Neurofeedback for Sleep
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A non-pharmacological intervention, namely instrumental conditioning of 12-15 Hz oscillations (ISC), for improving sleep quality and memory is tested. This frequency range is known to be abundant during (i) quiet but alert wakefulness (sensorimotor rhythm, SMR) as well as in (ii) light NREM sleep-spindles. ISC is known to influence sleep quality. Two studies were completed to further explore the effects and apply neurofeedback (NFT) to (sub-) clinical insomnia patients. In the first study 24 young subjects with sub-clinical symptoms of primary insomnia were tested. Each patient participated in an ISC-NFT as well as a sham-NFT training block. A counter-balanced double-blind follow-up study with 30 primary insomnia patients and 30 controls was conducted. Data of the first study confirmed a significant increase of 12-15 Hz activity over the course of the 10 SMR training sessions which were positively related to overnight memory consolidation changes. Number of awakenings were reduced and slow-wave sleep was increased following ISC but not sham. Furthermore, N3 sleep spindles were found to be enhanced after SMR training. Preliminary results of study 2 indicated that patients suffering from more severe insomnia did not benefit in sleep or memory over the 12 ISC sessions, However, all groups (healthy controls, sleep state mispercept, and insomnia patients) do enhance SMR-power (and fast spindles) exclusively in the SMR (but not placebo) condition. Subjectively the sleep complaint decreased over both conditions. Current results indicate that besides healthy individuals also young people suffering from (sub-clinical) primary insomnia can experience subjective as well as objective benefits from ISC-NFT. The results of a comprehensive double-blind study, however, suggest that full-blown insomnia patients are not benefitting from ISC-NFT across 12 sessions.

Poor sleep has been acknowledged as an increasingly prevalent global health concern. Neurofeedback technology was proposed to potentially facilitate restfulness and sleep onset, this was further explored through the creation and study of “Inter-Dream”, a novel multisensory interactive artistic experience driven by neurofeedback. Twelve participants were chosen for the study; they were individually rested, augmented by Inter-Dream. The results demonstrated a statistically significant decrease in pre-sleep cognitive arousal (p=0.01), negative emotion (p=0.008), and negative affect (p=0.004). EEG readings were also indicative of restorative restfulness and cognitive stillness, while interview responses described experiences of mindfulness and playful self-exploration. Taken together the work in the study highlights neurofeedback as a potential pathway for future research in the promotion of sleep, while also suggesting strategies for designing towards this within the context of pre-sleep.

The term sleep disorder refers to difficulty in initiating sleep, maintaining itor a relaxing sleep despite having enough time to sleep. Cognitive behavioural therapy is a non-drug muulti-dimensional treatment that targets behavioural and cognitive factors of this disorder. Some studies have shown that psychiatric and neurological disorders can be distinguished from distinct EEG patterns and neurofeedback can be used to make a change in these patterns. This study aimed to compare cognitive behavioral therapy and neurofeedback in the treatment of insomnia. The sample included patients, who had already been diagnosed with insomnia, Random sampling and the Pittsburg sleep quality index (PSQI) was used for the selection of the participants. The sample included 40 patients who were randomly selected, interviewed and then split into 3 groups. Data was analyzed using SPSS. Following the analysis the independent effect of the treatment was significant and one-way ANOVA with post hoc test L.S.D were carried out were on CBT and control (p=0.001), CBT and neurofeedback therapy (p=0.003), neurofeedback treatment and control (p=0.001). The results showed a significant difference between the groups. Based on the analysis the two aforementioned treatments, neurofeedback therapy in the first position and cognitive-behavioural therapy in the second position were most effective, and the control group showed the lowest efficiency. Both treatments were significantly effective, and so we can use both NF and CBT for the treatment of insomnia.

Insomnia is a common sleep disorder where you have a hard time falling and/or staying asleep. Studies have shown that the presence of cortical hyperarousal can contribute to an impairment of information processes which might interfere with normal sleep onset and/or consolidation. This study wanted to use tele-neurofeedback (NFB) and tele-biofeedback (BFB) to examine cortical hyperarousal and its influence on information processing. Seventeen insomnia patients were randomly assigned to either a tele-NFB or tele-BFB protocol and twelve control participants were used to compare the baseline sleep measures. At pre and post treatment, a polysomnography (a test used in the study of sleep)  was performed. Results of the study showed that sleep onset latency decreased pre to post treatment in both groups but there was a significant improvement in Total Sleep Time only after the NFB protocol; which focused on the inhibition of theta and high beta along with the reinforcement of SMR. Furthermore, only NFB training resulted in an overall improvement of subjectively measured sleep at home. 

