572886

research-article2015

ICTXXX10.1177/1534735415572886Integrative Cancer TherapiesLuctkar-Flude and Groll

Original Article

A Systematic Review of the Safety and Effect of Neurofeedback on Fatigue and Cognition

Integrative Cancer Therapies 1­–23 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534735415572886 ict.sagepub.com

Marian Luctkar-Flude, RN, MScN1, and Dianne Groll, RN, PhD1

Abstract Background. Many cancer survivors continue to experience ongoing symptoms, such as fatigue and cognitive impairment, which are poorly managed and have few effective, evidence-based treatment options. Neurofeedback is a noninvasive, drug-free form of brain training that may alleviate long-term symptoms reported by cancer patients. Objective. The purpose of this systematic review of the literature was to describe the effectiveness and safety of neurofeedback for managing fatigue and cognitive impairment. Methods. A systematic review of the literature was conducted using Joanna Briggs Institute (JBI) methodology. A comprehensive search of 5 databases was conducted: Medline, CINAHL, AMED, PsycInfo, and Embase. Randomized and nonrandomized controlled trials, controlled before and after studies, cohort, case control studies, and descriptive studies were included in this review. Results. Twenty-seven relevant studies were included in the critical appraisals. The quality of most studies was poor to moderate based on the JBI critical appraisal checklists. Seventeen studies were deemed of sufficient quality to be included in the review: 10 experimental studies and 7 descriptive studies. Of these, only 2 were rated as high-quality studies and the remaining were rated as moderate quality. All 17 included studies reported positive results for at least one fatigue or cognitive outcome in a variety of populations, including 1 study with breast cancer survivors. Neurofeedback interventions were well tolerated with only 3 studies reporting any side effects. Conclusions. Despite issues with methodological quality, the overall positive findings and few reported side effects suggest neurofeedback could be helpful in alleviating fatigue and cognitive impairment. Currently, there is insufficient evidence that neurofeedback is an effective therapy for management of these symptoms in cancer survivors, however, these promising results support the need for further research with this patient population. More information about which neurofeedback technologies, approaches, and protocols could be successfully used with cancer survivors and with minimal side effects is needed. This research will have significance to nurses and physicians in oncology and primary care settings who provide follow-up care and counseling to cancer survivors experiencing debilitating symptoms in order to provide information and education related to evidence-based therapy options. Keywords neurofeedback, safety, fatigue, cognitive impairment, cancer

Background With aging of the population and improved cancer treatment, the number of cancer survivors is increasing. It is estimated that there are currently more than 14 million cancer survivors living in the United States and Canada.1,2 Cancer survivors commonly experience numerous physical and psychological symptoms such as fatigue, cognitive impairment, pain, anxiety, and depression as long-term and late effects of the cancer and its treatment.3-7 Many of these symptoms, particularly cancer fatigue and cognitive impairment, or chemobrain, are poorly managed and have few effective, evidence-based treatment options.8-12 These issues affect the daily lives of cancer survivors, their family relationships, and return to work, often resulting in lowered quality of life.13-15 Complementary and alternative medicine

(CAM) therapy use is common among cancer patients and increasing, with cancer survivors with unmet needs more likely to use CAM to improve quality of life.16-20 Neurofeedback is a noninvasive, drug-free form of brain training reported to help with a variety of conditions, including pain, fatigue, depression, anxiety, sleep disorders, and cognitive decline.21 Thus, neurofeedback is an innovative CAM therapy with the potential to alleviate multiple

1

Queen’s University, Kingston, Ontario, Canada

Corresponding Author: Marian Luctkar-Flude, School of Nursing, Queen’s University, 92 Barrie Street, Kingston, Ontario, K7L 3N6, Canada. Email: [email protected]

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long-term symptoms reported by cancer survivors and improve their quality of life. Electroencephalography (EEG) biofeedback or neurofeedback is a scientifically based technique that can allow the brain to learn self-regulation skills.22 These skills have clinical relevance and changes in brain regulation will be manifested in symptomatic and subjective changes. During neurofeedback, brain activity is monitored through electrodes placed on the scalp and fed back to the participant through auditory and/or visual stimuli generated through computer software without introducing anything intrusive into the brain.23 Rather, neurofeedback provides new information, which can open up the brain to options within its own control; if the changes result in a new stable state, or one that provides continued benefits to the participant, then it will continue to be reinforced after the session is over.22 The mechanism of action is generally considered to be operant conditioning in which the brain is retrained to function in healthier brainwave patterns.24 The process is often described as exercise for the brain, which increases the efficiencies of specific brain function and enhances cognitive flexibility and control.24 Meditation, relaxation, martial arts, yoga, and cognitive training are other ways of gaining control over one’s mental state; however, neurofeedback is usually more rapid and efficient.25

Brain Waves and Neurofeedback Approaches The cyclical electrical activation and deactivation of neurons in the brain can be recorded as raw unfiltered brain wave signals by EEG.26 These EEG signals can be amplified and filtered into smaller parts, called frequencies that are used during neurofeedback. Neurofeedback delivers feedback at the time of the cycle when the brain wave moves into a desirable pattern, providing simple reinforcement that teaches the brain to prolong healthy brain wave patterns. Each frequency can be measured in terms of its speed in hertz (Hz) or cycles per second, and amplitude (height of the wave) measured in microvolts (µV). Slow frequencies (13 Hz) but not always.26 Single frequencies have been organized into discreet groups called bandwidths that are associated with specific characteristics: delta (1-4 Hz) associated with sleep, repair, complex problem solving; theta (4-8 Hz) associated with creativity, insight, deep states; alpha (8-12 Hz) associated with alertness, peacefulness; beta (13-21 Hz) associated with thinking, focusing, sustained attention; sensorimotor rhythm (SMR; 12-15 Hz) associated with mental alertness, physical relaxation; high beta (20-32 Hz) associated with intensity, hyperalertness, anxiety; and gamma (38-42 Hz) associated with cognitive processing and learning.26

There appears to be no single conceptual model to describe the processes and outcomes of neurofeedback among practitioners or manufacturers.27,28 As a result, numerous nonspecific (placebo/expectancy, client/therapist/family variables/interactions), treatment-specific (treatment protocols), neurophysiological and psychological factors have been used to explain how neurofeedback is effective in the treatment of a wide variety of symptoms and disorders.29 Neurofeedback training is generally aimed at changing the amplitude (inhibition or augmentation) of selected frequency bandwidths through the principles of operant and classical conditioning; however, there are numerous approaches and protocols that can be used. Alpha/theta training involves promotion of lower EEG frequencies for experiential and integrative purposes.30 This deep-states training is commonly used for alcoholism and posttraumatic stress disorder (PTSD).31 SMR/beta training involves training to improve physiological selfregulation, and functional normalization and optimization.30 The most common neurofeedback training approaches can generally be grouped under 3 guiding philosophies. (1) Targeted mechanisms-based, symptomresponsive approaches in which the neurofeedback provider selects a reinforcement brainwave target for the specific symptom are typically applied to traditional psychopathologies such as anxiety, depression and bipolar disorders, attention disorders, personality disorders, trauma recovery, addictions, pain syndromes, sleep disorders, and specific learning disabilities32; (2) QEEG-driven approaches that seek EEG normalization based on stationary QEEG measures are typically applied to more severely affected clinical populations such as neurological problems, traumatic brain injuries, strokes, seizures, dementias, developmental delay, cerebral palsy, and autism;32 and (3) nonlinear dynamical (NLD) approaches that are generalized approaches to neuroregulation based on the theory of nonlinear dynamical systems27 are generally applied to nonclinical populations for optimum mental fitness, brain exercise and meditation practice.30 However, all 3 approaches can be effective in all these domains.32 Other nontraditional neurofeedback approaches can also be used. A low-energy neurofeedback system (LENS) approach uses weak electromagnetic signals to provide feedback to the brain.33 Like NLD neurofeedback, LENS use a nonspecific treatment approach that is not guided by diagnosis.33,34 Hemoencephalography (HEG) neurofeedback or cerebral flow neurofeedback, is used to train individuals to improve cerebral blood flow to key areas of the brain which improves cerebral oxygenation and translates into enhanced mental capacity.35 HEG uses physiological signals based on blood flow dynamics rather than electrical activity and is reported to be particularly helpful with head injuries, attention deficit disorder and migraines.35,36

