Qeeg and-nfb 2021

Integrating
QEEG and
NFB into
Clinical
Practice
•Dr. Freddy S. Starr, M.D.,
FAACAP, BCN
•Founder
•Chief Science Officer
•Myneurva Holdings
•Dr.Starr@Myneurva.com
Freddy S. Starr, MD 2021 Myneurva Holdings

(BIO)-
FEEDBACK
• Bringing the workings of the body
into consciousness.
• Usually using a tool of technology to
sense something we cannot sense
ourselves
• Thermometer for skin temperature
• Galvanic Skin Response
• HRV devices
• Makes the “sense-less” information
“sense-able”

FEEDBACK

EEG-Neurofeedback
• Feedback of the brain - for the brain.
• In digital language
• Making the pre-conscious available to the
conscious mind.
• When you inform the brain of what your
brain waves are doing, your brain can use
that information to change how it works.

Is Neurofeedback Effective?
Frank H. Duffy, a professor and pediatric neurologist at Harvard
Medical School, has said that scholarly literature now suggests
that Neurofeedback “should play a major therapeutic role in many
difficulty areas, …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” (vii).
Duffy, FH., Editorial: The state of EEG biofeedback therapy (EEG
operant conditioning) in 2000: An editor’s opinion. Clinical
electroencephalography. 31 (1): v-viii, 2000.

The
Technique….
•Neurofeedback
•“AKA”
•EEG-Operant Conditioning
•Braintraining
•Braintuning

Cat Wireheads: cortical electrodes, not brain
stem or hypothalamic
• Cats often used in
electrophysiology
because head size the
same regardless of
breed, unlike dogs
Source: David Kaiser

Classical vs. Operant
Conditioning
• Programming and Un-
programming associations
to external and internal
stimuli
• Learning to repeat a
“particular” behavior (brain
wave condition) that
improves “outcome”

Enter The Space Race
– seed of EEG-NFB

d
Convulsan
t
propertie
s of
Hydrazine
for Space
Race
Use of
Operant
Conditioni
ng
Feedback
to train
animals in
the
voluntary
control
of EEG
rhythms
-
Available
Money
thru
death of
FUNDED
Pharmaco
logist

M. B. Sterman PhD, R. W. LoPresti PhD & M. D. Fairchild PhD (2010): Electroencephalographic and Behavioral Studies of
Monomethyl Hydrazine Toxicity in the Cat, Journal of Neurotherapy, 14:4, 293-300

Monomethyl
Hydrazine
(MMH)
Toxicity

5 mg/kg Spont Sub-cort SZ

18 mg/kg Generalized Sz

Trained Resistance to toxin – induced SZ in
CATS

Sterman et al (1967) showing usual toxic
prodrome and resistance to MMH-induced
seizures in a subgroup
NASA Rocket fuel
Avg 2 hours+ for seizures
with EEG trained cats
vs. 1 hour for normal cats
Time

Conclusion:
Convulsions were specifically delayed or prevented in animals trained to
suppress movement through the use of a special EEG conditioning
technique.

“… our results provide a
first basis for the ‘missing
link’ between the
historical long-term
training effects of
neurofeedback (Sterman,
1973) and direct
validation of neuroplastic
change after an individual
session of training.”

“two recent studies provide
cellular evidence of
synaptic changes induced
by network oscillations
(Tsukamoto-Yasui et al.,
2007; Tsanov & Manahan-
Vaughan, 2009).
“Conversely, changes in
synaptic plasticity have
been found to modulate
neuronal oscillations
themselves (Narayanan &
Johnston, 2007;
Tsukamoto-Yasui et al.,
2007). “

“In light of the
extraordinary
plasticity displayed
by the human brain
(Pascual-Leone et
al., 2005), EEG-
based
neurofeedback may
be a promising
technique to
modulate cerebral
plasticity in a non-
invasive, painless,
natural way. “

What Happened?...
• In 1982 Sterman’s NIH grant for 3 y was funded, but then they demanded
double blind after approving the initial design, then they pulled funding saying
goals already reached

Review of 19 studies with EEG Biofeedback for Epilepsy*
• 82% of studies demonstrated significant seizure reduction
• Average reduction exceeded 50%.
• Studies reported reduction in seizure severity.
• About 5% had complete control for up to one year
* Sterman, MB (2000). Basic Concepts and Clinical Findings in the Treatment of Seizure Disorders
with EEG Operant Conditioning. Clinical EEG, 31(1), 45-55.