Recent studies have suggested a role for sleep and sleep problems in the etiology of attention deficit hyperactivity disorder (ADHD) and a recent model about the working mechanism of sensori-motor rhythm (SMR) neurofeedback, proposed that this intervention normalizes sleep and thus improves ADHD symptoms such as inattention and hyperactivity/impulsivity. In this study adult ADHD patients (N=19) were compared to a control group (N=28) and investigated to determine if differences existed in parameters such as Sleep Onset Latency (SOL), sleep Duration (DUR) and overall reported sleep problems (PSQI) and is there is an association between sleep-parameters and ADHD symptoms. Secondly, 37 ADHD patients were investigated to determine the effects of SMR and Theta/Beta (TBR) neurofeedback on ADHD symptoms and sleep parameters and if these parameters would mediate the treatment outcome to sMR and TBR neurofeedback. A clear continuous relationship between self=reported sleep problems (PSQI) and inattention in adults with- and without-ADHD. TBR neurofeedback resulted in a small reduction of SOL, this change occurred in the last half of treatment which suggests that it may not be specifically related to TBR neurofeedback. SMR neurofeedback specifically reduced the SOL and PSQI score, and the change in SOL and PSQI correlated strongly with the change in inattention, and the reduction in SOL was achieved in the first half of treatment, suggesting the reduction in SOL mediated treatment response to SMR neurofeedback. Clinically, TBR and SMR neurofeedback has similar effects on symptom reduction in ADHD. These results suggest differential effects and different working mechniasms for TBR and SMr neurofeedback in the treatment of ADHD.

In this study a non-pharmacological intervention, namely instrumental conditioning of 12-15 Hz oscillations (ISC), for improving sleep quality and memory was introduced. EEG recordings over the sensorimotor cortex show a prominent oscillatory pattern in a frequency range between 12 and 15 Hz (sensorimotor rhythm, SMR) under quiet but alert wakefulness. This frequency range is abundant during light non-rapid eye movement sleep, and is overlapping with the sleep spindle frequency band, Some early findings indicated that ISC of sMR during wakefulness can influence subsequent sleep. The present study intents to apply Neurofeedback (NFT) to insomnia patients/ 24 subjects (Mean-34.83; SD=10.6) with clinical symptoms of primary insomnia were tested. A counterbalanced within-subjects design - 19 lab visits over the course of 3-6 weeks) was adopted. Each patient participated in an ISC_NFT as well as a sham-NFT training block. Polysomnographic sleep recordings were scheduled before and after training blocks. Data confirmed a significant increase of 12-15 Hz activity over the course of the ten SMR training sessions which was also positively related to overnight memory consolidation changes. Number of awakenings were reduced and slow-wave sleep was increased following ISC but not following sham-NFT. In addition, subjective sleep quality was enhanced over the course of the trainings. Last but not least sleep spindles in slow-wave sleep were found to be exclusively enhanced after SMR training. Current results indicate that besides healthy individuals also people suffering from primary insomnia can experience subjective as well as objective benefits from ISC–NFT.

The objective of the study was to assess whether two distinct Z-Score NFB protocols, a modified sensorimotor (SMR) protocol and a sequential, quantitative EEG (sQEEG)-guided, individually designed (IND) protocol, would alleviate sleep and associated daytime dysfunctions of participants with insomnia. Both protocols used instantaneous Z scores to determine reward condition administered when awake. Twelve adults with insomnia, free of other mental and uncontrolled physical illnesses, were randomly assigned to the SMR or IND group. Eight completed this randomized, parallel group, single-blind study. Both groups received fifteen 20-min sessions of Z-Score NFB. Pre-post assessments included sQEEG, mental health, quality of life, and insomnia status. ANOVA yielded significant post-treatment improvement for the combined group on all primary insomnia scores: Insomnia Severity Index (ISI p<.005), Pittsburgh Sleep Quality Inventory (PSQI p<.0001), PSQI Sleep Efficiency (p<.007), and Quality of Life Inventory (p<.02). Binomial tests of baseline EEGs indicated a significant proportion of excessively high levels of Delta and Beta power (p<.001) which were lowered post-treatment (paired z-tests p<.001). Baseline EEGs showed excessive sleepiness and hyperarousal, which improved post-treatment. Both Z-Score NFB groups improved in sleep and daytime functioning. Post-treatment, all participants were normal sleepers.

In this review article an overview of the history and current status of neurofeedback for the treatment of ADHD and insomnia is provided. Recent insights suggest a central role of circadian phase delay, resulting in sleep onset insomnia (SOI) in a sub-group of ADHD patients. Chronobiological treatments, such as melatonin and early morning bright light, affect the suprachiasmatic nucleus. This nucleus has been shown to project to the noradrenergic locus coeruleus (LC) thereby explaining the vigilance stabilizing effects of such treatments in ADHD. It is hypothesized that both Sensori-Motor Rhythm (SMR) and Slow-Cortical Potential (SCP) neurofeedback impact on the sleep spindle circuitry resulting in increased sleep spindle density, normalization of SOI and thereby affect the noradrenergic LC, resulting in vigilance stabilization. After SOI is normalized, improvements on ADHD symptoms will occur with a delayed onset of effect. Therefore, clinical trials investigating new treatments in ADHD should include assessments at follow-up as their primary endpoint rather than assessments at outtake. Furthermore, an implication requiring further study is that neurofeedback could be stopped when SOI is normalized, which might result in fewer sessions.