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Clinical Applications of Neurofeedback Biofeedback has recently been recognized by the American Academy of Pediatrics as a “Level 1—Best Support” intervention for attention and hyperactivity behaviors.37 Neurofeedback is also reported to help with a variety of conditions, including chronic pain, chronic fatigue syndrome, depression, anxiety disorders, sleep disorders, PTSD, migraines, and cognitive decline.21 It is unclear whether cancer survivors experiencing similar symptoms would benefit from neurofeedback and which approaches or protocols would be most effective for managing cancer fatigue and cognitive impairment. In the Canadian Cancer Society pamphlet Complementary Therapies: A Guide for People With Cancer, biofeedback is described as a type of mind-body therapy used to improve quality of life.38 In a clinical practice guideline for integrative oncology, mind-body modalities of CAM therapies are recommended for reducing anxiety, mood disturbance, and chronic pain and for improving quality of life in cancer patients; these techniques include meditation, hypnosis, relaxation, cognitive-behavioral therapy, biofeedback, and guided imagery.39 A published study protocol describes a clinical trial that will investigate the effectiveness of neurofeedback using SMR/beta training to improve neurocognitive functioning of children treated for a brain tumor.40 Results from a recent prospective study by Alvarez et al41 demonstrated the feasibility of neurofeedback for breast cancer survivors. The sample initially demonstrated significant dysfunction compared with general population norms prior to neurofeedback, and strongly significant improvements (P < .001) postneurofeedback on all 4 cognitive measures, a fatigue scale, 4 psychological scales, and 3 of 8 sleep scales; improvements were generally linear across the course of training, and were maintained at follow-up testing.41 These results suggested neurofeedback deserved further study as a novel, method of addressing long-term symptoms in cancer survivors that may be safe, effective, and acceptable to patients. Unfortunately, neurofeedback is not widely accepted by the general public or medical community because of lack of information and insufficient research to demonstrate its benefits, and lack of coverage by public or private health insurance plans.42 The Canadian Integrative Oncology Research Initiative identified 5 interrelated priority research areas, including clinical effectiveness and safety of complementary therapies.43 Information about which neurofeedback technologies and protocols are being used successfully and with minimal side effects is needed.

Purpose The purpose of this review was to explore the effect and safety of EEG biofeedback or neurofeedback on fatigue and

cognitive impairment which are long-term symptoms commonly experienced by cancer survivors. The review attempted to answer the following research questions: 1. What is the effect of neurofeedback on fatigue and cognition? 2. What side effects and/or adverse events are experienced during or following neurofeedback therapy administered for management of fatigue or enhancing cognition? 3. Which neurofeedback systems, approaches and/or protocols have demonstrated effectiveness for management of fatigue and/or enhancing cognition?

Methods Data Sources This systematic review was conducted using Joanna Briggs Institute (JBI) methodology, including JBI critical appraisal and data extraction tools.44 The research team had experience in review methodologies and was supported by a library scientist. Inclusion criteria were defined a priori. A comprehensive systematic search of 5 databases was conducted: OVID MEDLINE (1946 to November week 3, 2013); EMBASE (1947 to 2013 week 44); PsycINFO (1967 to December week 1, 2013); AMED (1985 to December 2013); and CIHAHL (1978 to December week 1, 2013). Hand searches were also conducted of the major journals reporting on neurofeedback and reference lists of included studies. The search strategy in the MEDLINE database was as follows (numbers in parentheses indicate number of articles at each stage of the search):  1. Neurofeedback/(232)   2. neurofeedback.mp. (453)   3. brain biofeedback.mp (1)   4. eeg biofeedback.mp (105)   5. 1 or 2 or 3 or 4 (523)   6. exp Fatigue/(20 824)   7. exp Cognition disorders/(64 144)   8. exp Cognition/(111 419)   9. 6 or 7 or 8 (189 112) 10. 5 and 9 (56) A study was eligible for inclusion in this review if it (1) reported on adult cancer survivors, individuals with other chronic health conditions or nonclinical populations seeking to decrease fatigue and/or enhance cognitive abilities; (2) reported results of randomized controlled trials, nonrandomized controlled trials, controlled before and after studies, cohort, case control, or descriptive studies that assessed effectiveness and/or safety of EEG biofeedback or neurofeedback therapy; and (3) was written in English. We

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Medline 56

Embase 67

PsycINFO 42

AMED 5

CINAHL 20

Hand Search Total Citations 197

Duplicates Removed 40

Total Citations Screened 157

Excluded by Title/Abstract 105

Full Article Review 52

Excluded by Inclusion Criteria 25

Critical Appraisal 27

Excluded by Study Quality 10

Included Studies 17

Experimental Studies 10

Observational Studies 7

Figure 1.  Search decision flow diagram.

excluded studies on children, editorials, reviews, expert opinion papers, and studies published as abstracts only.

score of 7 or more indicated high quality. See the diagram in Figure 1 for a summary of the search decision flow.

Study Selection and Critical Appraisal

Data Extraction, Synthesis, and Analysis

Titles and abstracts were screened to determine broad eligibility using the inclusion and exclusion criteria. All citations identified as “include for critical appraisal” or “unclear” were rescreened using full text reports. Papers selected for critical appraisal were assessed by the principal investigator (MLF) and another reviewer (DG or LP) for methodological quality prior to final inclusion in the review. One of 3 JBI standardized critical appraisal instruments were used depending on the study design: (1) JBI Critical Appraisal Checklist for Experimental Studies45; (2) JBI Critical Appraisal Checklist for Comparable Cohort/Case Control Studies46; or (3) JBI Critical Appraisal Checklist for Descriptive/Case Series.47 Given the paucity of research in this area, a cutoff score of 4 was established for each JBI checklist to ensure a sufficient number of studies to review while maintaining the strength of the methodological quality. A score of 4 to 6 indicated moderate quality, whereas as

The primary reviewer (MLF) extracted data from the 17 included studies using a modified JBI data extraction form to summarize the pertinent details from each study. Extracted data were transferred to synopsis tables to synthesize relevant data. Because this systematic review was conducted using JBI methodology, the results were presented in separate tables by study design (ie, experimental vs descriptive studies). The data extracted included the following specific details of significance to the review questions and objectives: reference, study design, patient population/sample, neurofeedback intervention (system, protocols, number of sessions), outcome measures, efficacy results, safety results, limitations, conclusions, study quality. The primary outcomes of interest were levels of chronic fatigue and cognitive impairment. Secondary outcomes of interest were side effects and adverse events. Given the heterogeneity of the intervention systems and protocols, no meta-analysis was conducted.

