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ROSHI Journal

Vol 1 No 8

The Untapped Potential of Neurofeedback
by William G. Collins, PhD

There are number of clinical groups that have received little research attention in the neurofeedback literature. One such group is individuals with severe traumatic brain injury (TBI). The benefits or efficacy of neurofeedback with this population has remained basically untested for number of reasons. The treatment of this population is significantly long term and often demands a multimodal approach. The cost of this treatment by can be in the tens of thousands of dollars. The standard medical belief is that a patient more than one year post injury will recover very little function. This results in almost no treatment options given and no further insurance reimbursement. The patient is left in limbo with little hope for recovery.

My son, David, is one of the individuals in this population. The reason for writing this paper is to show how neurofeedback can be utilized over time with significant results. The limitations mentioned above did not apply in this case because treatment was delivered by myself, thus limiting the cost significantly and allowing the treatment to span a number of years. This is an overview of the history and treatment of David who is now 27 years old.

David sustained a severe TBI as a result of an auto accident when he was 17 years old. He was the passenger in a car that hit a tree on the driver's side going about sixty miles an hour. The tree hooked the rear driver side wheel and spun the car around creating tremendous centripetal force. The impact left him with brain stem sheering and a small bleed near the right thalamic lobe. He was in a closed-eye coma for three days and in the hospital for three months. At three months the doctors determined that no further treatment was available and they suggested that he be placed in a nursing home permanently.

He was subsequently taken home and his room was equipped as a hospital room would be. He was nonverbal and non-ambulatory. He didn’t have a gag reflex so he couldn’t take liquid or food by mouth. He received sustenance by way of a G tube. He was in constant pain and slept for about two to three hours at a time. Because of the pain and his sleeping routine, somebody needed to be available to him 24 hours a day. At seven months post injury we began to communicate by going through lines of the alphabet and having him look up when we found a letter he wanted.

After 18 months, his condition began to improve slightly but new problems unfolded. His mood was volatile and his judgment was poor. He could back his wheel chair through a sliding glass door, while at physical therapy, or put his foot through the car windshield when being driven someplace. It was often unclear what the provocation was. This continued at a gradually reduced frequency until a year ago. I am mentioning these things to point out the degree and severity of his head injury.

We began searching for alternative treatment methods soon after he was brought home. We discontinued all prescription meds upon coming home. Our searching resulted in a seven year odyssey to find ways to help our son recover and as much function as was humanly possible. Neurofeedback was initiated at about six years post accident with very little success. David’s attention span was very short and his ability to visually track what was on the screen was difficult.

When he was tired or stressed his eyes would rotate up and to the left again, making it difficult to focus on the feedback screen. About a year ago I began to look into the Roshi and trying to find out what results people were achieving with it. This led me to Dr. Ibric and Chuck Davis. I began using the Roshi about six months ago and we have seen steady and significant progress since. Progress that far exceeded any gains in the proceeding nine years.

At the beginning of treatment with the Roshi, he was still unable to attend to the feedback screen for any length of time so I began treating him nocturnally. The active electrodes placed at FP1 and FP2. The reference and ground were placed on the left and right mastoid. This electrode placement was used because he was treated at night when asleep lying in his bed. Treatments averaged two to four hours a night, five to six days a week. This was done for three months.

Soon after I began treating him with the Roshi the degree of emotional volatility and the intensity of his aggressive behavior began dropping off dramatically. Currently there is almost no aggressive behavior. When he does get upset it’s brief and minimal. We have also seen a dramatic improvement in memory. David's awareness of his social surroundings and the appropriateness of his interactions with others have also improved dramatically. The use of the word dramatically is not an overuse of the word.

A year ago it would have been impossible or foolish to put him in the front seat of the car because of the behavioral described above. Now he drives everywhere in the front seat. A year ago the degree to which he could focus on the interactions in a group or try to be part of that were minimal. Now he seems to be very aware - interested in what's going on around him and makes every effort to participate.