Attention-deficit/hyperactivity disorder (ADHD) is highly associated with the delayed sleep phase disorder, a circadian rhythm sleep-wake disorder, which is prevalent in 73-78% of children and adults with ADHD. Besides the delayed sleep phase disorder, various other sleep disorders accompany ADHD, both in children and in adults. ADHD is either the cause or the consequence of sleep disturbances, or they may have a shared etiological and genetic background. In this review, the authors present an overview of the current knowledge on the relationship between the circadian rhythm, sleep disorders, and ADHD. They discuss the various pathways explaining the connection between ADHD symptoms and delayed sleep, ranging from genetics, behavioral aspects, daylight exposure, to the functioning of the eye. The treatment options discussed are focused on improvement of sleep quality, quantity, and phase-resetting, by means of improving sleep hygiene, chronotherapy, treatment of specific sleep disorders, and by strengthening certain neuronal networks involved in sleep, e.g., by sensorimotor rhythm neurofeedback. Ultimately, the main question is addressed: whether ADHD needs to be redefined. A novel view on ADHD was proposed, where a part of the ADHD symptoms are the result of chronic sleep disorders, with most evidence for the delayed circadian rhythm as the underlying mechanism. This substantial subgroup should receive treatment of the sleep disorder in addition to ADHD symptom treatment.

The transition from being fully awake to pre-sleep occurs daily just before falling asleep; thus its disturbance might be detrimental. Yet, the neuronal correlates of the transition remain unclear, mainly due to the difficulty in capturing its inherent dynamics. We used an EEG theta/alpha neurofeedback to rapidly induce the transition into pre-sleep and simultaneous fMRI to reveal state-dependent neural activity. The relaxed mental state was verified by the corresponding enhancement in the parasympathetic response. Neurofeedback sessions were categorized as successful or unsuccessful, based on the known EEG signature of theta power increases over alpha, temporally marked as a distinct "crossover" point. The fMRI activation was considered before and after this point. During successful transition into pre-sleep the period before the crossover was signified by alpha modulation that corresponded to decreased fMRI activity mainly in sensory gating related regions (e.g. medial thalamus). In parallel, although not sufficient for the transition, theta modulation corresponded with increased activity in limbic and autonomic control regions (e.g. hippocampus, cerebellum vermis, respectively). The post-crossover period was designated by alpha modulation further corresponding to reduced fMRI activity within the anterior salience network (e.g. anterior cingulate cortex, anterior insula), and in contrast theta modulation corresponded to the increased variance in the posterior salience network (e.g. posterior insula, posterior cingulate cortex). Our findings portray multi-level neural dynamics underlying the mental transition from awake to pre-sleep. To initiate the transition, decreased activity was required in external monitoring regions, and to sustain the transition, opposition between the anterior and posterior parts of the salience network was needed, reflecting shifting from extra- to intrapersonal based processing, respectively.

The functional significance of sleep spindles for overnight memory consolidation and general learning aptitude as well as the effect of four 10-minute sessions of spindle frequency (11.6-16 Hz, sigma) neurofeedback-training on subsequent sleep spindle activity and overnight performance change was investigated. Before sleep, subjects were trained on a paired-associate word list task after having received either neurofeedback training (NFT) or pseudofeedback training (PFT). Although NFT had no significant impact on subsequent spindle activity and behavioral outcomes, there was a trend for enhanced sigma band-power during NREM (stage 2 to 4) sleep after NFT as compared to PFT. Furthermore, a significant positive correlation between spindle activity during slow wave sleep (in the first night half) and overall memory performance was revealed. The results support the view that the considerable inter-individual variance in sleep spindle activity can at least be partly explained by differences in the ability to acquire new declarative information. The researchers concluded that the short NFT before sleep was not sufficient to efficiently enhance phasic spindle activity and/or to influence memory processing. NFT was, however, successful in increasing sigma power, presumably because sigma NFT effects become more easily evident in actually trained frequency bands than in associated phasic spindle activity.

Migraines are considered one of the most common primary headache disorders, Migraine attacks may occur due to a lack of sleep. Sleep is regarded as one of the smoothing factors of migraine pain. Patients with sleep disorders often suffer from headaches when they wake up compared with healthy individuals. This research was a quasi-experimental study with a pre-test-post-test design and a 2-month follow-up. The samples included 20 migraine patients within the age range of 15 to 55 years who were selected as volunteers for treatment by the neurologists and psychiatrists during 2017. The initial evaluation was then conducted based on the inclusion and exclusion criteria and using the Ahvaz migraine questionnaire, and Pittsburgh sleep quality index. The patients were randomly assigned to two neurofeedback (n=10) and transcranial Direct Current Stimulation (tDCS) (n=10) groups and evaluated three times. The obtained data were analyzed by the repeated measures ANCOVA and Chi-square test in SPSS. Based on the scores of both groups, no significant difference was observed between neurofeedback and tDCS groups. However, based on the results, neurofeedback decreased sleep latency, whereas tDCS increased sleep efficiency. Overall, these two treatments were effective in improving subjective sleep quality and sleep quality. Both neurofeedback and tDCS treatments could significantly enhance sleep quality of the patients in the post-test and 2-month follow-up. Given the effectiveness of both treatments, neurofeedback and tDCS are recommended to be used for improving the sleep status of patients with migraine.

The ‘hyper-arousal’ model of primary insomnia states that individuals with insomnia experience elevated physiological and cognitive arousal compared to normal people during both sleep and wakefulness. Studies have shown that those with insomnia show more high frequency electroencephalogram (EEG) signals - increased beta activity - compared to normal people which results in non-restorative sleep. This study looked at the effects of a beta-decrease neurofeedback (NF) protocol for insomnia patients. Participants were randomly split into either the NF treatment, where they received 10 NF sessions, or the wait-list control group, where they received no treatment. The following parameters were compared pre- and post-treatment as well as 2-weeks after the final treatment:  resting state EEG (eye-open, EO; eye-closed, EC), heart rate variability (HRV), sleep scales, sleep diaries, and Smart Wearable Device data. The results showed that participants in the NF group had decreased beta power, HRV, SL (sleep latency), and sleep scale scores as well as increased alpha power, TST (total sleep time), SE (sleep effectiveness), and sleep satisfaction. These findings provide new evidence for the effectiveness of NF for decreasing insomnia symptoms and its use for pregnant, psychopharmacotherapy-resistant and elderly people.