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Results Quality Assessment Twenty-seven relevant studies were included in the critical appraisals. The quality of most studies was poor to moderate based on the JBI critical appraisal checklists. Seventeen studies were deemed of sufficient quality to be included in the review. Of these, only 2 were rated as high-quality studies,45,46 and the remaining were rated as moderate quality.47-60

Findings Ten experimental studies (see Table 1) and 7 descriptive studies (see Table 2) were synthesized in this review.

Characteristics of the Included Studies The 17 included studies were published in English between 2000 and 2013 in 7 countries. Ten of the studies were conducted in the United States.41,45,47,49,54-59 and 1 each from Mexico,48 Austria,50 Turkey,51 Germany,52 France,53 and England.46 Seven of the 10 experimental studies were randomized controlled trials,45,46,48-51,54 and 3 had quasiexperimental study designs.47,52,53 The descriptive studies consisted of 4 uncontrolled case series,56-59 2 pre-post studies,41,60 and 1 case-control study.55 Six studies reported on results with patients with traumatic brain injuries,52,54,57-60 3 with fibromyalgia,45,51,55 1 with breast cancer survivors,41 1 with patients with central nervous system (CNS) problems,41,55-60 and 1 with medical students having high withdrawal scores.46 Additionally, 5 studies reported on results with nonclinical populations. Three studies were conducted with healthy elderly persons,47,48,53 1 with healthy adults,50 and 1 with healthy college students.49 Sample sizes ranged from 6 to 64 for the experimental studies and from 5 to 100 for the descriptive studies. Participant ages ranged from 19 to 84 years for the experimental studies and from 6 to 80 years for the descriptive studies.

Neurofeedback Interventions Used in the Included Studies A wide variety of neurofeedback systems and technology were used in the included studies, however they can be grouped into 5 general types of neurofeedback training. Four experimental studies used alpha/theta training46-48,53; 4 experimental studies49-52 and 1 observational study55 involved SMR/beta training; 4 descriptive studies involved QEEG training57-60; 1 descriptive study employed an NLD approach41; and 2 experimental studies45,54 and 1 descriptive study56 used a LENS approach. None of the studies

reported on HEG biofeedback. Interventions ranged from 4 to 98 neurofeedback sessions 1 to 5 times per week, with most studies reporting from 10 to 40 sessions delivered once or twice per week.

Effect on Fatigue and Cognition All the included studies reported positive results for at least 1 fatigue or cognitive outcome as measured by a variety of standard self-rating questionnaires and cognitive task tests. Fourteen of the studies reported improvements in cognition,41,45,47-49,52-60 and 8 of the studies reported improvements in fatigue.41,46,49-51,54-56 Alpha/theta training demonstrated mixed results on cognitive performance in three experimental studies with healthy elderly subjects. In the pilot study by Angelakis et al,47 a peak alpha frequency (PAF) neurofeedback protocol resulted in improvement in speed of processing and executive functioning but had no clear effect on memory, whereas an alpha magnitude protocol showed improvement in memory. In the study by Becerra et al,48 healthy seniors improved on 2 measures from the Wechsler Adult Intelligence Scale (WAIS-III), Verbal Comprehension (P = .02) and Verbal IQ (P = .05) as well as the total score on the NEUROPSI neuropsychological test battery (P = .01), which evaluates attention, executive function, and memory. The Memory Score of the NEUROPSI increased significantly in both the experimental and control groups (P = .01). Improved memory performance (P = .01) as measured by the Signoret Memory Battery was observed in members of all 3 treatment groups in the study by Lecomte and Juhel,53 which compared neurofeedback (NFB) to relaxation and a test/retest (TRT) group. Memory performance of several NFB participants improved significantly more than the average increase of increase observed in the TRT group (P = .001 to P = .022). Raymond et al46 reported that medical students with high withdrawal scores given reported feeling more energetic (P < .01) given alpha/theta neurofeedback, and that participants given mock feedback felt more tired (P < .05). Sensorimotor rhythm/beta training resulted in a significant main effect (P < .05) among a sample of nonclinical psychology students for the Integrated Variables of Attention Full-Scale Response Quotient (IVA FSRQ), which measures response control (response accuracy, impulsivity, and fatigue).49 Instrumental conditioning of SMR resulted in improved declarative memory performance in a study with healthy individuals as evidenced by higher retrieval scores on the Wechsler Memory Scale– Revised after only 10 sessions (P = .018).50 Two studies reported on the use of SMR training for individuals with fibromyalgia. Kayiran et al51 reported significantly lower VAS-fatigue scores following SMR training versus patients treated with escitalopram. Fibromyalgia patients in the

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2. Becerra et al, 2012 Mexico

1. Angelakis et al, 2007 USA

Author/Date/ Country

Randomized controlled trial (RCT)

Normal elderly 60-84 y n = 9 female n = 5 male n = 7 Exp 65.8 ± 2.4 y n = 7 Cont 67 ± 4.9 y

QuasiHealthy elderly experimental n = 4 women n = 2 men 70-78 y n = 3 Exp (Experimental) n = 2 Cont (control) n = 1 Pseudo

Study Design

Patient Population/ Sample Outcome Measures

Effectiveness Results

Safety Results

MEDICID IV Reduce theta absolute power (AP) 30 sessions Over 10-12 wk Reinforcement administered intermittently (60% to 80% of the time) versus sham NF

•• Verbal Comprehension Index Cognition: (P = .02) and Verbal IQ (P = .05) Wechsler Adult from WAIS-III and Total Score Intelligence on the NEUROPSI test (P = .01) Scale (WAIS-III) increased significantly for NF and NEUROPSI group attention, executive function •• In both groups, Memory Score of the NEUROPSI increased and memory significantly (P = .01) •• In control group, there was a significant decrease in the WAIS Performance IQ (P = .05) •• Reduced theta AP and increased alpha AP were only observed in the NF group

•• Some protocols •• PAF group self-rated as Parietal-occipital Cognition: Selfmay worsen some thinking faster but no change in rated standard midline performance items concentration psychometric electrode POz •• PAF group no change for tests; “n-back” BioGraph/ verbal memory, worse for visual and “Go/No-Go” ProComp memory, whereas active controls oddball cognitive Peak alpha improved visual memory tasks frequency (PAF) •• PAF group increased response 1-2/wk speed and accuracy on Stroop 31-36 sessions test and improved reaction time versus alpha on “n-back” test amplitude neurofeedback (NF) and pseudo NF

Neurofeedback Intervention

Table 1.  Data Extraction Experimental Studies.