Six months ago he would ask to go someplace and 15 minutes later would forget that he had asked. Now he remembers from day to day what he is wants to do or a place he wants to go. For 9 years he couldn’t/wouldn’t use the bathroom for bowels. Now he is using the bathroom every other day. He is able to eat things that he wasn’t previously able to handle. A peach six months ago would have presented two problems, one, slippery texture (easy to slide down the wrong way) and juice (easy to choke because he could not maneuver swallowing juice well). Today he can and does eat a peach, with enjoyment! He is polite, is often thanking us for helping him do something; this from a boy whose most often words were “I want…”, as he would spell out many times a day.

For years he has groaned and moaned at different times. We would explain that he was indeed making sounds, and all he needed to do was move his lips and practice a bit. He could not accept that the sounds he was making were of his volition, and would not try or work at making sounds. He simply did not understand how the sounds coming from him could be made into language once again. A year ago, he would rather sit in his chair, head down, rather immobile, waiting for another meal. He did not want to have a physical therapist do range of motion on him, he did not want to spell out more than a few words, he wanted to sleep, and sit. Movies didn’t enamor him, television didn’t get turned on, no music. His brain was telling his body to do less, do less, do less.

David 18 months ago
The picture, here, is of David a year and a half ago when he was at an inpatient physical therapy center here in St. Louis for six weeks. His wheelchair has lumbar and side supports. It’s was difficult for him to hold his head up for any length of time so there’s a head support. The bed can be totally enclosed so he can not fall out accidentally or, in our case, on purpose.

More Progress
Two weeks ago his first new word came out of his mouth, “Mom”. Since then he is practicing vowel sounds, says “Hi” to friends and family and has attempted several other words. His speech therapist is very pleased.

Nine years ago when we began communicating through the “letter board”, his first words were, “I want to die.” Last week when he communicated to us he said, “I love life.” The length of this article does not permit us to show all the differences. Needless to say, we are excited and looking forward to the next “new” accomplishment.

As the result of a recent trip to Dr. Ibric’s office and training by Dr. Hudspeth I've begun looking at the issue of connectivity (coherence) and have incorporated that in David's therapy. Thus far I have done about four twenty minute sessions using this approach. The active electrodes are now placed site specific based on Dr. Hudspeth's connectivity maps (currently FZ, T3). The results of this brief treatment are a decrease in the upper body and facial spasticity. This seems to have a given David greater control over mouth and tongue movement as well as the ability to push air past his vocal cords.

David now
The picture here was taken this weekend in our back yard. The contrast is stark. He has more control over his entire body. For years he has had a brace on his left arm to relieve a constant spasticity. Now he doesn’t need the brace.

I've written this brief paper as an expansion of the paper I wrote a month ago which was more clinical in nature. What I wanted to do is give people some background into the nature of David's injury and to help clinicians see the specific cognitive and physical changes that have taken place as a result of neurofeedback. I wanted to add the very human side of David and not just the Q’s. In the next two months I will present the most recent QEEG on David and will run that data through Dr. Hudspeth’s database.

David's Most recent QEEG
This is the last Q on David, which was done on 7/23/04. This is the map that I’m using to guide the current therapy.

The Personal ROSHI
Siegfried Othmer, PhD

The pace of change is increasing in our field, rather than leveling off. How exciting, except of course for those who are connected with the Efficacy Document, who got left behind in the last century.

Now Chuck Davis is challenging us to change our thinking once again. What excited me about the Magnetic Stimulation capability in the previous ROSHI is that it involves the use of an EEG tracking capability. This allows us to stimulate the brain whenever a certain threshold in EEG amplitude is exceeded, irrespective of the frequency at which this occurs. This represents a kind of limit to which the standard inhibit strategy can be taken. It is like Reuters having a search routine that always finds its way automatically to what should be generating headlines at a particular moment.

