (i.e., 5 Hz) electroencephalography frequencies, and manipulated by enhanced and inverse feedback. We showed that the participants were able to increase IBS by using NFB, especially when it was fed back at the theta frequency. Apart from intra- and interbrain coupling, other oscillatory activities (e.g., power spectral density, peak amplitude, and peak frequency) also changed during the task compared with the rest. Moreover, all the measures showed specific correlations with the subjective postsurvey item scores, reflecting subjective feeling and appraisal. We conclude that the use of IBS for NFB might help in specifying the contribution of IBS to interpersonal action coordination and in providing important information about the neural mechanisms of social interaction and the causal dimension of IBS.

From reversal to normal: Robust improvement in conflict adaptation through real-time functional near infrared spectroscopy-based neurofeedback training

Conflict adaptation refers to the improved conflict control induced after experiencing conflict and is a prominent index of adaptive cognitive control. Reversal of conflict adaptation may be maladaptive and predictive of certain mental disorders. Here, we employed real-time functional near infrared spectroscopy-based neurofeedback training, with the left dorsolateral prefrontal cortex as the target brain area, to investigate whether reversal of conflict adaptation during a word-color Stroop task could be recovered to be normal. Healthy human individuals with reversal pattern of conflict adaptation in the pretest were randomly assigned into the experimental or control groups. Distributed training for 80 min led to greater improvements in the experimental group who received real neurofeedback compared to those in the control group who received sham neurofeedback. These results indicated causal evidence for understanding the generation of conflict adaptation and heighten the prospects of clinical application of neurofeedback training.

Reinforcement of Self-Regulated Brain Activity in Schizophrenia Patients Undergoing Rehabilitation

The experiment was aimed to compare the effects of different forms of rehabilitation applied in patients with schizophrenia. Verification of the obtained results was based on the analysis of the level of cognitive and social functioning of the subjects. For this purpose, the following clinical tools were used: Positive and Negative Syndrome Scale (PANSS), Beck Cognitive Insight Scale (BCIS), Color Trial Test (CTT-1, CTT-2), d2 psychological tests, Acceptance of Illness Scale (AIS), Self-efficacy Scale (GSES), Quantitative Electroencephalogram Biofeedback (QEEG-BF), auditory event-related potentials (ERPs), and serum levels of brain-derived neurotrophic factor (BDNF). The subjects were mentally stable male schizophrenia patients who had been in remission. They were divided into two groups which received different types of rehabilitation for three months. Group 1 patients followed a standard rehabilitation and Group 2 patients received GSR Biofeedback (galvanic skin response Biofeedback, GSR-BF) training. Pretherapy and posttherapy measurements were made for each group. Experimental rehabilitation based on GSR-BF training resulted in regulatory control of neurophysiological mechanisms, and the parameters obtained demonstrated improvement in the subjects' cognitive and social function. The following therapy outcomes were observed: (1) reduce psychopathological symptoms (2) improving cognitive (concentration, attention) and social functions (3) increase in the neurotrophic factor BDNF. GSR-BF can be used as an alternative to conventional rehabilitation in schizophrenia patients.

Closed-loop neurostimulation for affective symptoms and disorders: An overview

Affective and anxiety disorders are the most prevalent and incident psychiatric disorders worldwide. Therapeutic approaches to these disorders using non-invasive brain stimulation (NIBS) and analogous techniques have been extensively investigated. In this paper, we discuss the combination of NIBS and neurofeedback in closed-loop setups and its application for affective symptoms and disorders. For this, we first provide a rationale for this combination by presenting some of the main original findings of NIBS, with a primary focus on transcranial magnetic stimulation (TMS), and neurofeedback, including protocols based on electroencephalography (EEG) and functional magnetic resonance imaging (fMRI). Then, we provide a scope review of studies combining real-time neurofeedback with NIBS protocols in the so-called closed-loop brain state-dependent neuromodulation (BSDS). Finally, we discuss the concomitant use of TMS and real-time functional near-infrared spectroscopy (fNIRS) as a possible solution to the current limitations of BSDS-based protocols for affective and anxiety disorders.