My
Conclusions

Electroencephalogram
EEG

Hans Berger
(1873-1941)
• As a soldier in the German Army in first
decade of 1900, Berger fell off his horse
directly in front of artillery cart and was
nearly run over
• When he returned to HQ, telegram
from his father saying his sister had
feeling that he had been injured
• Berger would explore physical means of
such psychic transmissions

EEG Lab Circa 1930
• Berger's experiments
carried on in spare time
and secrecy.
• As a diversionary
measure he gave public
discourses on telepathy,
offering hypotheses of
wave propagation to
explain it.

First EEG (1924)
• Berger made 73 EEG recordings from his 15y son, Klaus.
• First frequency encountered was in 10-hertz range,
(8 to 12 Hz) which he named alpha (others called the
Berger rhythm).
• After 5 years of investigation, he published his findings.
• In 1929 he reported how brain waves changed if subject
shifts from eyes closed to eyes open. Brain waves also
changed when the subject sat quietly with eyes closed
while solving a math problem.

AMPLITUD
E
• The power of the electrical impulse,
measured in microvolts. (µV)
• Like volume is to sound
• Slower waves have higher
amplitudes.
• It takes the brain a lot of energy to
produce the faster waves, so
amplitudes tend to be lower.

Signals are coherent
when phase relationship
is stable
COHERENCE

Illustration of
Coherence and
Phase Angle
Coherence is the condition of synchrony between the waves
generated in different regions or hemispheres of the brain.
For example: if the left and right occipital lobes are generating Alpha
waves of similar frequencies, there is some coherence between
them. The second measure to compare two waveforms is the phase
angle between them. In the illustration, two sine waves of the same
frequency are juxtaposed. One leads the other by a phase angle.
Soutar, R., PhD. New Mind Academy BCIA Coursework, Module II, Section III-viii-ix. (2002), Chorlian, D.B., Rangaswamy, Madhavi,
Porjesz, Bernice (2009). EEG coherence: topography and frequency structure. Experimental Brain Research, Journal 198:59-83 July 22,
2009. Springer International

FREQUENCY BANDWITHS
• Single frequencies organized into discreet groups
• Each bandwidth is associated with specific characteristics
• The amplitude and microvolt readings reflect all of the activity
within the bandwidth
• NF training has been aimed at changing the amplitude of a
selected frequency bandwidth

Brainwave frequencies and general mental
corollaries
0.5 – 4 Hz DELTA Sleep
4-7 Hz THETA Inward focus, distracted, daydream
8-10 Hz ALPHA (A1) Relaxed, not actively processing
10-12 Hz ALPHA (A2) Relaxed, not actively processing
12-15 Hz SMR (B1) Relaxed, external attention
(low beta)
15-18 Hz BETA (B2) Active external attention
19-35 Hz HIGH High correlation with anxiety,
BETA (B3) intensity, or lots of muscle
tension.
1

DELTA
• 0.5-4 Hz (cycles or waves per second)
• Usually associated with sleep, deep meditation
• Dominant wave in infants up to 6 months old
• 40% of the amplitude in infants
• <5% of the amplitude in a “normal”adult
• % increases with Dementia
• High Amplitudes…
• Learning Disabilities “Sleepy Brains”
• Brain Injuries, Toxic Brain, Coma, Narcolepsy.
• Eye Blinks and Eye Movement Artifact can be
confused as delta.

THETA
• 4-8 Hz (cycles or waves per second)
• Trance State, Daydreaming
• Intuitive, Creative, Internal Focus
• Thoughts in Theta are visual/emotional
• High Theta
• Learning Disabilities
• Filtering Problems (ADHD)
• Processing Problems (ADD)
• Pain
• Migraine
• Slow Reaction Time

ALPHA
• 8-12 Hz
• Alertness
• Peaceful
• Meditation
• Alpha Peak
Frequency
>10 µV
Suggests Superior Intelligence
• High Anterior (Frontal) Alpha
• Daydreamers
• Depression
• Marijuana Use
• Each 1 Hz increase in frequency
associated with a 0.21 increase in
reverse digit span score
independent of age.
• Alpha peak frequency associated
with Working Memory

SENSORIMOTO
R RHYTHM
(SMR) or Also
called BETA-1

Thalamic Projection
System
• Gating system by which
information is directed
toward the motor cortex
or blocked through the
thalamic oscillators
• 14Hz rhythm appears as
information flow to the
motor cortex is
progressively blocked.
• This became the
foundation of his work
with reducing the
frequency of seizure
disorders through SMR
or 14 Hz. training.
• Joel Lubar later applied
these findings with
considerable success to
individuals with AD/HD.

