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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