Biofeedback techniques in treatment of epilepsy

Are psycho physiological biofeedback techniques effective in the treatment of epilepsy? Discuss with reference to empirical studies.

Epilepsy is a relatively common neurological condition, and is defined by a person having more than one seizure. Anyone can develop epilepsy though it mostly occurs in people who have learning disabilities, and is usually diagnosed either before the age of twenty or after sixty years of age. Epilepsy is thought to occur when signals in the brain misfire, usually faster than normal and in bursts. The misfiring causes the body to have a seizure, which can be classified as either a generalised or partial seizure depending on where in the brain it occurs. A generalised seizure involves the whole brain, whilst a partial seizure originates in one part of the brain. The most customary way of treating epilepsy is by drug treatments that are effective in reducing, or even stopping seizures in the majority of cases. However for those sufferers who do not benefit from drug treatment, other methods of treating epilepsy are available. Although psycho physiological biofeedback techniques are not new, research looking into their effectiveness as an alternative to drug treatment for epileptics has recently become more popular. The development of biofeedback treatments is particularly useful for epilepsy sufferers who have not found drug treatment to be effective for them.

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Psycho physiological refers to studies that look at the interactions between the mind and the body, and how the body is functioning in relation to displayed behaviour. Most psycho physiological techniques are non-invasive and usually involve taking recordings from sensors placed on the surface of the skin. Biofeedback is chiefly used to assess brain processes and muscular tension, and can be used to correct irregular physiological functioning. By combining these two techniques an effective method of treatment for disorders such as epilepsy may be developed, without the need for drugs. Typically psycho physiological style sensors are used to assess biofeedback this is then used to teach epileptic participants to recognise behaviours prior to a seizure and try to control them. This is thought to be a technique that could help epilepsy sufferers manage the frequency of their seizures, because of the neurophysiological basis of epileptic seizures. Goldstein (1997) identifies a theory that was developed by Fenwick and Brown (1989; cited in Goldstein, 1997), which suggests that when a seizure occurs two groups of neurons are affected. Group 1 neurons fire continuously at the central point of the seizure, whilst group 2 neurons are proximal and can either fire normally or as the group 1 neuron’s do. Fenwick and Brown (1989; cited in Goldstein, 1997) suggest that because neurons surrounding an

epileptic episode can influence the occurrence and spread of the seizure, behaviour that affects activity in neurons can affect the occurrence of seizures. This theory is one of few that suggests a strong neurophysiological basis for epilepsy, as is research that utilises biofeedback techniques.

There are a number of psycho physiological biofeedback techniques that have been used to investigate treatment for epilepsy. Critchley, Melmed, Featherstone, Mathias and Dolan (2001) looked at brain activity during biofeedback relaxation. They trained participants to perform a biofeedback relaxation exercise, where participants used the information relayed from biofeedback to change their sympathetic tone by relaxing. Critchley et al (2001) then tested the participants using two control tasks, a task with biofeedback relaxation and a relaxation task without biofeedback. The results revealed that when participants used the biofeedback information during relaxation, activity in areas of the brain that had not been aroused during the control and relaxation tasks increased. These findings would suggest that deliberate control over ones brain activity is possible, and more specifically training can influence brain activity when a person is experiencing a particular sensation. When investigating the effectiveness of biofeedback relaxation in reducing seizures in epileptics, Puskarich et al (1992) looked at patients who had been trained with progressive muscular relaxation. The majority of the relaxation group found a reduction in the frequency of seizures over an eight-week period, whilst the control group did not encounter a significant reduction in seizure frequency over the same period. This would seem to show that biofeedback relaxation techniques can be successfully used to treat epilepsy, however research in this area often has small sample sizes and is time consuming. This means that small anomalies in the data can distort the final results and makes the study difficult to repeat.

Another psycho physiological biofeedback technique that has been investigated for the treatment of epilepsy is Galvanic skin response biofeedback. Nagai, Goldstein, Fenwick and Trimble (2004) examined the usefulness of galvanic skin response biofeedback training in reducing the frequency of seizures in adult epileptics. Two groups of participants, who suffered from drug-refractory epilepsy, were randomly assigned to either a biofeedback-training group or a sham control group. The participant’s galvanic skin response was measured during a biofeedback computer-training task for the experimental group, but during a modified computer

task for the sham control group. Nagai, Goldstein, Fenwick and Trimble (2004) found that a significant reduction in the frequency of seizures occurred for the biofeedback group, but not for the sham control group. This would suggest that the change was affected by the training given to the experimental participants, showing that the use of Galvanic skin response biofeedback is successful at treating epilepsy. Although Nagai et al (2004) suggest this particular study is only preliminary; the findings are encouraging and suggest that this type of research could produce an effective non-drug treatment for epilepsy.

