Neurofeedback according to the Othmer Method: Relaxation Training of Resting State Networks




In this brief summary treatment, the case will be made that Infra-Low Frequency Neurofeedback training is nothing more than traditional relaxation training that has been provided with optimal instrumental support. Whereas in relaxation training the trainee is invited to engage with his internal states, with instrumental support the feedback loop is closed directly with the brain. This increases the efficiency of the feedback loop and enhances outcomes. The only role performed by the instrument is to reflect back to the trainee the instantaneous state of his physiology.  Hence the agency in this process continues to reside entirely with the trainee. It does not reside with the instrument. Further, the target of relaxation training was and remains the enhancement of our functional capacities. It is a generic training that does not specifically target any disease or disorder.  Any symptomatic improvement is therefore secondary to the enhancement of functional capacities.


  The Historical Background of Relaxation Training


It is only necessary to go back to the early 20th century to tell the essentials of the story. Johannes Schultz developed the Autogenic Training procedure in Germany to facilitate relaxation through the voluntary motor system. By means of a routinized schedule of verbal inductions a state of deep muscle relaxation was sought. A few years later a similar development took shape in the United States, with the method of Progressive Relaxation developed by Edmund Jacobson. Progressive relaxation involved a successive tensing and relaxing of specific muscle groups in order to deepen the state of relaxation that could be achieved. Jacobson was so persuaded of the health implications of his method that the popular book he authored was titled “You Must Relax!” This was an early insight that is only now, nearly one hundred years later, being provided with a theoretical foundation.

Some years later Herbert Benson of Harvard University promoted what he called “The Relaxation Response.” The case was made on the basis of broad benefits for improvements in health status that he and his research group observed. This development was probably shaped by the increasing awareness in the West of meditative techniques from India. What emerged was a broad thrust of using mental states to promote changes in physiological states. This bypassed the mediating role of the motor system that had engaged Schultz and Jacobson.

On the other hand, the yogic tradition was introduced to the West in this same time frame and that tradition retained the direct involvement of motor control in the project of achieving controlled physiological states. Tai Chi falls into this category as well, and collectively all of these methods taught control of physiological states in the interest of enhancing spiritual practice.  It is likely that the close association with spiritual practice somewhat eclipsed the health implications of these techniques.

Yoga practice emphasizes control of the breath, and thus gave rise to our current Western appreciation of the power of breath control in regulating our physiology. The breath is under both voluntary and autonomic control, and by assuming voluntary control we can systematically influence the status of our autonomic nervous system. Through extended training procedures profound health benefits have been documented for cases of asthma, myofascial pain, PTSD, and other conditions.    

Other methods that generally tend toward the achievement of relaxed and controlled states (even if that is not their primary objective) include hypnotherapy, healing touch, cranio-sacral therapy, and guided imagery. All of these methods are in active use among the healing disciplines.  All of them are predicated on the expectation that the effects of these undertakings are lasting. It would not be defensible to resort to these methods merely for the transient experience of relaxed states. That would be fine for the domain of spiritual practice; it would not serve for applications to health care.

For applications in the realm of health care, relaxation training should be seen in the larger frame of training in physiological regulation. The over-riding objective of all of these methods is to enhance the capacity for maintaining physiological control under the duress of either external challenges or internal constraints due to disease or dysfunction.


Relaxation Training with Instrumental Support


During the 1960’s biofeedback on the alpha rhythm of the EEG was discovered and attracted professional interest. The predominant application was to the relief of anxiety conditions. Alpha training was also used as an aid to meditation practice. The model for the work with anxiety was relaxation training. Alpha band activity was associated with an absence of visual engagement. It may be considered the resting rhythm of the visual system. Reinforcement on alpha amplitudes in the EEG also led to a shift in attentional style from narrow and objective to broad and immersive attention. This was helpful in meditation practice.

In a technique referred to as “Open Focus,” the originator Lester Fehmi combined techniques of verbal induction with instrumental support and showed them to be essentially equivalent in terms of outcome. Some responded better to verbal cues; others did better with instrumental guidance.

The alpha training did not match its early promise, however, and it became a niche technology within the field of psychology. Biofeedback researchers shifted ground and began to work with measures of peripheral physiology that were instrumentally much less demanding and also had the advantage of face validity. With all of the standard methods---temperature training; galvanic skin response; electromyographic activity, heart rate variability---the prevailing model was relaxation training, or in less pedestrian terminology, the training of homeostatic regulation. Two of the leading figures in the field described the essence of peripheral biofeedback in two slightly different ways. Charles Stroebel, MD, Ph.D., referred to eliciting the “Quieting Response.” Thomas Mulholland, Ph.D., referred instead to “Behavioral Stillness.” In all of this work, essentially without exception, the real objective was the achievement of a greater level of control over the longer term, not merely the experience of relaxed states within the actual session.  It was the capacity to relax that mattered, not relaxation per se.

EEG biofeedback entered the discussion again with the discovery of the sensorimotor rhythm in animal research by Barry Sterman of UCLA.  This may be thought of as the resting rhythm of the motor system. Reinforcing on activity in this band led to reductions in motoric excitability and substantial improvements in the sleep architecture of cats. In a fortuitous experiment that was both controlled and totally blinded, reduction in susceptibility to chemically induced seizures was demonstrated.

