Neurofeedback as an Evidence-Based Alternative Therapy

Neurofeedback is a type of biofeedback that uses the real-time collection and display of electroencephalography (EEG) data to strengthen the brain’s natural ability for adaptation and self-regulation. A functional brain map is generated using the same recording equipment and procedures used in hospitals for epileptic and polysomnographic testing. The software that performs the analysis decomposes the brain signals at each of the nineteen scalp sites into frequency bands corresponding to various modalities of brain function. These bands are then cross-correlated between sites to determine the degree of coherence, and then this processed data is compared to an FDA-regulated normative database. This approach is also known as Quantitative Electroencephalography (QEEG). The resulting comparative brain maps guide the neurotherapist in determining which sites and in which direction (eg. inhibition or up-regulation) to train the client.

Neurofeedback training is based on principles of operant conditioning. Audio (and often) visual signals are paired with changes in EEG signals to reward the client for attaining and maintaining a desired brain state. After several sessions, the new brainwave patterns stabilize, with longitudinal studies demonstrating the maintenance of the trained state over the course of 5-10 years (the length of the reported investigations). Some clients may require 15 to 20 sessions or others may need up to 40 or even 60 sessions, depending on the disorder and its severity. Imaging studies have confirmed the functional changes observed in neurofeedback-based training.

Neurofeedback was first investigated in the 1950s. Though the accumulated empirical data proved that neurofeedback worked, it didn’t fit the existing medical model of the brain at that time, which prevented acceptance and adoption by the medical community.

Naturopathic physicians are likely to recognize this battle for acceptance from the history of their own field: in 1968 the United States Department of Health, Education, and Welfare issued a report concluding that naturopathy was not grounded in medical science and that naturopathic education was inadequate to prepare graduates to make appropriate diagnosis and provide treatment.

To counter these beliefs, professional organizations such as the Association for Applied Psychophysiology (AAPB), whose membership includes physicians, neurologists, clinical psychiatrics, and other licensed health care providers, have begun an effort to develop efficacy standards supporting the application of neurofeedback towards clinically recognized disorders. Efficacy is determined by evaluating formal studies done on each disorder. When a study is done, the treatment is very carefully standardized; medical personnel conducting the interventions should have great expertise in the treatment and the disorder and patients are very carefully selected. This approach is very similar to rating schemes developed by other organizations such as the American Psychological Association and the American Academy of Pediatrics. The guidelines for establishing efficacy can be found in the following publication:

Template for developing guidelines for the evaluation of the clinical efficacy of psychophysiological evaluations. Applied Psychophysiology and Biofeedback, 27(4), 273-281. LaVaque, T., Hammond, D., Trudeau, D., Monastra, V., Perry, J., Lehrer, P., Matheson, D., & Sherman, R. (2002).

The efficacy levels may be summarized as follows:

Level 1: Not empirically supported: Supported only by anecdotal reports and/or case studies in non-peer reviewed venues.
Level 2: Possibly Efficacious: At least one study of sufficient statistical power with well identified outcome measures, but lacking randomized assignment to a control condition internal to the study.
Level 3: Probably Efficacious: Multiple observational studies, clinical studies, wait list-controlled studies, and within subject and intrasubject replication studies that demonstrate efficacy.
Level 4: Efficacious: a) In a comparison with a no-treatment control group, alternative treatment group, or sham (placebo) control utilizing randomized assignment, the investigational treatment is shown to be statistically significantly superior to the control condition or the investigational treatment is equivalent to a treatment of established efficacy in a study with sufficient power to detect moderate differences; b) The studies have been conducted with a population treated for a specific problem, for whom inclusion criteria are delineated in a reliable, operationally defined manner; c) The study used valid and clearly specified outcome measures related to the problem being treated; d) The data are subjected to appropriate data analysis; e) The diagnostic and treatment variables and procedures are clearly defined in a manner that permits replication of the study by independent researchers; and, f) The superiority or equivalence of the investigational treatment has been shown in at least two independent research settings.
Level 5: Efficacious and specific: The investigational treatment has been shown to be statistically superior to credible sham therapy, pill, or alternative bona fide treatment in at least two independent research settings. Conditions treated at the highest levels of efficacy (4 and 5) include: Anxiety, ADHD, Chronic Pain, Constipation, Epilepsy, Headache, Hypertension, Motion Sickness, Raynaud’s Disease, Temporomandibular Disorder, and Urinary Incontinence in Females.

While neurofeedback is still not covered by most insurance plans, it is safer and longer-lasting than many commonly prescribed medications. The the equipment is portable, which increases accessibility to mobility-challenged patients. It also opens up the potential for clinical collaborations, where neurotherapists and naturopathic physicians might co-work with a given client to bring complementary expertise towards developing a targeted clinical intervention.

Neurotherapists offer the possibility for three kinds of collaborations with naturopathic physicians. First, QEEG-based brain maps can be offered to your patients as a lab testing service. Many clients, especially those with children suffering from attention issues, are dissatisfied with diagnoses based on questionnaires, rather than testing that examines the brain itself. Spect-scans can be prohibitively expensive in comparison with QEEGs ($3000 vs $300). Second, a neurotherapist can work with you to provide training targeted to a particular clinical condition, thereby offering you and your clients an evidence-based alternative to encourage the body to heal itself. Finally, many neurofeedback practitioners are focused on cognitive optimization – how we can keep ourselves sharp and age gracefully by engaging in preventative brain health. This last category has received a great deal of attention this past year, with major medical centers such as the Beth Israel Deaconess in Boston committing to a fitness center for brain health. (Read more here:

In conclusion, neurofeedback may offer you and your clients an alternative treatment to many clinical conditions and/or an approach to maintaining healthy brain functioning. Neurofeedback has over fifty years of supporting research and a network of like-minded professionals committed to the understanding and advancement of brain health. Naturopathic physicians interested in becoming board-certified in this specialty should consider contacting BCIA, the Biofeedback Certification International Alliance.

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