This cross-sectional descriptive study explored the use of neurofeedback by cancer survivors to manage long-term symptoms, and aimed to identify safe, effective neurofeedback protocols for this population. An online survey was administered to neurofeedback providers to identify: (1) use of neurofeedback b y cancer survivors; (2) types/protocols of neurofeedback used; (3) types of symptoms addressed; (4) success of training; and (5) prevalence/nature of side effects. Ninety-two neurofeedback providers participated, and of these 42 (46%) reported having provided neurofeedback to an average of six cancer survivors. Neurofeedback training was reported to eliminate/reduce symptoms including fatigue (16%/66%), cognitive impairment (23%/62%), sleep problems (14%/72%), stress(17%/70%), anxiety (27%/63%), depression (35%/50%), and pain (10%/54%). Transient side effects reported included fatigue (9%), headache (7%), spaciness (lack of focus) (6%), anxiety (4%), insomnia (3%), and dizziness (3%). Preliminary results suggest neurofeedback may be a safe and effective therapy for cancer survivors.

This pilot study tested the efficacy of a 30-min audio–visual stimulation (AVS) program for the treatment of chronic insomnia in older adults. Chronic insomnia has been conceptualized as entailing increased cortical high frequency EEG activity at sleep onset and during NREM sleep. The authors hypothesized that an AVS program gradually descending from 8 to 1 Hz would potentially reduce the excessive cortical activation that is thought to contribute to difficulties with initiating and maintaining sleep. Eight older adults (88 ± 8.7 years) complaining of chronic insomnia self-administered a 30-min AVS program nightly at bedtime for one month. Sleep was assessed at baseline and throughout the 4-week intervention. After using AVS for 4 weeks, significant improvement was reported in insomnia symptoms and sleep quality; with moderate to large effect sizes. The training effect (self-reported sleep improvement) was observed at the end of week one and persisted through the 1-month intervention. The results from this pilot study suggest that further exploration of AVS as a treatment for insomnia is warranted.

The purpose of this research was to confirm that prefrontal neurofeedback training has an impact on adolescents. The objective of this study was to prove its scientific effect through experimentation. The effect of the training was measured by the difference in neuro-frequencies before and after the training. For this research, an experimental group and a control group, each with 22 students in J High School located in the city of S participated in this study. From May to July 2019, the training was conducted three times a week and for 30 minutes per session. The neuro-frequency data collected were analyzed through the methods of F.F.T. The resulting changes from the neurofeedback training for each group were analyzed by T-Tests. The result of the study is as follows; Neurofeedback training has had a positive effect on adolescent attention and sleep. In conclusion, the environmental and educational factors also play an important role. As the interaction of the latter two factors yield an individual's unique brain structure and functionality, the impact of the neurofeedback training is important on adolescents. The derivation of the above results by utilizing scientific and objective methods reemphasizes the importance of this study.

The suggested functions of sleep are manifold, involving adaptive strategies, physical recovery and more recently "offline" information reprocessing. In this article the researchers present a study in which the same type of declarative (word-pair learning) and procedural (finger-tapping) task was conducted four times (weeks apart) in the evening with subsequent interference manipulation the next morning in insomnia patients. In addition 36 healthy controls spent 3 nights in the laboratory to test for (healthy) sleep-dependent memory consolidation. In addition, 12-15Hz (sensorimotor rhythm; SMR) as well as placebo "neurofeedback"was conducted in the insomnia group. With respect to the susceptibility to interference it became evident that interference affected the declarative memory domain much more than the procedural one. Forgetting from initial evening learning to a delayed recall after a week (as well as after interference) was also found more pronounced in insomnia patients than healthy controls.  Analyses of the sleep EEG and sleep spindles revealed a trait-like relationship between fast spindle activity (SpA) and (i) the initial learning levels in the declarative memory as well as (ii) an association with the declarative overnight memory change. Last but not least the double-blind neurofeedback protocol indicated that patients suffering from insomnia were able to enhance SMR-power and (fast) sleep spindles over the 12 SMR training sessions. Yet direct benefits for sleep quality or memory consolidation were not observed, rather the subjective sleep complaint decreased unspecifically across both conditions. Current results indicated that healthy as well as insomnia patients do show associations of (overnight) memory performance and (fast) sleep spindle activity and interestingly are even able to increase these spindles by means of instrumental 12-15Hz EEG conditioning. 