Once the detection threshold is exceeded, the resulting stimulus just slightly nudges the brain with optical or very low-level magnetic stimulation, sufficient to trigger the brain to mount a response. That response draws on whatever resources the brain has available at that moment and at that point in frequency space. If the brain is at all capable of reorganizing its affairs, then there will be a trend set in place toward the diminution of the disregulated brain rhythms. The EEG will move from lesser to greater complexity, and hence to greater stability. It will move toward better internal regulation, which will allow it to function more efficiently. There will be internal quieting. The brain can be thought of as moving toward its own internal “Relaxation Response.” Only in brain terms the relaxation state is not one of passivity or inactivity but rather one of optimum regulation, a translation into brain terms of the concept in physics of “Least Action.”

As a means of giving explicit information to the brain to effect renormalization of function, one might say that the traditional ROSHI does about as well as one can. In the interest of completeness, I must say that the LENS unit fits this picture also, and adds the dimension of explicit brain-mapping so that the targeted training can be conducted systematically and tracked rigorously. The LENS also differs significantly in terms of strategy, in that it starts the renormalization process by working the most stable regions of the brain first, and approaches the least well-regulated regions last. Yet it may well be true that when actual training times are considered, no system yields a faster response than the LENS. We have also learned from the LENS system that it is of secondary importance what frequency offset is used in the stimulation. A small or a large frequency offset works comparably well, insofar as we know. And finally, we have learned from the LENS about the sensitivity of vulnerable brains to the effects of over-dosing with whatever we do in terms of brain challenges with fixed reinforcement parameters.

So let’s assess where we are. We already know that conventional Light-Sound instrumentation (or AVE) is capable of replicating the results of neurofeedback with fixed-frequency training, i.e. with techniques that are entirely agnostic with respect to what is happening with the EEG underneath. We get quick results in terms of functional normalization with a ROSHI that targets the most deviant EEG frequencies, as well as with a LENS that targets the best-organized regions of cortex first.

Now let’s look at the negatives. The down-side of the AVE approach is that one is subject to negative side effects traceable to narrow targeting of specific frequencies. The downside of the ROSHI is simply that one is dependent on the EEG signal to guide the training, and dependent on complementary instrumentation for any conventional neurofeedback that one may wish to do. The downside of the LENS is that it is dependent on a lot of data acquisition to organize and monitor and adapt the training.

If we put together what we know from each of these systems, features that one might have thought essential from one perspective become merely optional from another. And perhaps inappropriate from a third. First, one does not have to track the EEG to stimulate the brain effectively. Second, one does not have to narrowly prescribe the stimulus frequency, according to work with the LENS. Third, one does not have to find the “right frequency” to train, as in conventional neurofeedback. On the other hand, we have lots of experience that as one persists in a particular brain challenge, negative consequences increasingly become a concern.

So if one puts all of these ideas together, one gets the personal ROSHI: The brain is stimulated either optically or magnetically in a frequency-agile fashion, all over the EEG spectrum. The brain is stimulated with a signal that mimics aspects of the EEG over a sufficient length of time that a reaction is provoked, but not so long that negative effects can creep into the picture. Every stimulus at an EEG frequency provokes the brain into momentary entrainment and disentrainment, a phenomenon in which the brain yields to the stimulus in first instance (entrainment), but one that the brain then also resists and counteracts (the disentrainment). The brain will strive to maintain the integrity of its own operations. Once a disturbance in its self-organization becomes apparent, it will react to counter it. Then, before a steady-state entrainment/disentrainment response can even set in, the stimulus moves to another frequency to initiate another challenge.

One analogy that comes to mind is the stimulators that exercise particular muscle groups while the body passively rests. Effortless exercise. In the present instance the brain is provoked into an ineluctable response while the person is otherwise passive, and need have no conscious engagement with the process. It also helps me to think of the elderly who have trouble maintaining their balance. If one would nudge them slightly in different directions non-stop as they stood, the "error-detection" circuitry would be challenged toward greater sensitivity. A recent invention stimulates the soles of the feet to accomplish the same thing. The stimulation is at such a low level that the person is hardly aware of it.