Conclusions

Study Quality

(continued)

Moderate •• PAF NF improved •• Small sample cognitive processing size, serve as speed and executive pilot data only function •• Participants •• No clear effect on were highmemory motivated and high-functioning •• PAF NF showed cognitive improvements in areas seniors that alpha amplitude NF (control) did not and vice versa •• Supports idea that EEG biofeedback is protocolspecific resulting in different effects depending on the frequency and modality of training Moderate •• Experimental NF •• Small sample group exhibited greater size, used improvement in EEG and nonparametric behavioral measures; permutational however, subjects of analysis of the control group also variance showed improved EEG (ANOVA) values and in memory, model with 2 which may be attributed factors (group to a placebo effect and time) •• Effect of the NFB treatment was clear in the experimental group, although a placebo effect may also have been present

Limitations

7

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3. Fritson et al, 2007 USA

Author/Date/ Country

RCT

Study Design

Table 1.  (continued)

Nonclinical psychology college students n = 32 19-38 y n = 28 female n = 4 male n = 16 Exp n = 16 Cont

Patient Population/ Sample Outcome Measures

Beta/sensorimotor Attention: Integrated rhythm (SMR) Variables of C3 (active)-C4 Attention + Plus (referential) (IVA + Plus); bipolar sensor Kaufman Brief placement with Intelligence Test A1 ground 2 (K-BIT 2); Wide sensor Range Intelligence 20 sessions Test (WRIT) 2/wk Fatigue versus sham NF

Neurofeedback Intervention

•• Multivariate analysis of variance (MANOVA) found significant main effect of training (P < .15) for the IVA FullScale Response Quotient (FSRQ); main effect of group and interaction were not significant •• Attention and intelligence scores did not show significant change

Effectiveness Results

Safety Results

Conclusions

Moderate

Study Quality

(continued)

•• •Participants •• SMR EEG only biofeedback completed may affect some 20 sessions, characteristics would have of nonclinical preferred individuals in as few 30-40 as 20 sessions sessions •• Specifically EEG •• Originally biofeedback enrolled improved response 39, but 7 control, including dropped out responses to because of auditory and visual scheduling stimuli conflicts •• Provides empirical •• Floor support for use effects of SMR EEG may have biofeedback with inhibited healthy adults to chance improve response of finding control (improve significant response accuracy, changes for decrease impulsivity intelligence and decrease fatigue) even if there is no obvious impairment, which is consistent with the idea of peak performance •• A greater number of sessions may be necessary for attention processes of healthy adults to be impacted by EEG biofeedback

Limitations

8

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4. Hoedlmoser et al, 2008 Austria

Author/Date/ Country

RCT

Study Design

Table 1.  (continued)

Neurofeedback Intervention Outcome Measures

Declarative THERA PRAX Healthy memory: SMR conditioning: individuals Declarative wordinstrumental n = 27 pair association conditioning of n = 13 male task sensorimotor n = 14 female Memory: Wechsler Mean age 23.63 y rhythm (ISC) Memory Scaleprotocol n = 16 Exp Revised 10 sessions n = 11 Cont Intelligence: versus Advanced randomizedProgressive frequency Matrices conditioning

Patient Population/ Sample

•• Calculated a 2-way ANOVA for retrieval scores (declarative memory), which increased after conditioning (P = .004) but no overall group difference •• Only SMR group had higher retrieval scores after 10 sessions (P = .018)

Effectiveness Results

Safety Results

Limitations

Moderate

Study Quality

(continued)

•• Significant SMR amplitude changes from early to late conditioning sessions confirmed success of the ISC •• These EEG changes transferred into sleep and even improved immediate memory retrieval after learning •• Memory consolidation was unchanged •• Possibly heightened attention or relaxation levels (during learning and/ or retrieval) after 10 ISC sessions, thus account for the observed improvement in word-pair recall

Conclusions

9

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RCT

Quasiexperimental

6. K  eller, 2001 Germany

Study Design

5. Kayiran et al, 2010 Turkey

Author/Date/ Country

Table 1.  (continued)

Traumatic brain injury n = 21 21-42 y n = 12 Exp n = 9 Cont

Fibromyalgia n = 36 n = 18 Exp Mean age 31.78 y n = 18 Cont Mean age 32.39 y versus escitalopram

Patient Population/ Sample Outcome Measures

Attention Beta activity training 10 sessions Over 2 wk versus computerbased attention training

Alien Technik3/32 Fatigue: Visual analogue scale and (VAS) for fatigue Brainfeedback-3 Fibromyalgia Impact SMR Questionnaire 20 sessions (FIQ) Over 4 wk

Neurofeedback Intervention

•• VAS-fatigue levels scores decreased significantly in both groups (P < .001) •• Mean VAS-fatigue scores were lower than those of the control group in every visit during follow-up (P < .05) •• A significant decrease in theta/SMR ratio was observed at the end of treatment •• The therapeutic efficacy of NF treatment began at second week and reached maximum effect at fourth week •• Effect of selective serotonin reuptake inhibitor (SSRI) treatment began at second week but reached maximum effect at eighth week •• NFT group increased the duration they were able to sustain beta activity above the threshold (P = .012) •• NFT group improved more than controls in the sustained attention task •• Control group improved mainly in computerized attention tests requiring focused attention for short periods of time •• NFT group improved in computer-based and paper-pencil tasks

Effectiveness Results

Safety Results

Conclusions

Moderate

Moderate

Study Quality

(continued)

•• NFT had a more extensive effect on attention deficits than the computerbased therapy •• suggests that NFT should focus not only on enhancement of beta activity but also on duration patients are able to hold beta activity

•• 2 patients •• All posttreatment in the NF measures showed group and significant 2 in the improvements in control both groups group were •• NF group displayed lost to greater benefits follow-up than controls •• Small sample •• Data support the size efficacy of NF as •• Lack of any a treatment for process pain, psychological which can symptoms, and lead to impaired quality explain the of life (QOL) mechanism associated with of NF for fibromyalgia FMS

Limitations

10

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7. Kravitz et al, 2006 USA

Author/Date/ Country

RCT

Study Design

Table 1.  (continued)

Fibromyalgia n = 64 n = 33 Exp n = 31 Cont Mean age 46.9 y n = 59 female n = 5 male

Patient Population/ Sample Flexyx neurotherapy system (FNS) Low-energy neurofeedback system (LENS) 22 sessions Over 11 or more weeks versus sham

Neurofeedback Intervention “Fibro-fog” Cognitive Fatigue Fibromyalgia Symptom Scales; Clinical Global Impressions Scales: Clinician (CGI-I) and participant (PGI-I); Fibromyalgia Impact Questionnaire (FIQ); CNS Dysfunction Questionnaire

Outcome Measures

Safety Results

Limitations

Conclusions

High

Study Quality

(continued)