Neurofeedback has been around for half a century, but despite some promising results it is not yet widely appreciated. Recently, some of the concerns about neurofeedback have been addressed with functional magnetic resonance imaging and magnetoencephalography adding their contributions to the long history of neurofeedback with electroencephalography. A key concern about neurofeedback is the missing framework to explain how improvements in very different and apparently unrelated conditions are achieved. A particularly promising approach is the analysis of resting state of fMRI data, which has revealed robust covariations in brain networks that maintain their integrity in sleep and even anesthesia. Aberrant activity in three brain wide networks (i.e., the default mode, central executive and salience networks) has been associated with a number of psychiatric disorders. Recent publications have also suggested that neurofeedback guides the restoration of “normal” activity in these three networks. The authors of this paper used very recent results from their analysis of whole night MEG sleep data together with key concepts from developmental psychology, a theoretical framework was proposed for neural representation of the self, located at the core of a double onion-like structure of the default mode network. The framework fits a number of old and recent neuroscientific findings, and unites the way attention and memory operate in awake state and during sleep. In the process, safeguards are uncovered, put in place by evolution, before any interference with the core representation of self can proceed. Within this framework, neurofeedback is seen as a set of methods for restoration of aberrant activity in large scale networks. By looking through the framework developed, neurofeedback’s safe nature was revealed while raising some concerns for interventions that attempt to alter the neural self-representation bypassing the safeguards evolution has put in place.

During the COVID-19 pandemic, health workers represented a group particularly vulnerable to work-related stress, but prevention and management of psychiatric symptoms are still under evaluation. Neurofeedback is a safe and non-invasive neuromodulation technique with the target of training participants in the self-regulation of neural substrates underlying specific psychiatric disorders. Protocols based on the increase of alpha frequencies, associated with the process of relaxation, were used for the treatment of stress, anxiety and sleep disturbances. The aim of the study was to assess the effectiveness of an alpha-increase NF protocol for the treatment of stress in healthcare workers exposed to the COVID-19 pandemic. Eighteen medical doctors belonging to the Sacco Hospital were recruited during the COVID-19 health emergency and underwent a 10 sessions NF alpha-increase protocol during two consecutive weeks, The level of stress was assessed at the beginning (T0) and at the end (T1) of the protocol through the following questionnaires: severity Acute symptoms Stress (SASS), Copenhagen Burnout Inventory (CBI), Pittsburgh Sleep Quality Index (PSQI), Brief-COPE. Statistical analyses were performed with Paired Samples t-Test for continuous variables, setting significance at P < 0.05. A significant increase in alpha waves mean values between T0 and T1 was observed. In addition, a significant reduction in the PSQI test score between T0 and T1 was observed. Alpha-increase protocol showed promising results in terms of stress modulation, sleep quality improvement and safety profile in a pilot sample of health-care workers. Larger controlled studies are warranted to confirm the results from this study.

The aim of the study was to investigate the effects of neurofeedback training on sleep quality and psychological skills of athletes using a psychophysiological approach. The research method was semi-experimental and applied with a pretest and posttest design and a control group. 31 athletes who were members of a sports team were chosen to enter the study. They were randomly assigned to the experimental and control groups. The experimental group received neurofeedback treatment. The neurofeedback training lasted 3 sessions a week, 45 min. each session for 2 months. The protocol was performed in a bipolar manner at C4-CZ points. The Pittsburgh Sleep Quality Index (PSQI) was used to extract a sleep quality profile and OMSAT-3 and Elisa methods were used to assess the psychophysiological stress of participants. Covariance analysis and dependent t test were used to analyze the data. The results suggested that neurofeedback training can balance stress and improve sleep quality of athletes which in turn greatly affects their performance.

Insomnia is one of the most prevalent sleep disorders. Recent studies suggest that cognitive and physical arousal play an important role in the generation of primary insomnia. Studies have also shown that information processing disorders due to cortical hyperactivity might interfere with normal sleep onset and sleep continuity. Therefore, focusing on central nervous system arousal and normalizing the information process have become current topics of interest. It has been well known that neurofeedback can reduce the brain hyperarousal by modulating patients' brain waves during a sequence of behavior therapy. The purpose of this study was to investigate effects of neurofeedback therapy on electroencephalography (EEG) characteristics in patients with primary insomnia. Thirteen subjects who met the criteria for an insomnia diagnosis and 14 control subjects who were matched on sex and age were included. Neurofeedback and sham treatments were performed in a random order for 30 minutes, respectively. EEG spectral power analyses were performed to quantify effects of the neurofeedback therapy on brain wave forms. In patients with primary insomnia, relative spectral theta and sigma power during a therapeutic neurofeedback session were significantly lower than during a sham session. There were no statistically significant changes in other EEG spectral bands. EEG spectral power in the theta band was found to increase when a neurofeedback session was applied to patients with insomnia. This outcome might provide some insight into new interventions for improving sleep onset. However, the treatment response of insomniacs was not precisely evaluated due to limitations of the current pilot study, which requires follow-up studies with larger samples in the future.