Self-regulation of slow cortical potentials has been study in relation to treating epilepsy. Rockstroh et al (1993; cited in Monderer, Harrison and Haut, 2002) looked at self-regulation of slow cortical potentials at time of investigation and at a one-year follow up. Rockstroh et al (1993; cited in Monderer, Harrison and Haut, 2002) found that participants that were successful at modifying slow cortical potentials had a significant reduction in seizures. This would suggest that self-regulation of slow cortical potentials is an effective treatment for epilepsy, however subsequent research found that when other variables were also tested alongside self-regulation it was not such a prominent factor. Strehl, Kotchoubey, Trevorrow and Birbaumer (2005) researched the possibility of using the management of brain potentials to reduce the frequency of seizures in patients who are unresponsive to drug treatment. They suggest that negative slow cortical potential changes in the brain assist paroxysmal activity, and that the suppression of negative cortical responses is correlated with constrained epileptic discharge. By using a psycho physiological biofeedback technique along with assessment of other factors, such as personality variables and cortical excitability, Strehl et al (2005) examined 34 participants. They found that despite a reduction of seizure frequency in the majority of participants, the outcome may be more to do with factors other than EEG biofeedback and neuropsychological tests. Strehl et al (2005) propose that the participants who had a significant reduction in seizure frequency did not have large negative slow cortical potentials at the beginning of training, and show high levels of stress, epileptic focus and score low on life satisfaction measures.

Another psycho physiological biofeedback technique that has been considered as a treatment for epilepsy is sensorimotor rhythm biofeedback. Tozzo, Elfner and May, Jr. (1988) looked at young patients who had previously been resistant to

treatment for their epilepsy. Sensorimotor rhythm refers to the 12- to 20-Hz frequency found over the sensorimotor cortex during behaviour inhibition. Studies have shown that control of this rhythm is obtainable, and that this is significant for epileptics because seizures are thought to be accompanied by disruption to this rhythm. Being able to teach patients to gain control over their sensorimotor rhythm could result in significant reductions in the frequency of seizures. Tozzo, Elfner and May, Jr. (1988) tested epileptic participants using a multiple baseline design that incorporated a sensorimotor rhythm biofeedback technique. They found that all the participants were able to increase the time they spent in sensorimotor rhythm, and that a good proportion of participants saw a reduction in seizures. Lantz and Sterman (1988) also carried out a research investigation using sensorimotor rhythm biofeedback to treat unresponsive epilepsy. Lantz and Sterman (1988) found that by enhancing 11- to 15-Hz frequencies and decreasing 0- to 5-Hz and 20- to 25-Hz, the participants obtained a significant reduction in seizure frequency.

There are many different types of psycho physiological biofeedback techniques that have been researched as an alternative treatment for epilepsy, and the majority have shown promising results. There are some methodological problems that need to be considered for future research, especially in the case of slow cortical potential self-regulation. Large sample sizes have not often been used, and the unfortunate fact that these techniques are time consuming means that they are difficult to carry out and replicate. However for those epileptics that have not found help form drug treatments the development of biofeedback techniques is invaluable. As in the case of the majority of research utilising the sensorimotor rhythm method, the studies are over ten years old and therefore do not reflect the advancement in technology since. More accurate methods of obtaining biofeedback are currently available, and if this method of treatment is to be more extensively tested new technology should be used.

References

Critchley, H.D, Melmed, R.N, Featherstone, E., Mathias, C.J. and Dolan, R.J. (2001). Brain activity during biofeedback relaxation: A functional neuroimaging investigation. Brain, 124, 1003-1012.

Goldstein, L.H. (1997). Effectiveness of psychological interventions for people with poorly controlled epilepsy. Journal of neurology, neurosurgery and psychiatry, 63, 137-142.

Lantz D, and Sterman, M.B. (1988) Neuropsychological assessment of subjects with uncontrolled epilepsy: effects of EEG feedback training. Epilepsia, 29, 163-171.

Monderer, R.S, Harrison, D.M. and Haut, S.R. (2002) Neurofeedback and epilepsy. Epilepsy and behaviour, 3, 214-218.

Nagai, Y, Goldstein, L.H., Fenwick, P.B.C. and Trimble, M.R. (2004) Clinical efficacy of galvanic skin response biofeedback training in reducing seizures in adult epilepsy: a preliminary randomised controlled study. Epilepsy and behaviour, 5, 216-223.

Puskarich, C.A, Whitman, S, Dell, J, Hughes, J, Rosen, A.J, and Herman, B.P. (1992). Controlled examination of progressive relaxation training of seizure reduction. Epilepsia, 33, 675-680.

Strehl, U., Kotchoubey, B., Trevorrow, T. and Birbaumer, N. (2005) Predictors of seizure reduction after self-regulation of slow cortical potentials as a treatment of drug-resistant epilepsy. Epilepsy and behaviour, 6, 156-166.

Tozzo, C.A., Elfner, L.F. and May, Jr. J.G. (1988). EEG Biofeedback and relaxation training in the control of epileptic seizures. International journal of psychophysiology, 6, 185-194.