Oct 17 2007

Neurofeedback and the Need for Science-Based Medicine

I am frequently asked to give my opinion as a neurologist about neurofeedback techniques – these are therapies based upon using real-time recording of brain waves (EEG) to help train the brain to have a more normal brain wave pattern. These techniques are still not generally accepted, and with good reason, but are none-the-less growing in popularity.

This recent news article is a good indication of why the popularity of this treatment is outstripping the evidence. The article itself is a great example of the standard template journalists use for reporting controversial science stories. Here is the template:

- Begin with a touching anecdote about a person who believes they were helped by the treatment; if it’s a child that’s even better.

- Uncritically report the claims of proponents, emphasizing its growing popularity and the humanity of its practitioners.

- Sprinkle in more anecdotes about how wonderful the treatment is.

- Insert token skepticism (optional).

- Allow proponents to counter the skepticism, without giving the skeptics a chance to counter the proponents.

- Finish by returning to the touching anecdote. Closing sentences usually take the form of – “it may be controversial,” or “skeptics may scoff,” or “who knows if it works or not,” but “this person knows it works because it has saved their life.”

A reporter can follow this template for any story – no matter how worthless or unscientific the treatment. There can always be found anecdotes of people who swear by the efficacy of the treatment. Proponents always have an excuse as to why their treatments are not more generally accepted, and always have ad hoc reasons to dismiss skepticism. You can literally plug the details of any controversial treatment into this template.

What this means is that the story itself tells us absolutely nothing about the legitimacy of the treatment on which it is reporting. But a discerning reader can read between the lines and see the red flags of quackery. The story reveals most of the important ones. For example, the story reports:

The Association for Applied Psychophysiology and Biofeedback says it is most effective for ADHD, anxiety, headaches, hypertension, urinary incontinence, and temporomandibular (jaw) disorders, although it is used to treat conditions ranging from autism to post-traumatic stress disorder.

The more different ailments a treatment is supposedly good for, the more suspicious you should be of the claims for it. To be clear, this does not mean the the treatment necessarily does not work, it should just raise suspicion about the validity of the claims being made for it. This is especially true when the ailments are very different. Headaches and autism are very different types of disorders, and headaches are just a type of problem, not a specific disease or entity. Urinary incontinence is not usually even a brain disorder.

What this tells you is that it is likely that the claims are not rigorously evidence-based. When practitioners and proponents are not basing their therapies on adequate clinical evidence there is a tendency for “indication creep.” (I just made up that term, feel free to use it.) If they are basing their judgments about whether or not the treatment works on anecdotal experience, then the treatment is likely to seem to work for anything and everything, and therefore the alleged indications for the treatment will increase without bounds. The corollary to this is that if a treatment seems to work for everything, it probably works for nothing.

The article also quotes a proponent as saying:

“The biggest problem in our field,” says Kerson, whose organization is based in Richmond, Va., “is the lack of research money. The money is tied up with the pharmaceutical industry, and they are not interested in seeing us grow.”

This is an excuse for lack of research. We are also simultaneously told that the therapy has been used for decades, and that its use is growing, with numerous organizations dedicated to teaching and using it. Excuses for lack of research are often simply lame or imply a conspiracy or bias against the therapy. The reality is that if the treatment had promise, it would get researched. Neuroscientists would be interested in the potential for the therapy and what it tells us about the basic biology. Basic science and clinical science play off each other, and researchers are motivated to pursue fruitful lines of research. There is also a great deal of research money available from the NIH (in the US) and other funding organizations. And if the research were not done in the US then other countries would take the lead. The pharmaceutical industry controls only their own R&D money – they don’t control medical research. Also, the NIH does not fund pharmaceutical research, they feel the industry should pay for their own research, so you cannot argue that research money is being used up by big pharma.

The fact that the treatment has been used for decades is reported to give it the appearance of legitimacy, but actually this is a strike against it. If it has been used for that long, why then are there no credible double-blind studies to demonstrate its efficacy? Also, the fact that use of this modality is outstripping the evidence is just another red flag that its proponents are not adequately science based. They are putting the practice cart before the research horse.

The real reason the research has not been done is because those using the technique don’t have to do research. Drug companies spend millions of dollars on pharmaceutical research because they have to (by FDA regulations). If you don’t have to spend the money or time to do the research then you probably won’t – unless there is built into the profession a tradition of dedication to science-based practices. So what the lack of research is really telling us is that the regulations are lax and the practitioners lack a culture of science-based practice.

Look for use of this standard journalist template and for these red flags when evaluating any story about a new or controversial health claim. But what about neurofeedback itself? Does it work, despite that lack of scientific rigor by its proponents? Well, the lack of research means that we cannot say definitively, but I do not think the treatment is very plausible.