As Above, So Below

The
Sensorimotor
Strip ---
(SMR)

BETA-2
• 15-22 Hz
• Thinking, Focused
• Sustained Attention, Problem-
Solving
• Externally Oriented
• High Amplitude….
• Left Hypo-activation
Depression
• Right Hyper-activation Anxiety
• Pre-anxiety Disorders
• Benzo use
• Irritability
• Hyperfocused.

Beta 3 (High
Beta)
• 22-30 Hz
• Very fast cognitive
processing
• If very high amplitude
• Epileptic Auras
• Cortical Irritability
• Hypervigilance
• Overthinking
• Ruminations
• Obsessive Compulsive

Gamma-The
Mysterious
• 35-42 Hz
• “The Binding Rhythm”
• Important to learning by bringing
together different aspects of an object
into a single precept.
• Associated with transcendent experiences
• Found throughout the scalp rather than
one discreet location
• Difficult to record due to multiple artifacts.

Common Artifacts

Cortical EEG Sources-
Where does EEG Come
from?
EEG has several strong
points as a tool for
exploring brain activity.
EEG's can detect changes
over milliseconds, which is
excellent considering
an action potential takes
approximately 0.5-130
milliseconds to propagate
across a single neuron,
depending on the type of
neuron.

EEG
Attributes

Quantitative Electroencephalogram (QEEG)
“Aka”
Brainmap
Brainscan
BEAM (Brain Electrical Analysis and Mapping)

Evolution of Neuroscience-In Brief…
Descartes learns from Bruno and Galileo.
• For 500 years we thought of the
brain like this…
…and realized it works more like
this.
Then we studied it

The
Function of
the Cortex

It is more like this.

EEG Connectivity Attributes

The Connectome of
Delta Airlines at
Atlanta

Brainwave Activity -
Summation
Local resonant loops: Take place
between local cell columns. There is a
great deal of resistance between local
cell columns, to avoid too much
excitation and seizure activity. Usually
above 30Hz (gamma).
Regional resonant loops: Take place
between cortical cell columns several
centimeters apart, as well as
corticothalamic sites. Resonances are
in the alpha and low beta range.

Triple Network Theory

Fourier
Analysis (or
JTFA) the
heart of a
Quantitative
EEG -

Jean Baptiste Joseph Fourier
(1768-1830)

Energy
distribution
by
Frequency

Entire Frequency Spectrum
for one site (here, Pz)

A “Normal”
Brain is a
Self-
Regulated
Brain

The 10/20
International
System

Two Dimensional “Heat Maps”
QEEG
• Provides basic location and
function.
• Gives Connectivity Information.
• Can be used to obtain metrics.
• Tells “what,” not “why”
• Does not give real time kinetic
information. It is a snapshot in
time.
• Does not provide depth.

Test-
Retest
Reliability

What is a Z Score?
• Z score= Mean of population________
• Standard Deviation of population
• For example, adult male heights are on
average 70 inches (5'10) with a standard
deviation of 4 inches. Adult women are
on average a bit shorter and less variable
in height with a mean height of
65 inches (5'5) and standard deviation
of 3.5 inches.
• Therefore an adult male who is -2 SD from the
mean would be 5’2”.
Reprinted with permission

The Bell Curve
Reprinted with permission

Z-scores
• Enables Comparison of the Individual to
Normative Database.
• Can be Derived for
• Each Frequency
• Each Phase or Coherence
Relationship
• Anatomically Source-localized areas.
• Each Location
• Discriminant Analyses available for…
• TBI probability, TBI severity,
Intelligence, PTSD, Pain, Depression…

2D Brain Maps
Absolute Power
Relative Power
Amp Asymmetry
Coherence
Phase Lag
Delta Theta Alpha Beta HiBeta
Z-Score

But the Brain exists in 3D….
ex. London Taxi Drivers - Hippocampus
• Gray matter
volume in London
taxi drivers with
extensive
navigation
experience versus
controls.
• Proc Natl Acad Sci U S A
97(8):4398-403, 2000.
Neurons that Fire together……

Low-Resolution Electromagnetic
Tomography (LORETA)
• Finds the Statistical 3-dimensional current SOURCES
• Using an EEG inverse solution.