•• More participants treated •• Side effects •• Those with •• Only the clinicianwith FNS than with sham monitored at each debilitating rated global improved partially or fully session graded chronic impressions on the CGI-I at session 22 0-3 fatigue were scores detected a (P = .01) and follow-up (P •• 52.5% reported not included; treatment-related = .04) at least one side thus sample response, which •• There was no significant effect at any time may have persisted through 1 treatment effect on any during treatment been atypical week posttreatment; secondary outcome •• Side effects of FMS significantly more measure and no specific differed patients participants treated symptom improved significantly (P < seeking with FMS were rated preferentially with active .007) between treatment as partially or fully versus sham FNS active (74.2%) and remitted sham (35.7%) •• A pretreatment •• Symptom delta/alpha EEG reported most amplitude ratio commonly fatigue >1 was associated was reported by with PGI-I but not 13 (10 in Exp); CGI-I response pain, including independent of headache was treatment group reported by 10 assignment (6 in Exp); 4 Exp •• Participants in the reported sleep study FMS group problems; 3 in were more likely to Exp reported rate study treatment stiffness or muscle as more effective spasms than previous •• None dropped treatment, and out due to side sham group were effects, but in more likely to rate a few cases, study treatment treatment was as no different or suspended worse than previous temporarily treatment •• Most important finding may be that for FMS patients EEG treatment alone is not sufficient for recovery

Effectiveness Results

11

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8. Lecomte and Juhel, 2011 France

Author/Date/ Country

Patient Population/ Sample

QuasiElderly experimental n = 30 65-85 y Mean age 75.25 y n = 23 women n = 7 men

Study Design

Table 1.  (continued)

Pendant EEG system/ BioExplorer Transverse captors: C3-Cz/Cz-C4 Alpha/theta training 4 sessions 1/wk versus Relaxation versus Test/ retest

Neurofeedback Intervention Effectiveness Results

•• Overall, an improvement of memory performance was observed in members of all 3 groups (P = .001) •• Memory performance of several members of the NFB group increased significantly more than the average increase of memory performance observed in members of the TRT group •• Increased performance in both memory tests was only significant in one member of the NFB group •• No relation was observed between changes in EEG activity and improved performance in either memory test

Outcome Measures Memory: 2 of 3 memory tests from the Signoret Memory Battery

Safety Results

Conclusions

Moderate

Study Quality

(continued)

•• Relatively •• NFB training small sample resulted on average size in an increase of •• Few training the spectral power sessions of the upper alpha •• Overall waves and in an good level increase of the and relative alpha/theta ratio, homogeneity despite the limited of memory number of training performance sessions displayed by •• The improved participants memory •• Type of performance task used observed in several to assess members of the memory NFB group cannot performance be attributed to may have changes in the been spectral power of insufficiently upper alpha waves matched or of theta waves, with the which NFB training cognitive might have enabled process •• The number of associate training sessions is with the probably insufficient frequency of wave ranges targeted by NFB training

Limitations

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Study Design

9. Raymond et al, RCT 2005 England

Author/Date/ Country

Table 1.  (continued)

Medical students with high withdrawal scores n = 12 NF 24.3 y Mock 19.83 y

Patient Population/ Sample Brainmaster Alpha/theta training 10 sessions 2/wk versus mock NF

Neurofeedback Intervention Fatigue Energy: Profile of Mood States (POMS)

Outcome Measures

•• Theta/alpha ratios rose significantly with time within sessions (P < .01) but did not change significantly across sessions •• Sessions of real NF produced on average greater improvements in mood than did sessions of mock feedback •• Changes were most notable in the subscale “energized-tired” NF group feeling much more energized, and mock group feeling less energized

Effectiveness Results

Safety Results

Limitations

High

Study Quality

(continued)

•• Results suggest that alpha/theta NF is a mood-enhancing and energizing experience that is not attributable to relaxation or pleasant sounds alone as heard in the mock condition

Conclusions

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Study Design

10. Schoenberger RCT (wait list control) et al, 2001 USA

Author/Date/ Country

Table 1.  (continued)

Traumatic brain injury (TBI) n = 12 21-53 y n = 2 men n = 12 women

Patient Population/ Sample Outcome Measures

Fatigue: J & J Enterprises Individualized 1-400 EEG Symptom biofeedback Rating Scale; Flexyx Multidimensional Neurotherapy Fatigue Inventory System (FNS) (MFI) 25 sessions Cognition: Auditory Over 5-8 wk Verbal Learning versus 6- to Test (AVLT); 8-week wait-list Paced Auditory control Serial Addition Test (PASAT); Rey-Osterrieth Complex Figure; Trail Making Test; Controlled Oral Word Association; Digit Span Backwards; Digit Symbol

Neurofeedback Intervention Safety Results

Limitations

Between-group analyses: •• Most common •• Sample •• Treatment group was side effect size may significantly improved experienced have been compared with the control during treatment too small group on the individualized was a temporary to detect rating scale (P < .01) intensification of an effect •• Between-group differences symptoms that on some were not significant for had previously measures the total MFI score but been problematic, significantly improved on including pressure the General Fatigue and in the head or Mental Fatigue subscales headache (3 (P < .02) people), dizziness •• Treatment group was (4 people), nausea significantly improved (1 person), compared with the tingling sensation control group on Digit (1 person) or Span Backwards (P < .05), physical pain the interference trial (P < associated .05) and the delayed recall with injuries trial (/50%) was noted Improvement in 88% of the Score (GIS) patients (mean 72.7%) •• all patients reported they were able to return to work following the treatment

Outcome Measures Safety Results

Limitations

Study Quality

•• In this uncontrolled open trial of QEEGguided coherence training, the majority of patients with MHI experienced substantial and rapid symptomatic improvement, including return to work

Moderate

•• The findings of significant Moderate changes in the Spectral correlation coefficient values must be presumed to underlie much of the improved cognitive functions

Conclusions

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Luctkar-Flude and Groll study by Caro and Winter55 reported 40% improvements in fatigue as measured by a subjective 0 to 10 scale (P = .006) and significant improvements in attention on 4 of 6 Continuous Performance Test (CPT) subscores (P < .01). A sample of patients with traumatic brain injury improved more in a sustained attention task following beta activity training than a control group who received computer-based attention training (P = .006). Quantitative EEG training improved cognitive measures in 4 studies of patients with brain injuries. Two case series studies by Thornton57,58 reported improvements in memory ranging from 39% to 181% as measured by story/paragraph recall. A third, larger study by Thornton and Carmody59 recorded 105% improvements in auditory memory and 143% improvements in reading memory among the traumatic brain injury subjects. Significant memory improvement (>50%) was noted in 88% of mild closed head injury patients as measured by the Global Improvement Score (GIS) in a pre-post study by Walker et al.60 All the patients in the study reported being able to return to work following the QEEG neurofeedback therapy. Nonlinear dynamical training was reported in only 1 study, a pre-post study with a wait-list control in which Alvarez et al41 demonstrated significant improvements in both cognition and fatigue in a sample of breast cancer survivors experiencing serious cognitive impairment and fatigue following cancer treatment. At posttest, the sample no longer differed significantly from the normative population on 3 of 4 Functional Assessment of Cancer Therapy– Cognitive (FACT-Cog) measures and the Functional Assessment of Chronic Illness Therapy–Fatigue (FACITFatigue) scales. Subjects demonstrated significant improvements on all 4 cognitive measures and the fatigue scale after only 20 sessions. Low-energy neurofeedback system training was effective in a randomized controlled trial of 64 persons with fibromyalgia as rated by clinicians on the Clinical Global Impressions Scale–Clinician (CGI-I) at session 22 (P = 0.01) and follow-up (P = .04), but there was no significant effect on the participant version of the scale (PGI-I) or the Cognitive Fatigue Fibromyalgia Symptom Scales or the Fibromyalgia Impact Questionnaire (FIQ) or the CNS Dysfunction Questionnaire.45 LENS was also used in a smaller trial with traumatic brain injury patients.54 The therapy resulted in significant improvements on some measures of cognitive function involving working memory versus a 6- to 8-week wait-list control group: Digit Span Backwards (P < .05), Interference Trial (P < .05), Delayed Recall Trial (P < .03) of the Auditory Verbal Learning Test (AVLT), and the most difficult trial of the Paced Auditory Serial Addition Test (PASAT; P < .02). Fatigue scores also improved significantly as measured by the Individualized Symptom Rating Scale (P < .01) and the General Fatigue and Mental Fatigue subscales (P < .02) of the Multidimensional Fatigue