Believing is achieving - On the role of treatment expectation in neurofeedback applications

In neurofeedback applications, neural activity is recorded, processed in real-time and fed back to the user in order to facilitate self-regulation of the putative neural mechanisms that underlie cognition and behavior. Numerous studies suggest that neurofeedback interventions are an efficacious treatment particularly for patients with attention-deficit/hyperactivity disorder (ADHD). In recent years, however, findings of several well-controlled studies raised doubts concerning the proposed mechanism of action behind the behavioral effect of neurofeedback. This study investigated the impact of expectation on the efficacy of a sensorimotor rhythm (SMR) training. In a within-subjects design 30 blinded volunteers with ADHD symptoms received a standard SMR training session after inducing no (no-expectancy condition), positive (placebo condition), and negative (nocebo condition) expectations regarding the effectiveness of neurofeedback (by telling them that they would train a specific frequency band that was previously shown to be either unrelated to attention, should improve attention, or interfere with attentional processes). After each training, participants were presented with a cognitive test and subsequently requested to rate their performance on it. We could show that participants were able to successfully modify their EEG signal during training. Further, we found an effect over trainings on objective attentional performance. Most importantly, we found that the expectancy of positive or negative treatment effects considerably changed participants' perception of neurofeedback's efficacy even in the absence of any objective evidence. This study presents strong first evidence for a substantial effect of self-confirming response expectancies as one factor underlying the efficacy of neurofeedback. Future research has to carefully consider the impact of such psychosocial mechanisms when evaluating the (specific) efficacy of neuromodulatory treatments.

ADHD: Reviewing the Causes and Evaluating Solutions

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder in which patients present inattention, hyperactivity, and impulsivity. The etiology of this condition is diverse, including environmental factors and the presence of variants of some genes. However, a great diversity exists among patients regarding the presence of these ADHD-associated factors. Moreover, there are variations in the reported neurophysiological correlates of ADHD. ADHD is often treated pharmacologically, producing an improvement in symptomatology, albeit there are patients who are refractory to the main pharmacological treatments or present side effects to these drugs, highlighting the importance of developing other therapeutic options. Different non-pharmacological treatments are in this review addressed, finding diverse results regarding efficacy. Altogether, ADHD is associated with different etiologies, all of them producing changes in brain development, leading to the characteristic symptomatology of this condition. Given the heterogeneous etiology of ADHD, discussion is presented about the convenience of personalizing ADHD treatment, whether pharmacological or non-pharmacological, to reach an optimum effect in the majority of patients. Approaches to personalizing both pharmacological therapy and neurofeedback are presented.

PET Imaging of Dopamine Neurotransmission During EEG Neurofeedback

Neurofeedback (NFB) is a brain-based training method that enables users to control their own cortical oscillations using real-time feedback from the electroencephalogram (EEG). Importantly, no investigations to date have directly explored the potential impact of NFB on the brain's key neuromodulatory systems. Our study's objective was to assess the capacity of NFB to induce dopamine release as revealed by positron emission tomography (PET). Thirty-two healthy volunteers were randomized to either EEG-neurofeedback (NFB) or EEG-electromyography (EMG), and scanned while performing self-regulation during a single session of dynamic PET brain imaging using the high affinity D2/3 receptor radiotracer, [18F]Fallypride. NFB and EMG groups down-regulated cortical alpha power and facial muscle tone, respectively. Task-induced effects on endogenous dopamine release were estimated in the frontal cortex, anterior cingulate cortex, and thalamus, using the linearized simplified reference region model (LSRRM), which accounts for time-dependent changes in radiotracer binding following task initiation. Contrary to our hypothesis of a differential effect for NFB vs. EMG training, significant dopamine release was observed in both training groups in the frontal and anterior cingulate cortex, but not in thalamus. Interestingly, a significant negative correlation was observed between dopamine release in frontal cortex and pre-to-post NFB change in spontaneous alpha power, suggesting that intra-individual changes in brain state (i.e., alpha power) could partly result from changes in neuromodulatory tone. Overall, our findings constitute the first direct investigation of neurofeedback's effect on the endogenous release of a key neuromodulator, demonstrating its feasibility and paving the way for future studies using this methodology.

Differential Effects of Up- and Down-Regulation of SMR Coherence on EEG Activity and Memory Performance: A Neurofeedback Training Study

Modulating connectivity measures in EEG-based neurofeedback studies is assumed to be a promising therapeutic and training tool. However, little is known so far about its effects and trainability. In the present study, we investigated the effects of up- and down-regulating SMR (12-15 Hz) coherence by means of neurofeedback training on EEG activity and memory functions. Twenty adults performed 10 neurofeedback training sessions in which half of them tried to increase EEG coherence between Cz and CPz in the SMR frequency range, while the other half tried to down-regulate coherence. Up-regulation of SMR coherence led to between- and within-session changes in EEG coherence. SMR power increased across neurofeedback training sessions but not within training sessions. Cross-over training effects on baseline EEG measures were also observed in this group. Up-regulation of SMR coherence was also associated with improvements in memory functions when comparing pre- and post-test results. Participants were not able to down-regulate SMR coherence. This group did not show any changes in baseline EEG measures or memory functions comparing pre- and post-test. Our results provide insights in the trainability and effects of connectivity-based neurofeedback training and indications for its practical application.