First, neurofeedback is based upon the notion that certain brainwave patterns are “normal” and others are “abnormal.” This is true, but not for the patterns neurofeedback proponents are talking about. Various disease states in the brain will result in abnormal EEG patterns – the whole brain can be slow, regions can be slow, or there can be epileptiform activity. But there is also a range of normal brain wave activity, mostly reflecting various states of attention vs relaxation. Neurofeedback distinguishes between various EEG patterns that neuroscientists would all deem normal and claims without a good basis that some are normal or healthy and others are not. They then use feedback to train patients to have a “normal” EEG pattern, when actually they are just using feedback to train patients either to relax or to focus their attention.

As far as that goes, neurofeedback can be basically a form of cognitive-behaviorial therapy. We can learn, and our brains to adapt and adjust (so called “plasticity”). So it is not surprising that if people practice relaxing they will get better at relaxing. This is the concept of biofeedback, and therefore I see neurofeedback as a form of biofeedback. But the claims made for it are couched in very different terms – not training the person how to relax or focus, but training the brain to have better brain waves. That is where the nonsense comes in. Treating brain waves is more sexy than just behavioral therapy; it makes it seem like something magical is happening.

I liken this to an athlete training for a sport by, say, shooting baskets over and over. The neurofeedback equivalent of this is to hook up electrodes to the athlete’s scalp and have them shoot baskets until their brainwaves look different and claiming that they are training the brain to be better at shooting baskets. Sure, they will get better at shooting baskets, but the brainwave angle is completely superfluous.

What we need are double-blind controlled trials that compare simple relaxation or cognitive-behavioral therapy without the neurofeedback to the same treatment with the addition of neurofeedback, to see if that element adds anything to the outcome. I suspect that it won’t, but I can be convinced otherwise by good evidence.

Neurofeedback proponents need to do some basic research to validate that the EEG patterns they are treating actually mean anything, and that their treatments add something measurable to the outcome. Until then they cannot justify continuing to use, let alone expanding, their treatments.

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9 responses so far

9 Responses to “Neurofeedback and the Need for Science-Based Medicine”

  1. Nevaron 17 Oct 2007 at 2:25 pm

    This brings to mind those brain wave entrainment techniques using binaural beats or what not. I assume that listening to music (or rhythms) probably does create certain responses in the brain, but can one really entrain one’s brainwaves to a certain frequency using these methods? I’m rather sceptical towards the whole idea.

    I mean; if I need to concentrate on something, I’m sure many physiological changes start occuring including changes in brainwave activity. So how do we know their concentration enhancement CD does anything without proper tests? This all sounds like a do-nothing-but-still-get-the-benefit thing to me.

  2. Skeptykon 19 Oct 2007 at 8:33 pm

    On the AAPB’s homepage, they advertise a conference on Heart Rate Variability, another therapy for which popularity and hype outstrips evidence.

    That said, HRV and NF practices, AFAIK, are not as invasive as, say, “acu-”puncture, and have some elaborate ritual elements which can contribute to enhanced placebo effect. As Steven said, retraininng your own brain waves is sexier than behavioral therapy. “Behave yourself” vs “Rewire yourself”? If presented that way, who would not prefer the cybercool of NF?

  3. mason 23 Oct 2007 at 12:41 pm

    Not sure i agree with the ‘indication creep’ idea – seems a bit limiting.
    If new discoveries in psychoneuroimmunology are anything to go by, then things are a lot more complex than that!
    There is some evidence now, for instance, on the benefits (and possible underlying processes) of meditation. Does it’s credibility become reduced because it has the potential to impact on all bodily systems?

  4. Steven Novellaon 23 Oct 2007 at 1:58 pm

    The fact that some treatments have broad legitimate applications does not invalidate the notion that practitioners that are not evidence-based will tend to apply their treatments to an ever broader list of indications. The question is, how to tell the difference.

    One criterion is to consider the potential for the mechanism of action – can it reasonably be applied to a range of disorders? The other is to consider how much the target disorders have in common – do they have a common underlying contributor that can be the target of the common treatment?

    Meditation causes relaxation, so it could theoretically benefit any symptom or disorder that relaxation would help, or that is worsened by stress.

    The list of disorders for neurofeedback given above, however, do not share a common mechanism. Headaches, ADHD, urinary incontinence and hypertension? Not much of a common theme here.

    What they do have in common is that they are common problems for which people frequently seek treatment, many people may not be responding to conventional treatment, or may simply desire a non-drug solution. Similar lists crop up for most dubious treatments. It’s not a coincidence.

  5. Rgevirtzon 16 Nov 2007 at 3:59 pm

    While I agree with your skepticism and actually teach my graduate students to adopt this kind of attiude, I think you need to look with a little more depth at the research that some of us are doing to determine not only efficacy but mechanism for the techniques mentioned. You mention HRV biofeedback and dismiss it as not having any empirical basis. A number of us have published several well controlled studies using heart rate variability feedback for disorders that have a likely autonomic pathway (IBS, Asthma, Headache, etc. ) I would call you attention to the study published in Chest by my colleage Paul Lehrer, Ph.D. showing efficacy for the procedure against a credible placebo condition. If interested, I can supply more citations of our work as well.

    Just because clinicians make irresponsible claims, it doesn’t mean that the baby needs to tossed with the bathwater.