Inventory (MFI) in comparison with the control group. An uncontrolled case series of 100 subjects with CNS problems demonstrated that LENS therapy was clinically effective with mean symptom ratings on the Subjective Symptom Rating Scale (SSRS) at posttreatment falling to exactly half of the pretreatment levels (P < .001).61 The top four r2 values in rank order of improvement were disorganization (.985), cognitive problems (.983), attention (.956), and fatigue (.955). Executive function ranked eighth (.903).

Safety of Neurofeedback Only 4 of the included studies commented on the side effects or safety of the neurofeedback interventions. Angelakis et al47 indicated that some neurofeedback protocols may worsen some performance items. In the RCT by Kravitz et al,45 side effects were monitored at each session, with 52.5% of subjects reporting at least 1 side effect at any time during the treatment. Side effects differed significantly (P < .007) between the LENS treatment group (74.2%) and the control group (35.7%) with the most commonly reported symptoms being fatigue, pain, sleep problems, and stiffness and muscle spasms. No subjects dropped out of the study due to side effects, however, in a few cases the therapy was temporarily suspended. The most common side effect experienced in the LENS trial by Schoenberger et al54 was a temporary intensification of previously problematic symptoms such as pressure in the head or headache, dizziness, nausea, tingling sensation, or physical pain associated with injuries. These reactions typically occurred within the first six or seven sessions and resolved within a few days. Fatigue and restlessness were the most common indications of overtreatment and session length was reduced accordingly. And finally, in the pre-post trial of breast cancer survivors conducted by Alvarez et al,41 the NLD neurofeedback approach was well tolerated and none of the participants reported any side effects or adverse effects.

Discussion The aim of this review was 3-fold: (1) to describe the effect of neurofeedback on fatigue and cognition, (2) to describe side effects and/or adverse events experienced during or following neurofeedback therapy administered for management of fatigue or enhancing cognition, and (3) to describe neurofeedback systems, approaches and/or protocols that have demonstrated effectiveness for management of fatigue and/or enhancing cognition. Research dating back to the 1940s has demonstrated that brainwave or EEG activity could be trained through classical and operant conditioning using biofeedback techniques.62 Clinical applications have ensued in the fields of neurology and psychology, protocols and equipment have been refined, and evidence has been building for its use in

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Integrative Cancer Therapies 

treatment of epilepsy, attention deficit disorder, closed head injury, learning disabilities, anxiety, depression, alcoholism and other addictions and autism spectrum disorders.63 Research studies have also reported that neurofeedback helps with chronic pain, chronic fatigue syndrome, sleep disorders, PTSD, migraines, and cognitive decline.21 As evidenced by the retrieval of only a single completed study41 and a single RCT protocol40 investigating effectiveness of neurofeedback for cancer survivors experiencing cancer fatigue or cognitive impairment, the results of this review demonstrate that the field of oncology has not yet evaluated this noninvasive therapy, which has the potential to ameliorate symptoms in cancer patients and cancer survivors. All the included studies related to fatigue and cognition were published since 2000, suggesting this area of research is relatively new. However, each of these studies reported positive results for at least 1 fatigue or cognitive outcome in a variety of clinical (traumatic brain injury, fibromyalgia, CNS problems) and nonclinical (college students, adults, elderly) populations. Despite relatively small sample sizes, statistically significant results were obtained. This suggests that neurofeedback addresses an underlying mechanism for fatigue and cognition common to these different issues or is responsive to a variety of neuropsychological pathologies either through targeted or generalized approaches. Results of this review are consistent with reports in the literature that describe neurofeedback as safe and well tolerated. Although only 4 studies commented on side effects, none of the studies reported subjects dropping out due to side effects. Neurotherapy rarely produces negative side effects, which is a major reason for its use.28 Adverse effects reported in the literature appear to be associated with volitional types of neurofeedback protocols that attempt to push the brain in specific directions, which can occasionally result in side effects and when improperly done, exacerbation of symptoms.64 In the case of nonvolitional neurotherapy, such as NLD approaches, the practitioner does not push the brain in any particular direction but cues the brain to strengthen its own self-regulatory networks.32 Reported side effects seem to be exacerbation of existing symptoms or complaints, and are usually very transient, dropping away after only a few sessions. These results are consistent with findings of a survey of providers using an NLD system.65 Of the 3 studies included in this review that reported side effects or adverse effects, 1 study involved peak alpha frequency training47 and 2 involved LENS therapy. The peak alpha training pushed the brain in a specific direction, which improved some cognitive measures at the expense of visual memory.47 The LENS neurofeedback interventions, which are nonvolitional, resulted in transient exacerbation of symptoms such as fatigue and pain. Participants in the single NLD neurofeedback study did not report any side effects.

There appears to be no single conceptual model to describe the process and outcomes of neurofeedback among practitioners or manufacturers.26,27 In this review, a variety of neurofeedback systems, approaches and protocols were employed for the purpose of ameliorating symptoms of chronic fatigue and improving cognition. All of the included studies reported positive results for at least one fatigue or cognitive outcome suggesting that multiple approaches may be effective. The lone study that evaluated neurofeedback with breast cancer survivors, although not an RCT, demonstrated promising results using an NLD approach: 23 women demonstrated significant improvements on all 4 cognitive measures and the fatigue scale after only 20 sessions with no side effects, adverse effects or dropouts reported. These results suggest that the NLD approach warrants further study through randomized controlled trials and larger sample sizes to confirm efficacy and safety as well as to establish the optimum range or number of sessions required to achieve lasting results. Overall, results suggest that protocols for any of the neurofeedback approaches should include a minimum of 10 to 20 sessions to demonstrate effectiveness, recognizing that individuals may require fewer or more sessions to alleviate their symptoms. This systematic review was conducted using JBI methodology, which includes studies using different research designs. Different appraisal tools are used to evaluate studies that are experimental (randomized control/pseudorandomized trial) versus observational/descriptive studies. Although observational/descriptive studies cannot be used to determine causation, they suggest relationships that could be further investigated through RCTs if appropriate, and thus were in included in this review, which explores a novel intervention that has not been well researched. Collectively, results of the studies included in this review represent at best level 2 evidence due to the inclusion of several small RCTs and quasi-experimental studies according to the JBI levels of evidence in which level 1 evidence, the strongest evidence would consist of results of a meta-analysis (with homogeneity) of experimental studies or one or more large experimental studies with narrow confidence intervals.44

Limitations The greatest limitation of this review is the small sample sizes used in both the experimental and descriptive studies. Confounding factors such as concurrent medication use were often not described. Methodological quality of the majority of the studies was only moderate, with few blinded, RCTs included. Use of different outcome measurement tools limits the ability to make comparisons between different neurofeedback protocols and approaches. As well the diversity of neurofeedback approaches and systems makes it difficult to categorize and explain the overall positive results.

