BIOFEEDBACK AND

NEUROFEEDBACK
THERAPY and COGNITIVE
REHABILITATION

Dr. Nader Korhani PhD

 What is Biofeedback?

Biofeedback is a form of therapy in which client is trained to control or regulate physiological functions
such as brain waves, body temperature, heart rate, muscle tension, and even blood pressure.
Biofeedback training makes it possible to provide the physiological cues about how the brain is performing
and reacting to different stimulation or psychological factors. These cues make it possible for the brain to
improve its own performance by learning what to change. Making information available to the brain about
how it is functioning, and asking it to make adjustments necessary leading to improved mental state or an
improved performance.
As you receive personal, real-time feedback on screen combined with effective breathing and meditation
exercises that you come to learn and practice in these sessions , you gradually learn to maintain "improved
state" through managing symptoms related to psychological conditions mentioned above. By retaining
these new skills over time, you are able to achieve a new level of overall well-being and health in your life.
 Commonly used types of Biofeedback
Electromyography (EMG)
Measures and evaluates nerves conductance and muscle tension; Used to measure physical pain and pain
management, stress, anxiety, and training for deep relaxation through body awareness.
 GSR BIOFEEDBACK
Galvanic skin response biofeedback; A type of biofeedback
therapy also called EDR (Electrodermal Response)Thermal
biofeedback, in which subtle changes in the autonomous
nervous system are monitored by the patient via a device
that measures the changes in skin conductivity caused by
minimal sweating

EDR biofeedback in peak performance training used for the

following strategies:
To illustrate how thoughts affect body and performance.
To monitor physiological relaxation.
To identify stressful components of the athletic
performance during imagery rehearsal.
To facilitate concentration training.
 HRV Biofeedback
Heart Rate Variability (HRV) Biofeedback:

Heart Rate Variability (HRV) biofeedback is a relatively new technique for training people to change the
variability and dominant rhythms of their heart activity. HRV biofeedback techniques are used for a variety
of medical and psychiatric conditions, including: anger, anxiety disorders, asthma, cardiovascular
conditions including heart failure, chronic obstructive pulmonary disorder (COPD), depression, irritable
bowel syndrome (IBS), chronic fatigue, and chronic pain.
 NEUROFEEDBACK
 A type of Biofeedback training system in which brain wave activity,
obtained by sensors on the scalp, is presented to an individual as a
video display.

 When brain activity moves toward patterns of improved self-regulation,

the display (often a video game) advances, slowing or stopping as brain
activity regresses.

 Neurofeedback is biofeedback for the Central Nervous System

 Targets firing patterns (brain rhythms) and regional blood flow

 Brain rhythms correspond to certain behavioral and cognitive states

 Cortical brain rhythms are detectable non-invasively (EEG)

 As the EEG inclines towards a desired frequency, a rewarding stimulus

is applied; The stimulus is auditory and/or visual
 Alpha / Theta Training

1. PTSD, Anxiety, Depression, Rage, Addiction, BDD and Anorexia?

 Trauma and long-standing anxiety can lead to limbic ‘locking’ with accompanying reductions in pre-
frontal lobe processing
 Goal is to ‘unlock’ the dominant limbic circuits to restore normal information flow and processing
between limbic + cortex
 Enables resolution of long standing trauma
 Described as witnessing the events versus experiencing them vividly and emotionally
 Therapeutic benefit rests in the self-corrective intuitive thinking that emerges, however often
vivid imagery also accompanies this state
 Training Beta

2. Beta Training: ADHD

 Biochemical Etiology:
 Reduced dopaminergic and noradrenergic innervation of cognitive, attentive and reward centers
 Stimulus seeking behavior is sought out

 Benefits of medication are typically medication dependent, and may not generate actually
physiological alterations
 Possible underlying deficiencies in cholinergic signaling
 Electroencephalic Correlates:
 Inappropriate cortical slow wave (theta = alpha) dominance during cognitive activities
 Poor SMR
 Neurofeedback Protocol:
 Reward beta, particularly left hemispheric and SMR
 Changing of neurons, the organisation of
their networks and their function via new
experience

 The brain's ability to reorganize itself by

forming new neural connections throughout
life.

 Neuroplasticity allows the neurons in the

brain to compensate for injury and disease
and to adjust their activities in response to
new situations or to changes in their
environment.

 Functional rehabilitation programmes

support neuroplasticity with goal-directed
experiential therapeutic programs in the
context of rehabilitation approaches to the
functional consequences of the injury.

Dr. Simone Carton 15.7.2015

1. Use it or lose it
2. Use it and improve it
3. Specificity
4. Repetition matters
5. Intensity matters
6. Time matters
7. Salience matters
8. Age matters
9. Transference
10. Interference

Dr. Simone Carton 15.7.2015

Dr. Simone Carton 15.7.2015
Family/social Pre-morbid
support
Brain pathology factors
e.g coping style

Cognitive
Affect Physical
Impairment

Insight Loss

Functional consequences

Adapted from Biopsychosocial Model (Evans 2006)

Dr. Simone Carton 15.7.2015

 Family/social Pre-morbid
support
Brain pathology factors
Stroke, head injury, etc e.g coping style

Cognitive
Affect Physical
Impairment e.g. Depression e.g. Hemiplegia
e.g. Memory Anxiety Sensory loss
Perception Anger Dysarthria
Language Confidence Pain
Attention Motivation
Executive Insight Loss

Functional consequences
e.g. Work
Biopsychosocial ADL
Model (Evans Leisure Preliminary Goals
2006) Driving Work, adl, leisure, etc.
Dr. Simone Carton 15.7.2015
Domains of Cognitive Function
 Attention and concentration
 Visuo-spatial and constructional skills
 Sensory perceptual function
 Language
 Memory
 Executive function
 Intellectual function
 Mood, thought content, personality
and behavior
Source: Halligan, Kischka & Marshall, 2003
 The aim of treatment is to improve the
person’s ability to carry out everyday tasks.