3-D Representation of EEG Source Density
Information – LORETA

LORETA Reliability (ECB)
Left Precuneus BA 19 (-31, -81, 22)
ECB1 = ECB 2: Alpha = .88 (ICC) =
.88, F (99) = 8.65, p < .000.
Anterior Cingulate BA 32 (-3, 31,
29) ECB1 = ECB 2: Alpha = .97 (ICC)
= .97, F (99) = 30.62, p < .000.
Left Prefrontal BA 8 (-38, 31, 43)
ECB1 = ECB2: Alpha = .95 (ICC) =
.95, F (99) = 22.40, p < .000.
Right Prefrontal BA 8 (39, 24, 43)
ECB1 = ECB2: Alpha = .97 (ICC) = .97, F
(99) = 40.58, p < .000.
Right Post Central Gyrus BA 3 (60,-
25, 43) ECB 1 = ECB 2: Alpha = .96
(ICC) = .96, F (99) = 23.72, p < .000.
Right Supramarginal Gyrus BA 40 (60,
-53, 22) ECB1 = ECB2: Alpha = .94
(ICC) = .94, F (99) = 14.75, p <.000.
Left Supramarginal gyrus BA 40 (-59,
-53, 22) ECB1 = ECB2: Alpha = .93
(ICC) = .93, F (99) = 14.14, p < .000.
Cuneus BA 7 (-3, -60, 29) EOB1 = EOB2: Alpha = .91
(ICC) = .91, F (99) = 11.38, p < .000.

Enter Artificial
Intelligence
“You gotta have the right tool for the job,
Mate.”
Kaz Starr

ANNA (Advanced
Neural Network
Analysis)
US PATENT
#10,863,912
• Using Artifical Intelligence is
the next evolution in EEG
Analysis.
• Removes Human error
• Allows for automation
• Rapid analysis.
• Diagnosis
• Prognosis ‘
• Matching with additional
meta-data (eg:
Genotype, food
preference).

ANNA is a Neuropsychiatry Expert Assistant

General
Indications for
ordering a
QEEG
• If you are not sure, just ask.

Neurofeedback…from
Azreal to Z-score.
Six decades of progress

Research
bibliography on
Neurofeedback
at www.isnr.org

Alcoholism & Alpha-Theta Training
• Peniston & Kulkosky (1989)
• Alpha activity deficits in alcoholics known since 1940s
• Drinking produces rewarding slow waves (alpha)
• Sober state has higher beta
• Teach alcoholics to produce alpha without drinking
• Like an electrical “vaccine” for the brain.

Addiction:
Peniston
Protocol

Scott &
Kaiser,
1999

Scott &
Kaiser, 1999

Attention Deficit Hyperactivity
Disorder

Monastra
study –
ADHD and
biofeedback
vs.
stimulant
therapy

NFB for Dyslexia
• Improvement for Spelling,
but not for Reading using
these protocols.
• Improvements in both
reported in 2 other trials
with different protocols
Breteler, R, Arns, M, et al, “Improvements
in spelling after QEEG based
Neurofeedback in dyslexia: a RCT study” J
or Integrative Neuroscience, 2007

Neurofeedback for TBI

Royal
Conservatory of
Music
Improvement in
Musical
Performance
• Dr. John Gruzelier, Ph.D, Tobias Egner, Ph.D. Department
of Cognitive Neuroscience and Behavior, Imperial
College, London, 2003, Neuroreport.
• Subjects: top music students
• Goal: could training show measurable
improvement in performance
• 15 minute musical performance assessed
prior and subsequent to training.
• Performances were video-recorded,
randomized and rated by expert musicians
external to the Royal College of Music.
•
• Six groups created – each with different training:
• Alexander Technique 2) Mental skills 3) Beta NF
• 4) SMR NF 5) Alpha-Theta NF 6) Exercise

Alpha-Theta neurofeedback
group had significant change
in musical improvements
•Overall Quality (+ 14.4 %,
p = .06)
Musical Understanding (+
16.4 %, p < .01)
Stylistic Accuracy (+ 13.5
%, p < .01)
Interpretative Imagination
(+ 17 %, p < .01)