Changes in attentional processing following neurofeedback in patients with persistent post-concussive symptoms: a pilot study

OBJECTIVE

Persistent post-concussive symptoms (PPCS) often include attention deficits, particularly orienting and executive attention. Research in other clinical populations has demonstrated that neurofeedback therapy (NFT) is effective at improving orienting and executive attention, although its effects on attentional networks in patients with PPCS are unknown.

METHOD

In this single-group pilot study, we examined attention-related event-related potentials (ERPs) - N1 and P3 - and cognitive outcomes following Live Z-score training (LZT), a variant of NFT.

RESULTS

No changes in early selective attention, as indexed by N1 amplitude, were observed; however, P3 amplitude, which indexes neural resource allocation, increased following LZT and returned to baseline by 3 months. Cognitive performance improved following treatment, which was sustained at 3 months. The magnitude of change in P3 and ANT performance did not differ between orienting or executive attention, suggesting LZT improved general attentional processing efficiency.

CONCLUSION

Our results suggest that LZT may positively affect attention globally, but does not target specific attention networks. These pilot data warrant the initiation of a clinical trial evaluating the effectiveness of LZT for treating attention deficits in patients with PPCS.

A randomized, controlled trial of alpha-rhythm EEG neurofeedback in posttraumatic stress disorder: A preliminary investigation showing evidence of decreased PTSD symptoms and restored default mode and salience network connectivity using fMRI

OBJECTIVE

The default-mode network (DMN) and salience network (SN) have been shown to display altered connectivity in posttraumatic stress disorder (PTSD). Restoring aberrant connectivity within these networks with electroencephalogram neurofeedback (EEG-NFB) has been shown previously to be associated with acute decreases in symptoms. Here, we conducted a double-blind, sham-controlled randomized trial of alpha-rhythm EEG-NFB in participants with PTSD (n = 36) over 20-weeks. Our aim was to provide mechanistic evidence underlying clinical improvements by examining changes in network connectivity via fMRI.

METHODS

We randomly assigned participants with a primary diagnosis of PTSD to either the experimental group (n = 18) or sham-control group (n = 18). We collected resting-state fMRI scans pre- and post-NFB intervention, for both the experimental and sham-control PTSD groups. We further compared baseline brain connectivity measures pre-NFB to age-matched healthy controls (n = 36).

RESULTS

With regard to the primary outcome measure of PTSD severity, we found a significant main effect of time in the absence of a group × time interaction. Nevertheless, we found significantly decreased PTSD severity scores in the experimental NFB group only, when comparing post-NFB (dz = 0.71) and 3-month follow-up scores (dz = 0.77) to baseline measures. Interestingly, we found evidence to suggest a shift towards normalization of DMN and SN connectivity post-NFB in the experimental group only. Both decreases in PTSD severity and NFB performance were correlated to DMN and SN connectivity post-NFB in the experimental group. Critically, remission rates of PTSD were significant higher in the experimental group (61.1%) as compared to the sham-control group (33.3%).

CONCLUSION

The current study shows mechanistic evidence for therapeutic changes in DMN and SN connectivity that are known to be associated with PTSD psychopathology with no patient dropouts. This preliminary investigation merits further research to demonstrate fully the clinical efficacy of EEG-NFB as an adjunctive therapy for PTSD.

Individual variation in alpha neurofeedback training efficacy predicts pain modulation

•

Sensorimotor alpha neurofeedback training effect on pain perception was assessed.

•

Neurofeedback training decreased the sensory-discriminative aspect of pain.

•

Neurofeedback training increased the affective-motivational aspect of pain.

•

Pain modulation by neurofeedback training was dependent upon the training efficacy.

•

Neurofeedback training efficacy predicted sensory-discriminative pain modulation.