The process includes

 Educating about the injury and how and why
it effects them in that way

 Re-establishment of direct skills through

direct retraining.

 Use of compensatory strategies and external

aids

Dr. Simone Carton 15.7.2015

 Anxiety  Aggression
 Low Mood,  Disinhibition
depression  Impulsive
 Apathy  Inflexible, Rigid
 Poor motivation  Self-centredness
 Anger  Emotional ‘Lability’-
 Frustration Mood swings
 Irritability  Emotional
 Low self-esteem flattening/ blunting
 Grief  Poor insight

Dr. Simone Carton 15.7.2015

Cognitive changes following ABI
 Intellectual functioning
 Attention
 Speed and capacity to process information
 Learning ability
 Memory - specify type e.g. verbal, non-verbal, immediate,
delayed, recognition, episodic, autobiographical, semantic etc
 Perception
 Construction
 Praxis – Able to plan & undertake basic tasks
 Language
 Executive (cognitive and behaviour)

Dr. Simone Carton 15.7.2015

 Depression
 Generalized Anxiety Disorder
 Panic attacks
 Obsessive Compulsive Disorder
 PTSD
 Conversion Disorders
 Delusions/
Misidentification (Depersonalisation/Derealization)

Dr. Simone Carton 15.7.2015

Depression Anxiety
Stroke: 30%
 Prevalence:
TBI: 27%
Stroke – 21%

Risk of suicide increases

 PTSD- 3-27%
following TBI.
3-4 times.
Teasdale and Engberg (2001)

Dr. Simone Carton 15.7.2015

Neuro-rehabilitation in the midst of:
 Despair
 Pessimism
 Regret
 Uncertainty
 Absence of hope
 Unresolved premorbid issues

Dr. Simone Carton 15.7.2015

 Cognitive

 Emotional

 Behaviour

 Personality

Dr. Simone Carton 15.7.2015

 Rehabilitation implies the restoration of patients to the highest level of
physical, psychological and social adaptation attainable. It includes all
measures aimed at reducing the impact of disabling and handicapping
conditions and at enabling disabled people to achieve optimum social
integration.
(WHO 1986)

 A problem-solving process in which the person who experiences a

neurological impairment or loss of function acquires the knowledge, skills
and supports needed for their optimal physical, psychological, social and
economic function.

Dr. Simone Carton 15.7.2015

Executive Communication Behaviour Emotion & Psychosocial
Functioning

Training of formal “The evidence is strongly in Multicomponent “CBT should be considered for
problem solving favour of efficacy of aphasia behavioural interventions, treatment of anxiety symptoms
therapy, provided…. is
strategies and their sufficiently prolonged” incorporating individually following mild to moderate TBI as
application to everyday Basso (2005). tailored contingency part of a broader
situations and functional management techniques neurorehabilitation programme.”
activities recommended and positive behaviour (SIGN 2011)
as practice guideline. approaches (SIGN, 2011)
Cicerone et al (2011)

Metacognitive strategy Cognitive-linguistic “Serious methodological Some evidence for efficacy of CBT
training (e.g. problem- therapies recommended as concerns weaken this for treating anxiety
solving, goal practice standard. Cicerone body of evidence” symptomatology after TBI (Soo
management training) et al. (2005) (Ylvisaker et al, 2007) and Tate, 2007).

Self-monitoring and self- CBT for depression following ABI

regulation ‘inconclusive’.
(Cicerone et al 2011)

Dr. Simone Carton 15.7.2015

 Assessment  Plan of action that is meaningful
 Premorbid history for the person
 Formal assessment of central
concerns  Educate
Eg Kapur and Clare & Wilson ‘How
 Real world/practical assessment
to cope with memory problems’.
 Insight
 Motivation  Support the inter-relationship
 Personality of all the relevant domains
 Support network

Common sense Clinical summersaults

Dr. Simone Carton 15.7.2015

 Ensure you have attention before proceeding

 Cue that what you are saying is important and they need to listen

 Keep instructions simple and direct

 Speak slowly

 Encourage retelling

 Cue to write information down

 Provide a quite area for work that is challenging

 Give advanced warning and preparation time prior to changing activity

Dr. Simone Carton 15.7.2015

 Minimise distractions  Structure the task within a
set time frame
 Talk yourself through the
task “What should I be  Take frequent breaks
doing now?”

 Use incentives
 Discover the best time of
day to work
 Don't rush things

 Plan a schedule of
 Check work for errors
activities

 Set deadlines
 Do one thing at a time
Dr. Simone Carton 15.7.2015
 Pay attention  Break down tasks into
small, chunks
 Minimize distraction
 Encourage/Remind
 Regular routine for family member to use
everyday activities strategies

 Provide a consistent and  Give plenty of time and

well organized living practice to learn new
environment things
Dr. Simone Carton 15.7.2015
Low Tech:
 Checklists
 Diaries
 Orientation boards
 Wall calendar/ planner
 Hot spot

High Tech:
 Computer software
 Alarms
 Phones
 SenseCam
 Switches
 Dictaphone

Dr. Simone Carton 15.7.2015