Sleep is a necessity, vital for both health and the majority of biological functions. With the recognised importance of sleep, sleep habits of elite athletes are a popular topic. Through a series of four studies, the article aimed to enhance the understanding of sleep habits of elite level athletes. The purpose of the thesis was to explore sleep behaviour, complaints, and mechanisms within elite level athletes subjectively and objectively during periods of competition. Study One was a cross-sectional questionnaire to identity the occurrence and reported sleep complaints of 283 Olympic and professional athletes prior to important competitions. Study Two objectively and pragmatically monitored four netball state teams via actigraphy through a multi-day national tournament and related findings to final competition standings. Study Three, an observational study, explored the potential physiological, neuroendocrine, and psychometric mechanisms responsible for sleep complaints following a night game. Finally, Study Four examined the effectiveness of a neurofeedback intervention for improving sleep in athletes. Based on findings from Studied One, Two and Three, a non-pharmacological sleep intervention of neurofeedback was developed and examined for its effectiveness in optimising sleep in athletes. Neurofeedback was found to improve overall reported sleep problems measured through the Pittsburgh Sleep Quality Index, increase sleep efficiency, and reduced sleep onset latency in the home environment compared with a placebo group using actigraphy. However, no differences were observed for sleep measures between the neurofeedback and a sham treatment when measured by polysomnography. Despite improvements in subjective measures and sleep onset latency in the home environment further exploration is warranted before neurofeedback is universally adopted in athletes as a treatment modality. Due to learned regulation of specific cortical networks, neurofeedback may however be an alternate modality for specific problematic elite level athletes when traditional behavioural modifications (sleep hygiene) methods are not effective in enhancing poor sleep. In summary, the current series of studies provides a foundation for understanding sleep in athletes. The results demonstrate sleep disruption is indeed prevalent around competition and may impact competition standings. Despite common assumptions in literature around the mechanistic reasons responsible for night game sleep complaints, trait arousal was found to correlate to poor sleep following night games. In addition, neurofeedback emerged as a potential novel sleep intervention for targeted individuals however further exploration is warranted before it is considered a routine sleep strategy for elite level athletes. Overall, the studies provide useful information that can be used by coaches and staff to develop targeted sleep education to enhance the wellbeing and performance of elite level athletes.

A non-pharmacological intervention, namely instrumental conditioning of 12-15 Hz oscillations (ISC), for improving sleep quality and memory was tested. The frequency range is known to be abundant during (i) quiet but alert wakefulness (sensorimotor rhythm, SMR) as well as in (ii) light NREM sleep-spindles. ISC is known to influence sleep quality. Two studies were completed to apply neurofeedback (NFT) to (sub-) clinical insomnia patients. In the first study 24 young subjects with sub-clinical symptoms of primary insomnia were tested. A counterbalanced within-subjects design (19 lab visits over the course of 3-6 weeks) was adopted. Each patient participated in an ISC-NFT as well as a sham-NFT training block. Polysomnographic sleep recordings were scheduled before and after training blocks. In a similar manned a counter-balances double-blind follow-up study was conducted with 30 primary insomnia patients and 30 (sex and age matched) controls. Data from the first study confirmed a significant increase of 12-15 Hz activity over the course of the 10 SMR training sessions which was also positively related to overnight memory consolidation changes. Number of awakenings were reduced and slow wave sleep was increased following ISC but not sham, Last but not least N3 sleep spindles were found to be enhanced after SMR training. Preliminary results of study 2 indicate that patients suffering from more severe insomnia do not benefit in sleep or memory over the 12 ISC sessions, However, all groups (healthy controls, sleep state mispercept, and insomnia patients) do enhance SMR-power (and fast spindles) exclusively in the SMR (but not placebo) condition. Subjectively the sleep complaint decreased over both conditions. Current results indicate that besides healthy individuals also young people suffering from (sub-clinical) primary insomnia can experience subjective as well as objective benefits from ISC-NFT. The results of a comprehensive double-blind study, however, suggest that full-blown insomnia patients are not benefitting from ISC-NFT across 12 sessions.

Insomnia is a sleeping disorder which is usually interpreted from a behavioural perspective, with a focus on cognitive and/or somatic arousal. Research suggests that there may be a a third arousal component in play that explains why approximately 20% of the population does not respond well enough to standard non-pharmacological treatment. Cortical arousal, reflected by heightened EEG frequencies during the sleep onset period and sleep, might interfere with normal sleep processes. 16 Insomnia patients (7 female, 9 men) were randomly assigned to either a sensorimotor rhythm (SMR) tele-neurofeedback (n=8) or an electromyography (EMG) tele-biofeedback (n=8) protocol. The sessions were performed from the patient's homes through a secure internet connection. The neurofeedback protocol consisted of the inhibition of theta (4-8Hz) and beta (20-30Hz) EEG activity, as well as the reinforcement of SMR (12-15Hz) all at Cz. The biofeedback protocol was an EMG inhibitor with electrodes placed at Fpz. A polysomnography was performed pre and posttreatment. Sleep Onset Latency (SOL), Wake After Sleep Onset (WASO), Total Sleep Time (TST), Sleep efficiency (SE) were the primary outcome variables. A significant decrease in SOL pre to post treatment in both groups was observed. Both neurofeedback and biofeedback seem promising applications for sleep onset problems. However, when an increase in TST is wanted, only the SMR neurofeedback protocol showed good results in this study.

Neurofeedback (NFB) training has demonstrated significant potential in achieving symptoms reduction in children with Autism Spectrum Disorder (ASD). However, children with low-functioning ASD are often uncooperative with the treatment. To evaluate whether NFB can eventually be administrated during sleep, a safety and feasibility pilot study was performed. A 9-year-old male patient diagnosed with ASD underwent NFB training for 30 min twice a week. This was operated at home during sleep by the parents. The NFB protocol aimed at increasing sensorimotor rhythm (SMR) while simultaneously decreasing theta activity over the sensorimotor strip. NFB during sleep was feasible and did not yield adverse side effects. Parents reported improved behavioral and emotional symptoms and enhanced language development following NFB training. Subsequently, the patient could participate in regular sessions of NFB in wakefulness. Overall, parental reports suggest that applying NFB during sleep in low-functioning ASD is feasible and might offer promising therapeutic avenues.