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Luctkar-Flude and Groll

Conclusions Despite issues with methodological quality, the overall positive findings and few reported side effects associated with neurofeedback for fatigue and cognitive impairment suggest this innovative CAM therapy could be helpful in alleviating these symptoms. Currently, there is insufficient evidence that neurofeedback is an effective therapy for management of fatigue and cognitive impairment in cancer survivors; however, these promising results support the need for further research with this patient population. More information about which neurofeedback technologies, approaches and protocols could be successfully used with cancer survivors and with minimal side effects is needed. Clinical trials comparing the effectiveness of specific neurofeedback protocols and approaches to sham neurofeedback and/or to other neurofeedback protocols are urgently needed to move this field forward. Trials should also compare neurofeedback with other approaches that encourage healthy self-regulation of the brain such as physical activity and mindfulness-based stress reduction strategies. Study limitations that should be addressed in future research include use of randomization and double-blinding, larger sample sizes and increased statistical power to increase the quality of individual studies as well as the overall level of evidence to efficacy and safety of various neurofeedback approaches. This review will provide preliminary data on which to build a protocol for a pilot RCT in a sample of cancer survivors to determine feasibility, recruitment strategies, validate instruments, and establish effect size for calculation of sample size for a larger clinical trial to evaluate the effectiveness and safety of neurofeedback in this population. In the long term, the proposed program of research may help cancer survivors with long term symptoms for whom other approaches have failed, or who do not want to continue to use medications, as well as provide scientific evidence of efficacy. The results will have significance to nurses and physicians in oncology and primary care settings who provide follow-up care and counseling to cancer survivors experiencing debilitating symptoms such as cognitive impairment (chemobrain) and cancer fatigue. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.

References 1. Siegel R, DeSantis C, Virgo K, et al. Cancer treatment and survivorship statistics, 2012. CA Cancer J Clin. 2012;62: 220-241.

2. Canadian Cancer Society. Canadian cancer statistics 2013. Canadian Cancer Society Web site. http://www.cancer.ca/ en/cancer-information/cancer-101/canadian-cancer-statisticspublication/?region=bc. Accessed October 24, 2013. 3. Brearley SG, Stamataki Z, Addington-Hall J, et al. The physical and practical problems experienced by cancer survivors: a rapid review and synthesis of the literature. Eur J Oncol Nurs. 2011;15:204-212. 4. Ganz PA. Monitoring the physical health of cancer survivors: a survivorship-focused medical history. J Clin Oncol. 2006;24:5105-5111. 5. Ewertz M, Jensen AB. Late effects of breast cancer treatment and potentials for rehabilitation. Acta Oncol. 2011;50:187193. 6. Mrozek E, Shapiro CL. Survivorship and complications of treatment in breast cancer. Clin Adv Hematol Oncol. 2005;3:211-222. 7. Brant JM, Beck S, Dudley WN, Cobb P, Pepper G, Miaskowski C. Symptom trajectories in posttreatment cancer survivors. Cancer Nurs. 2011;34:67-77. 8. Wagner LI, Cella D. Fatigue and cancer: causes, prevalence and treatment approaches. Br J Cancer. 2004;91:822-828. 9. Paquet L, Collins B, Song X, Chinneck A, Bedard M, Verma S. A pilot study of prospective memory functioning in early breast cancer survivors. Breast. 2013;22:455-461. 10. Portenoy RK. Cancer-related fatigue: an immense problem. Oncologist. 2000;5:350-352. 11. Berger AM, Gerber LH, Mayer DK. Cancer-related fatigue: implications for breast cancer survivors. Cancer. 2012;118(8 suppl):2261-2269. 12. Von Ah D, Habermann B, Carpenter JS, Schneider BL. Impact of perceived cognitive impairment in breast cancer survivors. Eur J Oncol Nurs. 2013;17:236-241. 13. Stanton AL. Psychosocial concerns and interventions for cancer survivors. J Clin Oncol. 2006;24:5132-5137. 14. Noal S, Levy C, Hardouin A, et al. One-year longitudinal study of fatigue, cognitive functions, and quality of life after adjuvant radiotherapy for breast cancer. Int J Radiat Oncol Biol Phys. 2011;81:795-803. 15. McLeod D. Survivorship and relationships. Webinar, Canadian Association of Nurses in Oncology, July 17, 2013. 16. Roberts D, Wilson C, Todd C, et al. Complementary therapies in cancer: patients’ views on their purposes and value pre and post receipt of complementary therapy—a multi-centre case study. Eur J Integr Med. 2013;5:443-449. 17. Rees RW, Feigel I, Vickers A, Zollman C, McGurk R, Smith C. Prevalence of complementary therapy use by women with breast cancer. A population-based survey. Eur J Cancer. 2000;36:1359-1364. 18. Mao JJ, Palmer SC, Straton JB, et al. Cancer survivors with unmet needs were more likely to use complementary and alternative medicine. J Cancer Surviv. 2008;2:116-124. 19. Roberts D, McNulty A, Caress AL. Current issues in the delivery of complementary therapies in cancer care—policy, perceptions and expectations: an overview. Eur J Oncol Nurs. 2005;9:115-123. 20. Fouladbakhsh JM, Stommel M. Gender, symptom experience, and use of complementary and alternative medicine practices among cancer survivors in the U.S. cancer population. Oncol Nurs Forum. 2010;37:E7-E15.

