Alicja KUBIK12
AgnieszkaBIEDROŃ1
Neurofeedback therapy in patients with acute
and chronic pain syndromes
- literature review and own experience
1lnstytut Neuromedica, Krakow Director:
Alicja Kubik, MD
2Chair of Pediatric and Adolescent Neurology Jagiellonian University
Head:
Prof. MarekKacinski
Additionalkey words:
neurofeedback stroke headache neuropathicpain cancerpain
Dodatkowe słowakluczowe:
neurofeedback udar mózgu bóle głowy bóle neuropatyczne bóle nowotworowe
Pain management is based mainly on pharmacotherapy which has many limitations. Non-pharmacological techniques, like neurofeedback (EEG- biofeedback) are alternative methods of pain treatment. Data from literature confirm high efficacy of neurofeedback in pain syndromes treatment, chronic and acute as well. Neurofeedback plays an important role in management of post stroke, post traumatic heada
ches and in primary headaches like tension type headaches or migraine.
Literature review and own experience indicate importance of number and fre
quency of performed neurofeedback trainings on treatment effectiveness.
Satisfactory results have already been observed after 30 trainings however usually 40-60 training have to be per
formed. Effectiveness of such therapy in pain syndromes is usually good or less often acceptable (50% reduction of headaches). Children with tension type headaches (differently than adults) need reminder therapy every 6-12 months, otherwise recurrence of headaches is observed. Based on our own experience neurofeedback thera
py seems to play role in neuropathic pain and cancer pain management.
Adres do korespondencji:
AlicjaKubik MD
Zakopiańska St. 2a,30-418Kraków tel. +48 695309191
e-mail: alicja. kubik@instytut-neuromedica. pl
Introduction
Development of biofeedback was pre ceded by observation ofcerebral bioelectric activityfluctuations occurring during intel
lectual activity. Berger, inventor of electro encephalography(1920), registered beta rhythmduring wakefulness and thinking and in 1963 Kamiyarevealed that withsuitable trainingbrainwaves could becontrolled. In 1968 Sterman indicatedpossibility of cats' motor activitydepression with increasing proportion of SMR(Sensory Motor Rhythm) rhythm in EEG recording [46].Evolution of quantitative EEG (QEEG) in 1970-1980- ties was fundamental for understanding neurophysiological basics of biofeedback.
Nowadays, biofeedback is generally ac cepted as a method rationally affecting
Bóle leczone są najczęściej far makologicznie, jednak i ta metoda m<
wiele ograniczeń. Stąd też alterna tywnym postępowaniem są technik nie farmakologiczne, w tym neurofe edback (EEG-biofeedback). Dane;
piśmiennictwa wskazują na znaczni skuteczność neurofeedbacku w lecze niu zespołów bólowych, przewlekłycł jak i napadowych. Zwraca się uwagi na znaczenie neurofeedbacku w bó lach poudarowych i pourazowych, jal również w pierwotnych bólach głowj napięciowych i migrenowych.
Zarówno inni autorzy jak i doświad czenia własne wskazują na istotni znaczenie dla skuteczności neurofe edbacku liczby przeprowadzonycł treningów i ich częstości. Dobry wynil tej terapii następuje w niektórych przy padkach już po 30 treningach, ale w większości przypadków terapia wyma ga 40-60 treningów. Efekt takiej terapi w zespołach bólowych jest z reguł}
dobry lub rzadziej zadowalający (re dukcja bólów o 50%). W napięciowycł bólach głowy głowy u dzieci, w od róż nieniu od dorosłych, co 6-12 miesięcj powinno się stosować 10 treningów przypominających, bez których bólt te częściowo nawracają.
Doświadczenia własne wskazuj:
również na pewne znaczenie treningów neurofeedbacku w bólach neuropa tycznych i nowotworowych.
living organism. Neurofeedback which ii basedon registrationand analysis of EEC plays the most importantrole. Knowledgeo association between bioelectric function o different brain areasandclinical symptom:
is crucial in this method [23]. One shoulc keep in mind that neurofeedback traininc influences autonomic nervous system.