Consistent empirical results show that both night and day sleep enhances memory consolidation. In this study the researchers explored the process of consolidation of memory during awake hours. Since theta oscillations play a central role in exchange of information, the hypothesis was made that elevated theta during awake hours will enhance memory consolidation. A neurofeedback protocol was used, to enhance the relative power of theta or beta oscillations. Participants trained on a tapping task were divided into three groups: neurofeedback theta; neurofeedback beta; control. A significant improvement was found in performance in the theta group, relative to the beta and control groups, immediately after neurofeedback. Performance was further improved after night sleep in all groups, with a significant advantage favoring the theta group. Theta power during training was correlated with the level of improvement, indicating a clear relationship between memory consolidation and theta neurofeedback.

Fibromyalgia is a chronic pain condition associated with sleep disturbances and cognitive impairments. This study looked at the effects of neurofeedback on pain intensity, symptom severity, sleep quality and cognitive function in individuals with fibromyalgia. Eighty participants were recruited and were split into two groups - the neurofeedback group receiving sensorimotor and alpha rhythm feedback for eight weeks and the control group receiving telephone support. Results showed that after eight weeks of neurofeedback training, pain severity and interference, fibromyalgia symptom severity, sleep latency and sustained attention improved in individuals with fibromyalgia. 

The purpose of this study was to investigate the effect of integrated nursing using “cognicise” (a combination of cognition and exercise) and neurofeedback on cognition and alpha waves in the elderly population. A quasi-experimental study was conducted with a single group pretest-posttest study consisting of 29 Korean adults aged 65 years or older. Each integrated nursing session consisted of cognicise training (10 minutes) and neurofeedback training (20 minutes) and all subjects participated twice a week for 10 weeks. The researchers used structured questionnaires to assess participants’ general characteristics, a Korean version of the Mini-Mental Status Examination for screening dementia, and the Brainmaster program to measure alpha waves. The results of the study showed improvement in concentration following the integrated nursing program in the majority of the participants. This study suggests that neurofeedback training can be used in conjunction with brain wave measurements  to improve the cognitive health of the elderly population. 

This article discusses two case reports that have examined the effects of using neurofeedback to treat individuals with restless leg syndrome (RLS) and periodic limb movements (PLMS). The first case report looked at an individual that suffered from both RLS and PLMS, and he was using neurofeedback as his only treatment modality. The second case report discussed an individual that only experienced RLS, and he was taking medication in addition to using neurofeedback. In both cases, neurofeedback rapidly improved their symptoms, although the improvements did not endure for the individual in case 1 so he returned for reinforcement sessions. The individual in case 1 also received less treatment sessions than the individual in case 2. Further research may determine whether more treatment sessions are necessary for individuals who are using neurofeedback as their sole form of treatment, to maintain improvements in symptoms. However, the relief that these patients reported after receiving neurofeedback treatment suggest that even if reinforcement sessions are required or they still have to remain on medication, neurofeedback can provide them with a greater relief of symptoms compared to taking medication alone.

Neurofeedback (NFB) provides real-time feedback about neurophysiological signals to patients, thereby encouraging modulation of pain-associated brain activity. This review aims to evaluate the effectiveness and safety of NFB in alleviating pain and pain-associated symptoms in chronic pain patients. Twenty-one studies were included. Reduction in pain following NFB was reported by one high-quality randomized controlled trial (RCT), five of six low-quality RCT or non-randomized controlled trials (NRCT) and 13 of 14 case-series. Pain reduction reported by studies ranged from 6% to 82%, with 10 studies reporting a clinically significant reduction in pain of >30%. The overall effect size was medium. Improvements in depression, anxiety, fatigue and sleep were also seen in some studies. Neurofeedback is a safe and effective therapy with promising but largely low-quality evidence supporting its use in chronic pain. Further high quality trials comparing different protocols is warranted to determine the most efficacious way to deliver NFB. 

This study was conducted to investigate the effect of neurofeedback on reducing cortical arousal on insomnia compared to cognitive-behavioral treatment for insomnia (CBT-I). Seventeen adults with insomnia, free of other psychiatric illnesses, were randomly assigned to neurofeedback or CBT-I. All participants completed questionnaires on insomnia [Insomnia Severity Index (ISI)], sleep quality [Pittsburgh Sleep Quality Index (PSQI)], and dysfunctional cognition [Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS-16)]. The neurofeedback group showed decreases in beta waves and increases in theta and alpha waves in various areas of the electroencephalogram (EEG), indicating lowered cortical arousal. The ISI and PSQI scores were significantly decreased, and sleep efficiency and sleep satisfaction were increased compared to the pre-treatment scores in both groups. This study confirmed that neurofeedback training could alleviate the symptoms of insomnia by reducing cortical hyperarousal in patients, despite the limited effect in reducing cognitive dysfunction compared to CBT-I.