Downloaded from ict.sagepub.com at GEORGIAN COURT UNIV on February 28, 2015

22

Integrative Cancer Therapies 

21. Hammond DC. Comprehensive neurofeedback bibliography: 2007 update. J Neurother. 2007;11:45-60. 22. Collura TF. Technical Foundations of Neurofeedback. New York, NY: Routledge; 2014. 23. Hammond DC. Neurofeedback with anxiety and affective disorders. Child Adolesc Psychiatr Clin N Am. 2005;14:105-123. 24. Hammond DC. What is neurofeedback: an update. J Neurother. 2011;15:305-336. 25. Swingle PG. Biofeedback for the Brain: How Neurotherapy Efffectively Treats Depression, ADHD, Autism and More. New Brunswick, NJ: Rutgers University Press; 2008. 26. Demos JN. Neurofeedback modalities and the brain. In: Demos JN, ed. Getting Started With Neurofeedback. New York, NY: W.W. Norton; 2005:68-89. 27. Fultz DE. Behaviorism and neurofeedback: still married. Curr Concepts Neurother. 2002;6:67-74. 28. Fultz DE. The current status of behaviorism and neurofeedback. Int J Behav Consult Ther. 2009;5:160-163. 29. Evans JR, Rubi MCM. Ours is to reason why and how. In: Evans JR, ed. Handbook of Neurofeedback: Dynamics and Clinical Applications. New York, NY: Informa Healthcare; 2009:61-81. 30. Othmer SF, Othmer S. Interhemispheric EEG training: clinical experience and conceptual models. In: Evans JR, ed. Handbook of Neurofeedback: Dynamics and Clinical Applications. New York, NY: Informa Healthcare; 2009:109-136. 31. Robbins J. A Symphony in the Brain: The Evolution of the New Brain Wave Biofeedback. New York, NY: 2008: 156-192. 32. Othmer S. Emerging trends in neurofeedback: II. The challenge of QEEG-based and NLD-based neurofeedback protocols. Biofeedback. 2002;30(3):43-45. 33. Ochs L. The low energy neurofeedback system (LENS): theory, background, and introduction. J Neurother. 2006;10:5-39. 34. Tattenbaum R. William’s story: a case study in optimal performance. Biofeedback. 2012;40(1):21-25. 35. Demos JN. Brain basics and body anatomy and physiology. In: Demos JN, ed. Getting Started With Neurofeedback. New York, NY: W.W. Norton; 2005:22-56. 36. Carmen JA. Passive infrared hemoencephalography (pIR HEG). http://media.wix.com/ugd/40ef5a_1dd0b179537af2df 437b241b797b4914.pdf. Accessed September 23, 2013. 37. American Academy of Pediatrics. Evidence-based child and adolescent psychosocial interventions. 2013. http://www. aap.org/en-us/advocacy-and-policy/aap-health-initiatives/ Mental-Health/Documents/CRPsychosocialInterventions. pdf. Accessed September 23, 2013. 38. Canadian Cancer Society. Complementary therapies: a guide for people with cancer. 2009. http://www.cancer-asian.com/ images/education/pdf/en/313-142.pdf. Retrieved January 30, 2015. 39. Deng GE, Frenkel M, Cohen L, et al. Evidence-based clinical practice guidelines for integrative oncology: complementary therapies and botanicals. J Soc Integr Oncol. 2009;7:85-120. 40. de Ruiter MA, Schouten-Van Meeteren AY, van Mourik R, et al. Neurofeedback to improve neurocognitive functioning of children treated for a brain tumor: design of a randomized controlled double-blind trial. BMC Cancer. 2012;12:581.

41. Alvarez J, Meyer FL, Granoff DL, Lundy A. The effect of EEG biofeedback on reducing postcancer cognitive impairment. Integr Cancer Ther. 2013;12:475-487. 42. Rubi MCM. Neurofeedback around the world. J Neurother. 2006;10(4):63-73. 43. Weeks LC, Seely D, Balneaves LG, et al. Canadian integrative oncology research priorities: results of a consensus-building process. Curr Oncol. 2013;20:e289-e299. 44. The Joanna Briggs Institute. Joanna Briggs Reviewers’ Manual. Adelaide, Australia: The Joanna Briggs Institute; 2011. 45. Kravitz HM, Esty ML, Katz RS, Fawcett J. Treatment of fibromyalgia syndrome using low-intensity neurofeedback with the flexyx neurotherapy system: a randomized controlled clinical trial. J Neurother. 2006;10(2-3):41-58. 46. Raymond J, Varney C, Parkinson LA, Gruzelier JH. The effects of alpha/theta neurofeedback on personality and mood. Brain Res Cogn Brain Res. 2005;23:287-292. 47. Angelakis E, Stathopoulou S, Frymiare JL, Green DL, Lubar JF, Kounios J. EEG neurofeedback: a brief overview and an example of peak alpha frequency training for cognitive enhancement in the elderly. Clin Neuropsychol. 2007;21: 110-129. 48. Becerra J, Fernández T, Roca-Stappung M, et al. Neurofeedback in healthy elderly human subjects with electroencephalographic risk for cognitive disorder. J Alzheimers Dis. 2012;28:357-367. 49. Fritson KK, Wadkins TA, Gerdes P, Hof D. The impact of neurotherapy on college students’ cognitive abilities and emotions. J Neurother. 2007;11(4):1-9. 50. Hoedlmoser K, Pecherstorfer T, Gruber G, Anderer P, Doppelmayr M, Klimesch W. Instrumental conditioning of human sensorimotor rhythm (12-15 Hz) and its impact on sleep as well as declarative learning. Sleep. 2008;31:1401-1408. 51. Kayiran S, Dursun E, Dursun N, Ermutlu N, Karamürsel S. Neurofeedback intervention in fibromyalgia syndrome; a randomized, controlled, rater blind clinical trial. Appl Psychophysiol Biofeedback. 2010;35:293-302. 52. Keller I. Neurofeedback therapy of attention deficits in patients with traumatic brain injury. J Neurother. 2001;5(1-2):19-32. 53. Lecomte G, Juhel J. The effects of neurofeedback training on memory performance in elderly subjects. Psychology. 2011;2:846-852. 54. Schoenberger NE, Shif SC, Esty ML, Ochs L, Matheis RJ. Flexyx Neurotherapy System in the treatment of traumatic brain injury: an initial evaluation. J Head Trauma Rehabil. 2001;16:260-274. 55. Caro XJ, Winter EF. EEG biofeedback treatment improves certain attention and somatic symptoms in fibromyalgia: a pilot study. Appl Psychophysiol Biofeedback. 2011;36:193-200. 56. Larsen S, Harrington K, Hicks S. The LENS (Low Energy Neurofeedback System): a clinical outcomes study on one hundred patients at Stone Mountain Center, New York. J Neurother. 2006;10(2-3):69-78. 57. Thornton K. Improvement/rehabilitation of memory functioning with neurotherapy/QEEG biofeedback. J Head Trauma Rehabil. 2000;15:1285-1296. 58. Thornton KE. The improvement/rehabilitation of audi tory memory functioning with EEG biofeedback. Neurorehabilitation. 2002;17:69-80.

Downloaded from ict.sagepub.com at GEORGIAN COURT UNIV on February 28, 2015

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Luctkar-Flude and Groll 59. Thornton KE, Carmody DP. The relation between memory improvement and QEEG changes in three clinical groups as a result of EEG biofeedback treatment. J Neurother. 2013;17(2):116-131. 60. Walker JE, Norman CA, Weber RK. Impact of qEEG-guided coherence training for patients with a mild closed head injury. J Neurother. 2002;6(2):31-43. 61. Larsen S, Sherlin L. Neurofeedback. An emerging technology for treating central nervous system dysregulation. Psychiatr Clin North Am. 2013;36:163-168.

62. Arns M. Historical archives: the beginning. J Neurother. 2010;14:291-292. 63. Evans JE. Handbook of Neurofeedback. Binghamton, NY: Haworth Press; 2007. 64. Hammond DC, Kirk L. First, do no harm: adverse effects and the need for practice standards in neurofeedback. J Neurother. 2008;12(1):79-88. 65. Zietsma C. Survey report on the use of Zengar Neur Optimal™. https://www.zengar.com/files/File/pdfs/NeurOptimal PractitionerSurvey08.pdf. Accessed May 17, 2013.

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A Systematic Review of the Safety and Effect of Neurofeedback on Fatigue and Cognition.

Many cancer survivors continue to experience ongoing symptoms, such as fatigue and cognitive impairment, which are poorly managed and have few effecti...
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