    Lehrer, Vashillo, and Vashillo (2004) Biofeedback as a treatment for asthma, Chest, 126,352-361

  6. krissncleoon 11 Jan 2008 at 8:13 pm

    The other day I asked about a company called Brain State Technologies that uses Brain State Conditioning-their “unique form of biofeedback-to treat troops returning home from the war. Said company claims that biofeedback can cure/heal everything from adhd, depression, migraines to anger management problems and seemingly, and host of other ailments. My question, does boifeedback work in these situations, was anwsered in your blog “Neurofeedback and the Need For Science Based Medicine.” Veterns and Families.org and The warrior Transition Project use anecdotal testimony and media pieces to promote their product. They claim that because neurofeedback has been around for decades and that it can cure a wide variety of ailments, but they do not say how measuring beta and alpha waves will do this. I’m still in college so I didn’t know if this was a new treatment or pseudoscience.

    There is a very nice lady that comes into the cafe where I work and she told me her son is going through the program so she asked me what I thought about it. Now I have something to tell her. For the sake of the veterns comming home I hope that their other treatments are based in science.

    Thank you so much.

    Kriss

  7. alec_son 06 Mar 2009 at 4:02 pm

    Actually there are some fairly rigorous studies involving treatment of ADHD with neurofeedback, for example:

    http://www.add.org/articles/TheRoleofNeurofeedbackintheTreatmentofADHD.html

    Although this was a clinical study, it looks as though they were reasonably strict in testing for and statistically controlling any systematic differences between groups. Their results look impressive, although I wish the article had also included some measure of statistical significance.

    However, many more studies are needed. An article I read:

    http://www.odemagazine.com/doc/61/neurofeedback/

    points out there as of yet there are no theories as to why neurofeedback actually works. It seems the field has a promising start, but needs more rigorous (non-case) studies to form a clearer picture of what’s going on.

  8. adriancmvdon 20 Mar 2009 at 1:27 am

    Hi there,

    I’m here to provide you with a complete and well organized resource that studies Neurofeedback.

    1- http://isnr.org/ComprehensiveBibliography.cfm
    Compiled by D. Corydon Hammond, PhD Professor, Physical Medicine & Rehabilitation University of Utah School of Medicine

    Also
    Frank H. Duffy, M.D., Professor and Pediatric Neurologist at Harvard Medical School, stated in an editorial in the January, 2000 issue of the journal Clinical Electroencephalography that the scholarly literature suggests that neurofeedback should play a major therapeutic role in many difficult areas. “In my opinion, if any medication had demonstrated such a wide spectrum of efficacy it would be universally accepted and widely used” (p. v). “It is a field to be taken seriously by all” (p. vii).

    My comment:
    The suggestion by Dr. Novella for a DOUBLE BLIND research design applied to this Behavioural learning procedure not adequate, because THE PERSON IN TRAINING PERCEIVES HIMSELF- there is no way to blind it.
    When false feedback is provided, a subject recognizes this and so the Blind unfolds.

    The AAPB, in it’s 40th year, publishes an efficacy guide that is quite skeptical and also critical. It is called Evidence Based Practice in Biofeedback and Neurofeedback. The 2008 edition is released but being sold at present. I can thus merely offer you the 2004 version.
    2- http://aapb.org/tl_files/AAPB/files/Yucha-Gilbert_EvidenceBased2004.pdf

    The results of these Efficacy ratings is possible because the resource used to train, THE EEG, is as exacting and specific as any hospital EEG. So when a person progresses in “real life”, the concurrent phenomenological manifestation can be tracked and studied.
    I ask you if there is a simple, cost effective and real-time accurate method to do say the same for pharmacological interventions…? Other than, of course, EEG readings.

    May this message be read along with the above to INFORM the reader.

    All the best, And Thanks to Steven,

    Adrian Machado Van Deusen

  9. r34498on 25 Aug 2011 at 5:50 pm

    It’s easy enough to double blind the “Brain State” neurofeedback, because the software essentially “records” the session in order to show “results” to unsuspecting clients. When trainers select the protocol to use (PP alpha up, or FF theta down, etc.) the study designer could randomly assign subjects to a treatment group or a control group and the program protocol called out for their session could simply be a previously recorded session of another person, rather than a so called live feedback session. The musical tones being played to the client would not be discernable as the “correct” “encouragers” or “discouragers”. The company claims that the brain will only change if it “sees itself”, so conveniently, clients are reassured, there is no way to harm a client by accidentally running a protocol with sensors that fell off or something. It’s brilliant marketing. I’d bet cash that responsive clients would report feeling the effects. The whole operation is classic placebo effect….warm blanket, cold bottled water, soothing ambiance and a person paid to listen to their problems for two hours at a time! The company employs a reputation monitoring company that electronically tails ex-employees and threatens to sue them if they report their experience to the Better Business Bureau or the state board of mental health examiners and FLOODS the search engines with positive “testimonials”. The prisoner “research” involved FOUR inmates, selected not at random, but by the warden who knew their temperaments (and gullibility). It’s a crime what they get away with.

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