I am also reminded of the saying of Frank Lloyd Wright, “Anything said either for or against the truth ultimately serves the truth.” In other words, one does not have to exercise brain function in exactly the right place, and under exactly the right conditions, or even in the intended direction, in order to obtain improved self-regulation. There is no such thing as bad exercise when it comes to the brain, so long as the provocation is sufficiently modest. Whereas the original ROSHI worked explicitly in an error-correction mode by targeting the worst deviations, the same strategy can also be applied agnostically across the board to good effect. That is to say, no decision is required as to which frequency range most deserves attention, nor must we even prescribe the right direction (in this case the phase) in which to apply the stimulus. By covering the entire range of EEG frequencies up to 40 Hz, and the entire range in terms of phase, “no tone is left un-Sterned,” as the saying goes.

The worst that one can say about this is that some of these stimulations may be less effective than others in guiding the brain toward better function. At worst, we may be casting some seed upon stone. First of all, we don’t even know that this is the case, given the work with LENS using a broad range of frequency offsets. We already have evidence that training at any EEG frequency can elicit an effect. And with respect to phase of the applied stimulation, it is initially random with respect to the phase of the EEG at that frequency. Hence, there will almost always be a phase offset initially in the natural course of events. That comes with the territory.

But secondly, what if some of the targeting here were to be less efficacious than another? Is that really a concern? At worst this approach might be costing us some training efficiency, but we shall have gotten in trade a considerable liberation in terms of instrumental complexity. Since this kind of training does not require any specific targeting, or mid-course correction, or much of a concern about sudden negative side effects, it can be readily transitioned into remote use. Under such circumstances, efficiency is really no longer paramount, since the training is not done on the meter. We don’t tell people to “hurry up and meditate” either. There is also the consideration that a multiplicity of brain challenges is probably more wholesome, and more comprehensive in its effects, than a narrowly focused targeting strategy.

One can therefore envision a division of labor in which the clinician gravitates toward those techniques that call upon specialized knowledge, critical discernment, assessment skills, and the ability to apportion client needs into the psychodynamic and physiological domains. The client meanwhile utilizes those technologies at home that can be benignly deployed there. The personal ROSHI is among the latter.

Now I don’t know how Chuck gets to these places, but I have had to get comfortable with these ideas in my own way. I have reconstructed some of my own thought process above. But I can only imagine that Chuck had one more thing in mind, and that is to deflate the stool sitters and chest beaters in this field who insist that things can only be done in a particular way---or not at all, as in the case of the writers of the Efficacy Document. I am happy to share in this fashion in his little triumph, particularly since the Efficacy Document tries to draw a narrow curtain of propriety around this nascent field.

The history of this field has been one of a progressive shedding of constraints on our thinking, starting with a narrow interpretation of what was involved with training of the sensorimotor rhythm. We found that we did not have to just train the right frequency at the right place for the right condition. The opposite was more nearly the case. The brain can be cued toward improved self-regulation at any frequency, at any location on the scalp, and for any condition in which the central nervous system plays a role. The personal ROSHI represents one end of the continuum of clinical options: it imposes no constraints, no preconditions, no rules on the enterprise of enhanced self-regulation. It is the ultimate counter to the hegemonists threatening to define this field. It could not have come along at a better time.

Nature is ultimately simple in its principles, though it may be multi-fold and complex in execution. The personal ROSHI represents perhaps the most straight-forward implementation of what we may mischievously call “Newton’s Third Law of Brain Function:” Any action that modestly interferes with brain function elicits a reaction by the brain. As long as that action is not sufficient in and of itself to destabilize the brain, then the consequence of that action-reaction dynamic will be to leave the brain with a greater capacity for self-regulation over time. That’s almost all that needs to be said. You train the brain, and you watch to see that you are not making things worse. If you are not making things worse, then you are probably on the path to making them better.

The personal ROSHI is an important development in the thrust toward “agnostic” protocols, namely those that do not depend upon explicit steering. And there is nothing more salutary in response to the growing fundamentalist threat to this field than a healthy dose of agnosticism. The personal ROSHI also fits the category of the “Blind Watchmaker,” an essentially autonomous, non-judgmental, non-prescriptive strategy to train the brain toward improved performance. It will set a standard against which all specific claims will need to prove themselves.

Siegfried Othmer

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