In March 2008 Biofeedbacksection o Polish Clinical Neurophysiology Societ) was founded, however not untilJune 201' was biofeedback accepted by Polish Clinica NeurophysiologySociety as one of5 clinica neurophysiology method in Poland, nexttc EEG, EMG, evoked potentials, and auto nornic system investigation [21]. In the pas years this method wasneglectedand regar dedonlyas a generally available videogame
440 A. Kubik, A. Bied oi
that is why its clinicalsignificance needs to be enhancedbypublications in Polish and foreign journalswith contribution of Polish authors.Neurofeedbackisnaturally associa
ted with human development by documen
tation of human emotional development, lo calized functions of central nervoussystem and compensationof neurodevelopmental and acquired disturbances [24].
Neurofeedbackhasbecome an effective method ofpain syndromes management, particularly headaches in children [19].
Cessation of continuous and intermittent pain is a challengefor every doctor and man who wants torelieve human suffering [7].One should not besurprised thathigh percentage ofpatientsundergoing neurofe
edback therapy are adultsand children with pain syndromes.Better localization of pain centers andelaboration of more objective scales for pain intensity estimation are re
quired foruseof this non-pharmacological method[4].
Stroke and traumatic headache
Sensor-motor integration is associated with frontoparietalarea of sensory-motor cerebral cortexand itsimpairment (for exam ple due to stroke) resultsin paindisorders, epilepsy and ADHD [32]. Effectiveness of neurofeedback therapy of patients after stroke has beenconfirmed recently. Howe
ver, performance of 40 trainings is needed for positive therapy result[9]. 6-monthneu
rofeedback therapy used of patient after a left hemisphericstroke caused inhibition of 4-7Hzactivityand simultaneous increase of 15-21 Hzactivity in the sensory-motor and speech areas, which resulted in signi ficantclinical improvement. Improvement ofspeech fluency,concentration andvisu al-motor coordination has been observed [38]. Observationof 8 patientswith chronic stroke who haveunderwent neurofeedback therapy revealed improvement of motor functions[40].
Our 9-year experienceof neurofeedback therapy confirms these observations. In 9 patientswith paresthesias afterstroke first positive results have been observed only after 20 trainings. 40 to 60 trainings 3 times aweek, have given permanent analgesic effect.In this time 15 patients with troubleso me headaches after craniocerebral trauma have been treated as well. In this group 40- 60 neurofeedback training, 3 times aweek have been done. Good and probably perma
nent effect(>1 year observation)has been achieved. Biofeedback together with basic andeducative treatmenthasbecome an im
portant method ofposttraumaticheadaches management,which has been confirmed by quantitativeanalysis ofEEG [30].
Moreover,our own experience concerns 4 patients withtrigeminalgiaand 2 patients withcancer pain syndromes (breastcancer, ventricular cancer). Also in these patients, previously treated pharmacologically, neu
rofeedback therapy has brought good anal
gesic result. Non-pharmacologicalmethods have provedto be effective in pain mana
gement nextto pharmacological methods [22,43]. In these cases biofeedback has taken important place, more in prevention ratherthan treatment [15].
Primary headache
The most numerousgroups of patients treated with neurofeedback are patients with differenttypes of headaches. The doctorwho dealswith biofeedback has to excludeorganiccause ofheadache before introduction oftreatmentofprimary heada ches (idiopathic). Amongpatients (children and adults) with headaches, thegroup of patients with chronic headaches takes an important place (occurring more than 15 daysper month) dueto necessity of phar macological treatment used for cessation of attack,prophylaxis and longtermtreatment [2,20]. Nowadays, it has been confirmed that psychological approach as well as neurofeedback therapycause decrease of headache intensity [37].
Tension typeheadache
Over 70 publications had been publi shed until 2008 indicating effectiveness of biofeedback in managementof primary tension type headaches [33]. Examination ofcognitive andpsychosocial development and self-regulationare used forassessment of neurofeedback as therapeuticmethod in patients with headaches [29]. Neurofeed back has been used not onlyin specialist centers but also in domestic conditions, which has positiveinfluence on behavior of treated children. Intensive developmentof neurofeedback has resulted in meta-analy- sis concerning its effectiveness in treatment of patientswith headaches [35,44]. Howe ver,there are still reportsin which analysis of obtained results based only on experts opinion[11,47].