Studies have shown an association between sensorimotor α-oscillation and pain perception. It suggests the potential use of neurofeedback (NFB) training for pain modulation through modifying sensorimotor α-oscillation. Here, a single-session NFB training protocol targeted on increasing sensorimotor α-oscillations was applied to forty-five healthy participants. Pain thresholds to nociceptive laser stimulations and pain ratings (intensity and unpleasantness) to identical laser painful stimulations were assessed immediately before and after NFB training. Participants had larger pain thresholds, but rated the identical painful laser stimulation as more unpleasant after NFB training. These pain measurements were further compared between participants with high or low NFB training efficacy that was quantified as the regression slope of α-oscillation throughout the ten training blocks. A significant increase in pain thresholds was observed among participants with high-efficacy; whereas a significant increase in pain ratings was observed among participants with low-efficacy. These results suggested that NFB training decreased the sensory-discriminative aspect of pain, but increased the affective-motivational aspect of pain, whereas both pain modulations were dependent upon the NFB training efficacy. Importantly, correlation analysis across all participants revealed that a greater NFB training efficacy predicted a greater increase in pain thresholds particularly at hand contralateral to NFB target site, but no significant correlation was observed between NFB training efficacy and modulation on pain ratings. It thus provided causal evidence for a link between sensorimotor α-oscillation and the sensory-discriminative aspect of pain, and highlighted the need for personalized neurofeedback for the benefits on pain modulation at the individual level. Future studies can adopt a double-blind sham-controlled protocol to validate NFB training induced pain modulation.

Posttraumatic Stress Disorder Is Associated with α Dysrhythmia across the Visual Cortex and the Default Mode Network

Anomalies in default mode network (DMN) activity and α (8–12 Hz) oscillations have been independently observed in posttraumatic stress disorder (PTSD). Recent spatiotemporal analyses suggest that α oscillations support DMN functioning via interregional synchronization and sensory cortical inhibition. Therefore, we examined a unifying pathology of α deficits in the visual-cortex-DMN system in PTSD. Human patients with PTSD (N = 25) and two control groups, patients with generalized anxiety disorder (GAD; N = 24) and healthy controls (HCs; N = 20), underwent a standard eyes-open resting state (S-RS) and a modified resting state (M-RS) of passively viewing salient images (known to deactivate the DMN). High-density electroencephalogram (hdEEG) were recorded, from which intracortical α activity (power and connectivity/Granger causality) was extracted using the exact low-resolution electromagnetic tomography (eLORETA). Patients with PTSD (vs GAD/HC) demonstrated attenuated α power in the visual cortex (VC) and key hubs of the DMN [posterior cingulate cortex (PCC) and medial prefrontal cortex (mPFC)] at both states, the severity of which further correlated with hypervigilance symptoms. With increased visual input (at M-RS vs S-RS), patients with PTSD further demonstrated reduced α-frequency directed connectivity within the DMN (PCC→mPFC) and, importantly, from the VC to both DMN hubs (VC→PCC and VC→mPFC), linking α deficits in the two systems. These interrelated α deficits align with DMN hypoactivity/hypoconnectivity, sensory disinhibition, and hypervigilance in PTSD, representing a unifying neural underpinning of these anomalies. The identification of visual-cortex-DMN α dysrhythmia in PTSD further presents a novel therapeutic target, promoting network-based intervention of neural oscillations.

Modulation of Intrinsic Brain Connectivity by Implicit Electroencephalographic Neurofeedback

Despite the increasing popularity of neurofeedback, its mechanisms of action are still poorly understood. This study aims to describe the processes underlying implicit electroencephalographic neurofeedback. Fifty-two healthy volunteers were randomly assigned to a single session of infra-low frequency neurofeedback or sham neurofeedback, with electrodes over the right middle temporal gyrus and the right inferior parietal lobule. They observed a moving rocket, the speed of which was modulated by the waveform derived from a band-limited infra-low frequency filter. Immediately before and after the session, the participants underwent a resting-state fMRI. Network-based statistical analysis was applied, comparing post- vs. pre-session and real vs. sham neurofeedback conditions. As a result, two phenomena were observed. First, we described a brain circuit related to the implicit neurofeedback process itself, consisting of the lateral occipital cortex, right dorsolateral prefrontal cortex, left orbitofrontal cortex, right ventral striatum, and bilateral dorsal striatum. Second, we found increased connectivity between key regions of the salience, language, and visual networks, which is indicative of integration in sensory processing. Thus, it appears that a single session of implicit infra-low frequency electroencephalographic neurofeedback leads to significant changes in intrinsic brain connectivity.