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EpilepsyEpilepsy

Meta-Analysis of EEG Biofeedback in Treating Epilepsy by Tan G, Thornby J, Hammond DC, Strehl U, Canady B, Arnemann K and Kaiser DA Journal of Clinical EEG & Neuroscience, July, 2009

ABSTRACT About one third of patients with epilepsy do not benefit from medical treatment. For these patients electroencephalographic (EEG) biofeedback is a viable alternative. EEG biofeedback, or neurofeedback, normalizes or enhances EEG activity by means of operant conditioning. While dozens of scientific reports have been published on neurofeedback for seizure disorder, most have been case series with too few subjects to establish efficacy. The purpose of this paper is to meta-analyze existing research on neurofeedback and epilepsy.

We analyzed every EEG biofeedback study indexed in MedLine, PsychInfo, and PsychLit databases between 1970 and 2005 on epilepsy that provided seizure frequency change in response to feedback. Sixty-three studies have been published, 10 of which provided enough outcome information to be included in a meta-analysis. All studies consisted of patients whose seizures were not controlled by medical therapies, which is a very important factor to keep in mind when interpreting the results. Nine of 10 studies reinforced sensorimotor rhythms (SMR) while 1 study trained slow cortical potentials (SCP). All studies reported an overall mean decreased seizure incidence following treatment and 64 out of 87 patients (74%) reported fewer weekly seizures in response to EEG biofeedback. Treatment effect was mean log (post/pre) where pre and post represent number of seizures per week prior to treatment and at final evaluation, respectively. Due to prevalence of small groups, Hedges’s g was computed for effect size. As sample heterogeneity was possible (Q test, p=.18), random effects were assumed and the effect of intervention was -0.233, SE= 0.057, z = -4.11, p<.001.

Based on this meta-analysis, EEG operant conditioning was found to produce a significant reduction on seizure frequency. This finding is especially noteworthy given the patient group, individuals who had been unable to control their seizures with medical treatment.

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Basic Concepts and Clinical Findings in the Treatment of Seizure Disorders with EEG Operant Conditioning (abs.) by Sterman MB

Two issues concerning sensorimotor EEG operant conditioning, or biofeedback, as a therapeutic modality for the treatment of seizure disorders are the focus of this review.

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Neurofeedback Treatment of Epilepsy (abs.) by Walker JE and Kozlowski GP

With electroencephalographic (EEG) biofeedback (or neurofeedback), it is possible to train the brain to de-emphasize rhythms that lead to generation and propagation of seizure and emphasize rhythms that make seizures less likely to occur.

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Research Papers

Neuropsychological Assessment of Subjects with Uncontrolled Epilepsy: Effects of EEG Feedback Training (abs.) by Lantz DL and Sterman MB

A battery of neuropsychological tests was administered at baseline, postcontrol period, and posttraining period to 24 drug-refractory subjects with epilepsy participating in a study of sensorimotor electroencephalographic (EEG) normalization feedback training.

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EEG Feedback Training in the Treatment of Epilepsy: Some Questions and Some Answers (abs.) by Kuhlman WN and Allison T

A basic question in EEG feedback training of epileptic patients is whether the decrease in seizures is specifically due to the training or to other factors. Questions may also be raised as to what EEG changes are involved. Preliminary results in five patients suggest that seizure reductions can occur with training which are not due to placebo or nonspecific effects or to changes in medication compliance.

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EEG Feedback Training of Epileptic Patients: Clinical and Electroencephalographic Analysis (abs.) by Kuhlman WN

To evaluate the clinical efficacy and mechanisms underlying EEG feedback training of epileptic patients, 5 adult patients with poorly controlled seizures were studied for 4-10 months during which quantitative analysis of seizures, the EEG, and serum anticonvulsant levels was conducted. Sustained seizure reduction did not occur during the first 4-5 weeks in which feedback signals were presented randomly in relation to the EEG. When feedback was then made contingent upon central 9-14 c/sec activity, seizures declined by 60% in 3 patients.

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EEG Biofeedback and Relaxation Training in the Control of Epileptic Seizures (abs.) by Tozzo CA, Elfner LF, May JG

Research utilizing sensorimotor rhythm (SMR) biofeedback with epileptics suggests that it is useful in decreasing seizures. Subjects were 6 young adults with a diagnosis of epilepsy of at least two years who had been unable to control their seizures with different regimens of anticonvulsant medications.

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EEG Operant Conditioning in Intractable Epileptics (abs.) by Lubar JF, Shabsin HS, Natelson SE, Holder GS, Whitsett SF, Pamplin WE, Krulikowski DI

Eight epileptic patients with mixed seizures refractory to medical control participated in a double-blind crossover study to determine the effectiveness of operant conditioning of the EEG as an anticonvulsant procedure. Baseline levels of seizures were recorded for four months prior to the beginning of treatment. Participants then received false (noncontingent) feedback for two months followed by an ABA-patterned training program lasting a total of ten months.