Results of 9 years ofour own experien ce with neurofeedbackcan beobserved in 270 patients with tension-typeheadaches, 180 children and 90 adultpatients. 30 to 60 neurofeedback trainings have been performed in these patients, 2-3 times per week. Results of such therapyhave been goodor satisfactory in majority of patients (50% reduction of headacheintensity). Dif ference in neurofeedbackefficacy between children and adult patients has been noticed.
In children, every 6-12 months reminder therapy consisting of 10 trainings had tobe performed in order to sustain clinicaland neurophysiological improvement.
Migraine
Neurofeedback therapy has beenused inpatientswith tensiontypeheadaches and migraine as well[31]. Quantitative EEGexa minations indicate significant role of visual cortex in migraine pathogenesis[12] and it is suggested that migraine headache and aura are secondary to cortical spreading depressionproposed by Leao (propagating neuronal and glial depression)[17]. Neuro
nal disturbances evoke vasomotorchanges, play important role inmigrainepathogenesis but also in stroke andcraniocerebraltrauma [14,18]. Results of quantitative EEG exa
minationand asymmetry of EEG recording suggestthat migraineurs are susceptible to migraine attack even 36 hours before its occurrence [13]. However based on quantitativeanalysis of EEG, biofeedback has had little influence on prevention of cortical spreadingdepression propagation
in migraine and stroke patients [16].
Migraine changesqualityof life at every age however, it has significant influence at developmental age [27]. Individual ac ceptance of chronic disorder is needed in orderto face the fear of another attack (unavoidable evenin doctor’s opinion).Pro gnosisofmigrainewith aura with childhood onset should be basedon EEG analysisin the first place [43]. Quantitative analysis of EEG recording playssignificantrole in differentiatingmigraine from epilepticevents [39]. Simultaneous evolution ofchanges of cerebral blood flow andslow-wave bioelec tric activityhas been observedin children with migraine with aura on SPECT and EEG [36].One should keep inmind influence of visual stimulation on cerebral bloodflowin children with migrainewith visualaura [10].
However estimation of migraine headache in the first yearof patient’s observation seems unjustifiable[42].
Pharmacological as well as non-phar macological methods should be used in migraine therapy [1,28,34]. Ibuprophen, sumatriptan and flunarizine have been used for cessationof migraineattacks [5], however none of currently usedtreatment in migraine is satisfactory [26]. Recently, biofeedback has been pointed out by some authors as an effective method next to anti-emetic drugs, codeine, nonsteroidal anti-inflammatory drugs, paracetamol, 5HT1 antagonists, beta-blockers, pizotifen, topiramate, diet changes and techniques reducing stress [6]. Relaxation therapy and neurofeedback play important role in management of migraine in children and adolescents, during such therapy changes in beta-endorphins concentration have been observed [8]. Biofeedback is regarded as one of therapeutic method used in migraine patents [1].It is consideredaseffective pro
phylactictreatment of migraineattackin chil
dren [3]. Thesignificanceof neurofeedback therapy in children withmigraine hasbeen confirmed by clinicaldata[41]. Quantitative EEGexaminations indicate important role of neurofeedback in reducingfrequency of migraine attacks [45].
Our own experience in this field is based on examination of 165 patients (45 adultsand120 children)with migraine.110 patientshad migraine without aura and 55 withaura.40-60 trainings wereperformed in these patients (2-3 per week). Resultswere good in 2/3 andsatisfactory (50% decrease of attacks intensityand frequency) in1/3 of the patients.
Summary
Every-dayclinical practice and scienti ficreports constantly add new information about use of neurofeedback therapy inpain management of adults and children. Little experience (general and own) in this field results from small number of adult patients and children who undergo this therapy. In Poland information about biofeedback is still scarce. Our ownexperience has preceded by atleast 8 years(6 years in the clinical and didactic aspect) formal acceptanceof biofeedback as a neurophysiology method in Poland [23]. Publication ofreliabledata (evidencebased medicine)concerning role
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and effectiveness ofneurofeedback therapy in management of chronic as well as in acute pain syndromesis needed [25].
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