This study wanted to examine the effectiveness of using real-time fMRI neurofeedback (rtfMRI-NF) therapy to study the pathogenesis and treatment of chronic insomnia disorder (CID). 28 patients with CID participated in the study and completed neurofeedback sessions targeting their amygdala activity for three sessions in six weeks. Resting-state fMRi data were collected pre- and post-intervention and voxed-based degree centrality (DC)  was used to examine the effect of the NFB training. The results of the study showed increased DC in various regions of the brain for patients with CID. The researchers were also able to conduct seed-based functional connectivity analyses based on the altered DC regions to learn more about the altered functional networks. For patients with CID, clinical scores in several measures such as the Pittsburgh sleep quality index, insomnia severity index (ISI), Beck depression inventory and Hamilton anxiety scale had also decreased. There was also a positive correlation between the changed ISI score and DC values in the right insula. This study confirmed that neurofeedback training could alter the frontal hubs which could then reshape abnormal functional connections caused by insomnia and improve the sleep quality of patients with CID. 

Previous research examined the effectiveness of treatments that aim to improve rest in elderly people. Neurofeedback (NF) is an intervention aimed to train self-regulation of brain functions which has also been proven to be beneficial for rest quality. The aim of this study was to determine the effect of NF on the quality of sleep in elderly women that reside in nursing homes or elderly care institutions. The researchers recruited 14 participants and assigned them to a NF group and a control group and compared scores post-intervention. The results of the study indicated that sleep quality improved and alpha frequency increased significantly after the NF intervention. Even though there is evidence of changes in psychological indicators and increased sleep quality in the NF group, the researchers suggest that these effects may not be powerful enough to contribute to sleep quality evaluation because of the living conditions of the participants. 

In this study, real-time functional magnetic resonance imaging neurofeedback (rtfMRI-NF) was used to train 28 chronic insomnia disorder (CID) patients to regulate the activity of the left amygdala for three sessions in 6 weeks. The resting-state regional homogeneity (ReHo) methodology was adopted to explore its role on resting-state fMRI data, which were collected before and after training. Moreover, the relationships between changes of clinical variables and ReHo value of altered regions were determined. Results showed that the bilateral dorsal medial pre-frontal cortex, supplementary motor area (SMA), and left dorsal lateral pre-frontal cortex had decreased ReHo values, whereas the bilateral cerebellum anterior lobe (CAL) had increased ReHo values after training. Some clinical scores markedly decreased, including Pittsburgh Sleep Quality Index, Insomnia Severity Index, Beck Depression Inventory, and Hamilton Anxiety Scale (HAMA). Additionally, the ReHo values of the left CAL were positively correlated with the change in the Hamilton depression scale score, and a remarkable positive correlation was found between the ReHo values of the right SMA and the HAMA score. This study provided objective evidence that amygdala-based rtfMRI-NF training could reshape abnormal ReHo and improve sleep in patients with CID. The improved ReHo in CID provides insights into the neurobiological mechanism for the effectiveness of this intervention. However, larger double-blinded sham-controlled trials are needed to confirm the results from this initial study.

It is known that EEG recordings over the sensorimotor cortex typically have an oscillatory pattern in the frequency range of 12-15 Hz (sensorimotor rhythm, SMR) under quiet but alert and wakeful conditions. The same frequency is also associated with sleep. Therefore, this study sought to determine if conditioning SMR during wakefulness would improve sleep and cognitive functioning in individuals with insomnia. 24 participants with primary insomnia completed a SMR and sham-conditioning training block in a counterbalanced manner. 12-15 Hz activity significantly increased over the 10 SMR training sessions, alongside decreased awakenings, and increased slow-wave and subjective quality of sleep. Further, SMR training enhanced overnight memory consolidation and sleep spindle changes, associated with a beneficial cognitive effect. 

This study is a follow-up to Krepel et al. and explores improvements in cognitive function after SMR neurofeedback. 37 participants reporting sleep problems received SMR neurofeedback. Cognitive measures included the continuous performance/working memory (CPT/WM), the Stroop task, and Trailmaking A and B were assessed pre and post intervention. Neurofeedback learners had a significant improvement in CPT/WM response time, omission errors and Stroop incongruent performance compared to non-learners. A significant effect of time was found for both groups for the Stroop, Trailmaking test part B, and Stroop interference score. There was no significant correlations between sleep changes and changes in cognition in this sample. It was found that SMR neurofeedback specifically improved attention (response time and omission errors in CPT/WM) and working memory (Stroop incongruent) for SMR learners compared to non-learners. However, overall the whole sample still had improvements in measures of executive function and visual attention, indicating practice or non-specific effects. Therefore, future studies need to include randomized control trials to determine if SMR neurofeedback has a direct effect on cognitive improvements or are mediated by sleep improvements. 

Following the onset of the COVID-19 pandemic, health care workers have been found to represent a vulnerable group with increased exposure to greater risk and higher levels of work-related stress. The authors conducted this pilot study to examine the use of alpha-increase neurofeedback to mitigate these stress-related symptoms and improve sleep. Eighteen medical doctors that were on-duty during the COVID-19 health emergency underwent an intensive alpha neurofeedback protocol and mean alpha wave values were recorded at the beginning and end of the intervention. Moreover, the Rapid Stress Assessment, Copenhagen Burnout Inventory (CBI), Pittsburgh Sleep Quality Index (PSQI), and Brief-COPE were administered as psychometric assessments. The authors rounds a significant increase in alpha wave values and a significant reduction in PSQI scores following neurofeedback showing promising results for the use of alpha neurofeedback in improving sleep quality and modulating stress in a sample of healthcare workers.