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Operant Conditioning of the EEG in Two Patients with Epilepsy: Methodologic and Clinical Considerations (abs.) by Finley WW

Methodologic and clinical considerations are discussed in sensorimotor rhythm (SMR) biofeedback research on two dissimilar but severe epileptic males. The first case, an akinetic epileptic who prior to feedback training experienced 80-100 clinical seizures every 10 hours, showed considerable seizure reduction after 6 months of SMR and epileptiform training.

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EEG Operant Conditioning for Control of Epilepsy (abs.) by Wyler AR, Robbins CA, Dodrill CB

We report the results of 23 severely epileptic patients who were given EEG feedback training. The paradigm reinforced the patients’ 18 Hz activity over the scalp approximation of their focus while suppressing temporalis EMG and low frequency EEG activity.

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Complex Partial Epilepsy: A Therapeutic Model of Behavioral Management and EEG Biofeedback by Reiter JM R.D., Lambert DJ, Andrews A, Cobb TE&K

Individuals with complex partial epilepsy” are managed most often by medical neurologists whose primary focus is the treatment of seizures with anticonvulsant medication. Paradoxically, often these medications produce interference with thinking and memory, and drowsiness.

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Predictive Factors for Controlling Seizures Using a Behavioral Approach by Andrews DA and Schonfeld WH

A behavioral approach using EEG biofeedback for controlling complex-partial seizures has been successful at the Andrews/Reiter Epilepsy Research Program.

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Remediation of Nocturnal Seizures by EEG Biofeedback (abs. pg. 5) by Walker J M.D.

Two cases of epilepsy are presented with seizures occurring only at night. The first case was a 34 year old woman with post-traumatic seizures dating from early childhood. Her seizures always occurred after going to bed at night, either while falling asleep (20%) 3-5 hours, or after falling asleep (80%).

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Relationship Between Epilepsy and ADHD, Learning Disability and Mental Retardation (pg. 11) by Hughes J

One theory for the understanding of ADHD is the under-activity of the mesolimbic orbital frontal area, (i.e., a “lazy” frontal lobe). Data show that uncontrolled seizures cause a decline in school results, even when the seizures are short lasting, with subtle manifestations.

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Changes in Lateralized Memory Performance in Subjects With Epilepsy Following Neurofeedback Training (abs. pg. 2) by Sterman MB Ph.D. and Lantz D. Ph.D.

Both seizure reduction and neuropsycho- logical improvements have been reported following neurofeedback training directed to normalization of the sensorimotor EEG. These findings could be interpreted as nonspecific effects rather than specific changes brought about by EEG training.

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Behavioural Treatment of Slow Cortical Potentials in Intractable Epilepsy: Neuropsychological Predictors of Outcome (abs.) by Daum I, Rockstroh B, Birbaumer N, Elbert T, Canavan A, Lutzenberger W

The study aimed to explore the predictive value of neuropsychological tests within the context of acquisition of slow cortical potential (SCP) self-control, a technique which has beneficial effects on seizure frequency in epilepsy. Patients with epilepsy who successfully achieved SCP control had longer digit or block-tapping spans than less successful patients.

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Effects of Sham Feedback Following Successful SMR Training in an Epileptic: Follow-up Study (abs.) by Finley WW

After 1 year of SMR biofeedback training of a severe epileptic teenage male, incidence of atonic seizures decreased from 8/hr to less than 1/3 hr. SMR increased from 10% to 70%. Epileptiform discharges decreased from 45% to 15%.

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Neurotherapy and Drug Therapy in Combination for Adult ADHD, Personality Disorder and Seizure Disorder: A Case Report by Hansen LM B.S., Trudeau DL M.D., Grace DL Ph.D.

This is a case report of an adult female patient with ADHD, temporal seizure disorder, and Borderline Personality Disorder treated with 30 weekly sessions of SMR neurofeedback and carbamazepine. Post treatment measures showed improvements in T.O.V.A., self report and QEEG. Both neurofeedback and carbamazepine showed the most effect in early treatment. Progress continued after discontinuance of the drug.

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Biofeedback in Epileptics: Equivocal Relationship of Reinforced EEG Frequency to Seizure Reduction (abs.) by Kaplan BJ

It has been reported that biofeedback training of 12- to 14-Hz activity recorded over Rolandic cortex was accompanied by a reduction in seizure incidence in four human epileptics (Sterman et al., 1974).

