AMPLITUDE NEUROFEEDBACK: A REVIEW OF THE RESEARCH

ANSA CONFERENCE 2018, BRISBANE

MOSHE PERL, PHD, BCN, QEEGD, MAPS

DAVID PERL, BE(HONS)/BSC

info@neurotherapy.com.au

• What is the published research on neurofeedback?

• What can be said about the various neuromodulation

modalities available today?

• Is there evidence that one modality is superior to

another?

• Is there evidence that one modality is better for certain

issues, while another modality is better for other issues?

• This project aims to help answer some of these

questions.

Introduction

• The search began at ISNR – reviewing their

comprehensive bibliography - https://www.isnr.org/isnr-

comprehensive-bibliography

• I was interested in:

• When were the studies published?

• What kinds of neuromodulation techniques were used?

• How many subjects were involved in these experiments?

• What disorders?

The project

• Once we started looking, we saw that there were all sorts

of other studies in the bibliography.

• There were many studies on proof of concepts – showing

that a particular modality was having some effect on

brain function, usually not directly clinically relevant.

• We wanted to know, how many studies measure actual

treatment outcomes, as opposed to book chapters,

reviews, meta-analyses, non-clinical experiments, etc?

The project

• We decided to only to consider peer reviewed

studies. Why?

• When a study is peer reviewed, one has some

assurance that the author of the study has employed

at least a modicum of scientific rigour in the

preparation of the article, that the outcomes

reported seem reasonable and that the

methodology is given in enough detail to allow

replication.

The project

• For purposes of clarity, I decided to group all

amplitude training modalities together. These

included:

• Beta/SMR training

• Alpha training

• Alpha-Theta training

• Theta/beta ratio training and other ratio trainings

• One case study using Neuro Optimal methodology

“Amplitude” neurofeedback

• Slow cortical potential training - SCP

• QEEG based training

• Coherence training

• LENS training

• 19 channel z-score training

• Infra low frequency training

• Haemoencephalography (HEG)

Other modalities included

Stimulation

• Audiovisual entrainment (AVE), including photic

stimulation, Roshi

• Alpha Stim

• Photic stimulation

• Vagus stimulation

• Neurofield magnetic stimulation

Other modalities (cont.)

• Direct current stimulation

• Transcranial magnetic stimulation

• fMRI neurofeedback

Other modalities (cont.)

Two Modalities Head to Head:

• 3 randomised control studies (RCT)

• Both modalities counted (as all studies found both modalities

equally beneficial)

Two modalities used to treat subject:

• QEEG based – amplitude and coherence

• 5 studies not counted as cannot determine which modality was

crucial to success

Two modalities used in one

study

We settled on four categories:

• Case study (1 – 3 cases)

• Case series, with pre and post measures. Cherry picking only positive

outcome cases was not accepted.

• Some controls, such as a waiting list control, two groups, one clinical one

non-clinical, partial randomisation. Review of past records for somewhat

matching clients, who received different treatment was not accepted as

a control group.

• RCT studies, cross over repeated measures with alternate treatment,

contrasting two effective modalities with random assignment.

Classification of type of study

This is a high level study, so we simply classified

outcomes as

• Positive – researchers deemed results to be

significantly positive

• Negative – researches deemed results to not be

significantly positive

Classification of outcome

We divided the neuromodulation timeline into three:

• 2009 – the present

• 1999 – 2008

• 1998 and earlier

Classification by date of

publication

Time constraints did not permit search far beyond the ISNR

bibliography listing

• We also looked for additional material on SCP and LENS:

• https://www.neurocaregroup.com/adhd-neurofeedback-

and-sleep.html

• https://www.site.ochslabs.com/lens-references

• Reviewed over 50% of relevant studies from these two sites

• We will be happy to add other studies to the database we

have developed

• We will be happy to share the database with those interested.

Search for other studies

• 690 studies listed on ISNR’s bibliography as of April 5, 2018

• 7 more added for SCP and LENS

• 4 duplicate errors

• 146 duplicates – studies belonging to more than one condition

• For these, we currently only list them in their first location – i.e. for only one disorder

• For 73 articles only their abstract was found

• 33 articles were not found

• 170 articles were book chapters, reviews, or theoretical

• 70 articles were studies that did not involve treatment of a disorder

• 2 articles had flawed methodologies

Results

By Year

Pre 1999, 94

1999-2008, 88

2009-2018, 89

By Study Type

RCT, 44

Control, 58

Case Series,

97

Case Study, 71

Modality No. Studies Successful

Amplitude 196 186

SCP 14 13

QEEG guided 7 7

LENS 7 6

Coherence 3 3

Z Score 7 7

HEG 6 6

By Modality - Overall

Modality No. Studies Successful

Infra-low 2 2

Stimulation 11 11

rTMS 3 3

tDCS 1 1

fMRI 4 4

Head to head 3 3

Combined 6 6

Modality No. Studies RCT Control Case Series Case Study

Amplitude 196 30 47 67 52

SCP 14 5 3 6 0

QEEG guided 7 0 0 6 1

LENS 7 0 0 5 2

Coherence 3 1 1 1 0

Z Score 7 0 0 5 2

HEG 6 1 1 2 2

By Modality vs Study Type

Modality No. Studies RCT Control Case Series Case Study

Infra-low 2 0 0 0 2

Stimulation 11 1 2 4 4

rTMS 3 0 1 2 0

tDCS 1 0 0 1 0

fMRI 4 2 1 1 0

Head to head 3 3 0 0 0

Combined 6 0 1 1 3

By Modality vs Study Type p2

By Disorder

Disorder No.

ADHD 83

Addiction 17

Anxiety 11

ASD 15

Decline 2

Depression 17

Dissociation 3

Epilepsy 34

Disorder No.

Immune System

7

LD 2

Medical 8

OCD 4

Pain / headache

13

Parkinsons 4

Peak 13

Personality disorder

1

Disorder No.

Prison 3

PTSD 6

Schizophrenia 2

Sleep 3

TBI 17

FASD 1

Tourettes 1

Anger 1

Example Disorder - ADHD

Total Amplitude SCPCoherenc

eHEG Stimulation fMRI

Head to

Head

83 66 7 2 2 2 2 2

Example Disorder - Addiction

Total Amplitude SCP

17 16 1

Example Disorder - Anxiety

Total Amplitude LENS

12 11 1

Questions / Discussion

Conclusions

• Amplitude training still constitutes the vast

majority of studies

• With neuromodulation methodologies

diversifying, we need good studies so that we

know which technique works best for which

disorder

Conclusions – roles studies can

play

• Case studies remain very important, especially for clients with

unusual presentations

• Case series give stronger support to a methodology:

• Strong “how to” component – replicability is the key

• We need to know your methodology

• If several practitioners, practicing independently validate a

particular approach, with a particular client group, that is very

powerful endorsement

Conclusions – roles studies can

play• Clinic studies with controls eliminate some of the non-specific/unspecified

elements (some say placebo) of the intervention as the cause of change

• We need studies that are done with controls in a clinical setting for several

reasons:

• We don’t really care about the non-specifics, we want to maximise them

• We don’t randomly accept clients – they choose us

• Clinic clients reflect real world conditions – the same as what walks through our

doors

• RCTs are best for indicating the specific effect of a treatment. They are

needed to help gain mainstream recognition of neuromodulation

Conclusions – don’t worry

• Don’t get overwhelmed by complexity.

• Amplitude training still works, and still works well. It never didn’t

work well.

• Every practitioner in this room, regardless of which

modality/form of neuromodulation they use, is working to do

the best that they can do to help their clients. And we need

to support each other in this endeavour and not get in each

other’s way.