Most of the pain-related studies for neurofeedback have been conducted with chronic pain patients. However, there have been a few small studies looking at how neurofeedback can affect acute pain. Several neuroimaging studies have shown that similar brain regions are involved in both acute pain and chronic pain.
As such, research is needed to ascertain whether neurofeedback could be an effective treatment for use pre and post operatively, and also for acute conditions, with a view to preventing the chronification of pain. Plans are currently underway to conduct a study testing the efficacy of the Axon system for treating pain and pre-operative anxiety, along with post-operative training to reduce acute pain and prevent the development of chronic pain.
The aim of neurofeedback for chronic pain is to allow a person to self-regulate their own brain activity and improve their symptoms by interacting with the unconscious processes involved in chronic pain. To date, nobody has reported an effect of alleviating boredom. The aim of the games is not to play them like you would a traditional game.
Instead, we provide a gamified way of interacting with the brain, deliberately designed to target specific brain networks and frequencies of activity. If the games were too over-stimulating, other networks of brain activity could be activated, and the patients would not be targeting the chronic pain areas. Most patients are highly motivated to engage with the training, as they are seeking relief from their symptoms, rather than wishing to play a game as such, and so boredom has not been a factor.
Compared to most research grade headsets, the Axon system is mobile, battery powered, relatively lower cost, and will be sold as a medically certified clinical grade headset. Rather than compare our headset to others, I believe what makes us unique is the integrated Axon system – i.e. the headset with miniaturised EEG technology, our Axon app, optimised software for artifact rejection, games aimed at allowing a person to access and modulate their own brain activity, and our clinician portal allowing clinical oversight of patient outcomes.
As developers of all components in the system, we are able to provide a comprehensive treatment for chronic pain which is configurable to a clinician and patient’s requirements.
The Axon system will be approximately US$1,650 for the first year and, US$1,350 for subsequent years. That translates roughly to NZ$2,500 for the first year, including the cost of the headset and access to the Axon app and brain training games.
EEG neurofeedback is a safe and effective treatment for many conditions. Neurofeedback is considered such low risk, that it is widely used as a treatment for ADHD in children. Side effects are rarely reported, but patients may occasionally experience a mild headache or drowsiness after a training session. We have noticed some of these effects in patients on our UK and NZ trials, however any effects quickly wore off after the session, and reduced over time as the individual got used to neurofeedback.
The Axon system is very easy to use and has been designed with minimum preparation in mind. Typically, there is an initial one-on-one training and fitment session with the patient, supported by training videos on how to use the system and a comprehensive instruction manual. The Axon app guides you through each step of the session, and patients report it is very easy to use.
We have had people from all age groups with varying technical abilities who have easily learned to use the system. Exsurgo offers training to clinicians, who are then able to assist with patient training. We also conduct regular useability assessments, and we are always keen for feedback from patients and clinicians.
Users of the Axon system learn to upregulate their alpha frequency (8-13Hz) through repeated training sessions over a relatively short period of time when treating chronic pain. By doing this, they are able to facilitate neuroplastic learning, thus increasing their ability to access brain states associated with relaxation and focus, and decrease time spent in brain states associated with chronic pain, such as anxiety.
‘Flow state’ or ‘The Zone’ refers to a feeling where everything has a sense of fluidity and connectedness, and you are completely in the moment. You may lose a sense of time, your senses may be heightened and you feel calm and focussed.
Flow state is frequently reported after individuals learn how to self-regulate their brain activity using neurofeedback. Patients report increased relaxation, a sense of connectedness and feeling in the moment, as well as increased quality of life akin to enjoyable activity. With regular training the patients increase the likelihood of making long-lasting neuroplastic changes in their brains, as opposed to any short-term gains experienced during an enjoyable activity.
Thus, training with the Axon system may increase their overall enjoyment from other activities by changing their pain perception and regulation, allowing them to engage more fully in activities aimed at increasing their quality of life.
The Axon system records brain activity over the somatosensory cortex, which is involved with pain perception and regulation. By recording and providing real-time feedback, a patient is able to upregulate their alpha and down regulate hi-beta and theta along this region, which is associated with neuronal activity related to pain, inflammation, sensitisation, emotional regulation, attention, and cognitive processing.
Neural activity at the somatosensory cortex is part of the incoming and outgoing network of pain messages that are processed in the brain, which are then sent to the deeper cortical regions, such as the Thalamus, which is the hub for processing multi-directional chronic pain related activity. As such, modulating brain activity at the somatosensory cortex can change the pain messages, affecting the primary and secondary symptoms of chronic pain.
Apart from a head measurement to ensure the correctly sized headset, the only calibration required is performing a 2-minute EEG baseline recording prior to each training session. This allows the app to calculate a training threshold. The software will check and notify the user if there is an electrode connection issue, including high impedance connections.
Neurofeedback can be used immediately with no prior work needed. The Axon system could be used in conjunction with other cognitive therapies such as ACT or CBT, which may increase the efficacy of both approaches. Patients have reported feeling an increased sense of agency over their chronic pain when they perform neurofeedback training sessions.
When a person is told it is “all in their head”, the implication is that their chronic pain is imagined or not really a disease. This is not true and the WHO has classified chronic pain as a disease state. However, chronic pain is definitely processed by the brain and so modulating brain activity can have an effect on the severity and and progression of the disease. Once a person realises they can have a direct impact on how their brain processes pain, this can be a very empowering and motivating factor, which can only have a positive effect on their psychological wellbeing.
TMS involves applying magnetic pulses to induce electrical activity in a specific brain area through electromagnetic induction. Neurofeedback does not involve any kind of external stimulation (magnetic/electric/kinetic), but instead records brain activity at the location of the scalp electrode and presents the activity to the user in a visual form. TMS does not usually involve any interaction, whereas neurofeedback is interactive.
Neurofeedback actively engages the patient in their own treatment, enabling them to enhance/reduce activity at specific frequencies around specific brain regions. This self-motivated approach can be empowering and psychologically beneficial for patients, as well as being more gentle than other neuromodulation techniques, such as TMS.
With the Axon system, a patient doesn’t have to visit clinics for expensive treatment, instead doing it in the comfort of their own home at a time that suits them, and where they can feel relaxed and at ease.
EEG neurofeedback is a form of biofeedback that focuses on the modulation of brain activity associated with a particular disease or psychological state, rather than physiological processes that can be modulated with biofeedback. Though complementary, these two techniques are quite different and are not usually compared against each other for efficacy but have been combined simultaneously in some studies.
There is overlap between the techniques, in that neurofeedback affects brain areas associated with physiological responses, such as CNS arousal and heart rate variability, but in practice both techniques differ in many ways and are used for different reasons.
Traumatic brain injury is often exacerbated by memories of traumatic events which can affect a person’s ability to cope with daily life. Neurofeedback has been evidenced as an effective tool in the treatment of trauma including PTSD, and this is one of the earlier areas of neurofeedback research in the US.
One study recently reported that individuals with intractable PTSD (i.e., resistant to behavioural therapies and medication) resulting from torture and refugee experiences, showed clinically significant decreases in their PTSD symptoms (including anxiety and depression) after EEG neurofeedback. These patients also showed increased cognitive control. Similarly, another recent study in children with developmental trauma due to abuse and neglect, showed a reduction in PTSD symptoms and improved executive functioning after neurofeedback training.
From these studies, we can postulate the use of neurofeedback as a valuable adjunctive treatment for PTSD, and we have plans to test the Axon system in the future with patients suffering from anxiety, depression, and trauma.