Normative
Databases
enable Z-score
neurofeedbac
k training

Z-Score NFB
for Long-
term
Insomnia
• “Our results suggest that
using updated, advanced
electronic hardware and
innovative Z-Score
Neurofeedback software,
daytime NFB in the
laboratory is effective for
the treatment of insomnia
disorder.
• Scores on all the primary
sleep and Quality of Life
measures pre- to post-
treatment were significant.
• All eight participants
achieved normal or near
normal sleep.
• Furthermore, the
treatment response was
sustained for at least 6–9
months at follow-up in
more than half of the
study completers.”
•Hammer, B, et. Al, Neurofeedback for
Insomnia: A Pilot Study of Z-Score SMR
and Individualized Protocols , Appl
Psychophysiol Biofeedback DOI
10.1007/s10484-011-9165-y

Z-Score NFB for Long-
term Insomnia
•Hammer, B, et. Al, Neurofeedback for Insomnia: A Pilot Study of Z-Score SMR and
Individualized Protocols , Appl Psychophysiol Biofeedback DOI 10.1007/s10484-011-
9165-y

• Long-term Follow-up from 14-18 Hz Training of the cognitive
division of the Anterior Cingulate
• Significant Differences in pre and postworking memory and
processing speed scores.
• Long-term Cortical Changes demonstrated.

Long-term effects of LORETA NFB
training in cognitive portion of AC –
Cannon & Lubar – SUBJECT B
• Wechsler Adult Inteligence Scale (WSIS-III) 16-point Mean increase
• Working Memory
• Pre- 109
• Post- 130 …
• +21 pts. P<0.01
• Processing Speed Index
• Pre- 117
• Post- 128
• +11 pts. P<0.05

Long-term effects of LORETA NFB training in cognitive
portion of AC – Cannon & Lubar – Conclusions
• Data suggests LORETA NFB produces significant and long-term
changes in
• Absolute Power
• Coherence
• Intelligence Scores
• Progressive effects from end of Training to Long-term follow-up
studies.
• Subjective reports of improved information retention and less
anxiety

Neurofeedback in Post Traumatic Stress
Disorder
• Over forty published research papers supporting the use with
multiple different modalities.
• Van Der Kolk Et Al, 2019, “Compared with the control group NF
produced significant PTSD symptom improvement in individuals with
chronic PTSD, as well as in affect regulation capacities.” Training at
right Temporal and Parietal Sites
• Bokura et al 2019, Left Amygdala Training Reduced ratings of
Depression, and Post Traumatic Stress Disorder.
• Kropotov et Al 2019 “Neurofeedback was found to be a potent
intervention for refugees suffering from Post Traumatic Stress
Disorder…significantly lower symptoms of PTSD, Anxiety, and
Depression compared to controls,” with training at left Parietal.
• HOW CAN THEY ALL WORK?

Starr et Al Random Sample of a Normal Urban Population, N=300.
Primary Care PTSD Screening Tool, 10% Prevalence of PTSD was detected.

Results may indicate derangements
in each of the three networks.

Myneurva’s Cross-Frequency Network
Neuroaugmentation: 5 years/40,000 Pt Hrs

How do I
explain NFB
to Patients?
• Neurofeedback works
by helping to restore a
better balance of
waves in various parts
of the brain.
• All brain functions are
wave dependent… this
is why it is broadly
applicable

The Low-Down
on Clinical NFB
• Typical is 2-3 x a week for 20-60 min
• Can do 2x a day x 10 days for intensive
treatments
• 20 sessions is one dose; 95% of individuals will
achieve a 2 SD Improvement in QEEG.
• 2-3 doses in a given year will provide long
lasting relief for appropriate conditions.
• Effects are Gradual…
• Quantum Dilemma of self-knowledge present
• Can be immediate – like with migraine HA
• Transient Side-Effects: (uncommon)
• Tiredness, time-limited headache, agitation.
• Adverse Effects: (rare)
• Vocal Tics, OCD, mania, depression, anxiety,
seizure, anger, emotional lability, fatigue,
multiple migraines, dissociation
• Usually from too strongly reinforcing something
(beta or alpha/theta or ultra-low frequency)
• Uncommon with Z Score and frequent QEEG
(Every 10 Sessions).

The Low –
Down
Continued
• qEEG-NFB can change the face
of mental health diagnosis and
treatment – and offer potential
for long-term resolution of
symptoms rather than the
temporary relief of
medications.
• For traditional therapy it can
make people “more available”
with improved self-insight, and
ready for therapy
• Best when all aspects of brain
health addressed

Heart
Health……...
Brain
Health

Questions?
• Dr.starr@myneurva.com

Qeeg and-nfb 2021

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