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Changes in EEG Power Spectra During Biofeedback of Slow Cortical Potentials in Epilepsy (abs.) by Kotchoubey B, Busch S, Strehl U, Birbaumer N

The goal of the study was to explore parallel changes in EEG spectral frequencies during biofeedback of slow cortical potentials (SCPs) in epilepsy patients. Thirty-four patients with intractable focal epilepsy participated in 35 sessions of SCP self-regulation training.

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Modification of Slow Cortical Potentials in Patients with Refractory Epilepsy: A Controlled Outcome Study (abs.) by Kotchoubey B, Strehl U, Uhlmann C, Holzapfel S, König M, Fröscher W, Blankenhorn V, Birbaumer N

To compare self-regulation of low-frequency EEG components (slow cortical potentials, SCPs) with other methods of seizure control for patients with drug-refractory partial epilepsy and to separate the real anti-convulsive effect from placebo effects.

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Behavioral Management of Epileptic Seizures Following EEG Biofeedback Training of the Sensorimotor Rhythm (abs.) by Lubar JF and Bahler WW

Eight severely epileptic patients, four males and four females, ranging in age from 10 to 29 years, were trained to increase 12-14 Hzeta EEG activity from the regions overlying the Rolandic area. This activity, the sensorimotor rhythm (SMR), has been hypothesized to be related to motor inhibitory processes (Sterman, 1974).

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Cortical Self-Regulation in Patients with Epilepsies (abs.) by Rockstroh B, Elbert T, Birbaumer N, Wolf P, Düchting-Röth A, Reker M, Daum I, Lutzenberger W, Dichgans J

The present study aimed at investigating to what extent the regulation of excitability in cortical networks, as indicated by surface-negative slow cortical potentials (SCPs), is impaired in epileptic patients and to what extent training of SCP self-regulation by means of biofeedback and instrumental learning procedures might affect seizure frequency.

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Effects of Central Cortical EEG Feedback Training on Incidence of Poorly Controlled Seizures (abs.) by Sterman MB and Macdonald LR

This study examined the clinical effects of central cortical EEG feedback training in 8 patients with poorly controlled seizures.

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Quantitative Analysis of Training, Sleep EEG and Clinical Response to EEG Operant Conditioning in Epileptics (abs.) by Sterman MB and Shouse MN

This report is a follow-up to a previous paper which described seizure rate changes with central cortical EEG feedback training in 8 poorly controlled epileptic subjects.

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Biofeedback Treatment in Patients with Refractory Epilepsy: Changes in Depression and Control Orientation (abs.) by Uhlmann C and Fröscher W

Depression is a common and serious interictal problem in patients with epilepsy. The genesis of depressive disorders is multifactorial. One aetiological aspect focuses on psychosocial factors.

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A Double-Blind Investigation of the Relationship Between Seizure Activity and the Sleep EEG Following EEG Biofeedback Training (abs.) by Whitsett SF, Lubar JF, Holder GS, Pamplin WE, Shabsin HS

The sleep EEGs of eight medically refractory epileptic patients were examined as part of a double-blind, ABA crossover study designed to determine the effectiveness of EEG biofeedback for the control of seizures.

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EEG-Biofeedback and Epilepsy: Concept, Methodology and Tools for (Neuro)therapy Planning and Objective Evaluation by Kirlangic ME, MS

Objective diagnosis and therapy evaluation are still challenging tasks for many neurological disorders. This is highly related to the diversity of cases and the variety of treatment modalities available. Especially in the case of epilepsy, which is a complex disorder not well-explained at the biochemical and physiological levels, there is the need for investigations for novel features, which can be extracted and quantified from electrophysiological signals in clinical practice.

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Related Research

Nonpharmacologic Management of Epilepsy Comorbidities (pdf) by Stella B Legarda, MD; Susan Ford, BCIA-EEG4; Alexei Kondratyev, PhD; Karen Gale, PhD

Neurofeedback is in essence EEG operant conditioning. The individual receiving neurofeedback is given a computerized visual program to watch, the content of which is mostly driven by real-time EEG “behavior” at examiner-selected EEG frequencies. Along these lines, the individual is cued with respect to the presence of excessive excursions in EEG amplitudes that may arise from paroxysmal activity and other physiologic noncephalic factors.

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EEG and Clinical Predictors of Medically Intractable Childhood Epilepsy (abs.) by Ko TS and Holmes GL

To identify electroencephalographic and clinical factors associated with both seizure control and medical intractability in children with epilepsy.

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Overtreatment in Children with Epilepsy (abs.) by Holmes GL

Children with epilepsy are at risk for overtreatment, defined as the use of an excessive number or amount of antiepiletic drugs (AEDs).

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New Concepts in Neonatal Seizures (abs.) by Holmes GL, Khazipov R, Ben-Ari Y

The immature brain is more prone to seizures than the older brain as a result of an imbalance between excitatory and inhibitory input.

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