This work led to a burgeoning of interest in the use of EEG training for a variety of conditions, but principally targeting hyperkinesis (ADHD). A number of studies were published on the work with ADHD and with seizure disorder, which laid the foundation for subsequent developments. Further progress in this area was largely clinically driven, so findings were mostly observational rather than formal, and therefore not publishable.

The operative model was the reduction in motoric excitability and the accompanying increase in nervous system stability.  Again the work was grounded in relaxation training and the resulting promotion of homeostatic control. The very same targeted relaxation training was leading to the observation of clinical benefit for a variety of conditions ranging from deficits in executive function to sleep disorders and pain syndromes.  

 Over time it was observed that the principles involved in the alpha training and the SMR training applied to EEG frequencies generally. The whole EEG spectrum opened up for EEG-based training. If the training was properly executed, the result was a calming of the nervous system, allowing it to function out of states of lower levels of excitation. Concomitantly there was an expansion of the number of conditions for which benefits of the training were being identified in clinical practice.

Opening up the entire EEG spectrum to possible utilization in a reinforcement strategy brought in train the need for selection criteria. An optimization strategy was adopted by means of which each individual would migrate toward his or her personal optimum reward strategy through successive A/B hypothesis-testing over the course of sessions. The training strategy would be progressively refined on the basis of the response to the training. In this quest for the optimum in each case a lot of experience was gathered on parametric dependences (i.e. reward frequency and electrode placement). As results were surveyed for a large number of cases, it became clear that trainees generally responded faster and better when reinforcement occurred at the lower EEG frequencies.

Eventually this led to the utilization in feedback of infra-low frequencies in the EEG that had been largely neglected since the early days of EEG research. With each progression toward lower frequencies, trainees responded more quickly, more specifically, and to greater clinical benefit. As in the entire discussion up to this point, two issues are primary: The first is the induction of state change with the reinforcement; the second is the gradual acquisition of improved self-regulatory skills---at the brain level.

It is the immediate induction of state change with the reinforcement that guides the clinician to the optimum reinforcement conditions. The target is a state of calm alertness, that is to say, calmness within a state of good function rather than of somnolence, lassitude or torpor. Once this state is achieved within session, this also constitutes the conditions for a good long-term outcome. Throughout the entire training process, the guiding objective is the achievement of calm, relaxed states, but in a context of alert vigilance and readiness for engagement.



The Development of a Theoretical Model


What needs to be explained is why simple relaxation strategies, aided or unaided by instrumentation, should have such broad and wide-ranging benefits for a variety of ailments and complaints. The strongest and most effective relaxation training found to date appears to be the infra-low frequency training. If a model can be found to explain the manifest efficacy of this kind of training, then that same model may serve to explain the power of relaxation training in general.

It was just at the turn of the millennium that the brain’s resting state networks were discovered in functional magnetic resonance imaging. These networks are highly active even when the brain is not externally engaged, i.e. in resting states of the system. Significantly, they are only incrementally less active when the brain is engaged with the external world. This necessarily implies that it is the resting states that govern our level of function both in engaged and in disengaged status.

Resting state networks need to be described in three very different ways, each entailing its own potential failure mode. Foundational is the structural connectivity of the networks, the white matter bundles that connect the distributed branches of the networks. At the next level we have the functional connectivity that integrates activity between disparate hubs of the networks. And at the top level we have the brain dynamics that plays out within the constraints of both structural and functional connectivity.

At the higher EEG frequencies the signal is dominated by EEG dynamics. Engaging with this phenomenology has been very useful clinically, having led to the emergence and growth of the field of EEG biofeedback or neurofeedback over the last forty years.

At the low EEG frequencies, well below the conventional cutoff of 0.1 to 0.5 Hz, we are dealing with the slow cortical potential (SCP). This signal has been shown to correlate with the functional magnetic resonance imaging signal, which is only available to us at these low frequencies. Since the fMRI signal has been used to characterize functional connectivity within the resting state networks, it follows that the slow cortical potential must also reflect these same relationships.

It is therefore reasonable to propose that the infra-low frequency training directly impinges upon the functional connectivity of resting state networks, and that the implicit challenge of the brain witnessing its own activity in this regime brings about a functional reorganization.

The usual rules apply. When the brain engages with information bearing on physiology, the brain tends to move in the direction of calmer states. Moving toward calm states then also improves homeostatic regulation and nervous system stability. We frame matters this way because the arousal level of the trainee is the observable for the clinician.

One can also frame the discussion differently, as follows: When the brain engages with information bearing on its physiology, it treats this new feedback loop just like others. The information is utilized to improve the brain’s regulation of its own states. Once such improved regulatory status is established, the brain is capable of functioning just as well at a lower level of excitation, and hence moves toward lower levels of activation and arousal. In any event, the quality of regulation is coupled to arousal level, and this coupling can be understood in terms of the properties of our resting state networks.

In recent years numerous publications have appeared that document deficits in the functional connectivity of resting state networks in disparate conditions such as schizophrenia, the autism spectrum, and the dementias. It is therefore reasonable to assume that the disregulation of resting state network connectivity accounts for the substantial intractability of the psychopathologies while at the same time furnishing a mechanism for their sometime recovery. In this model, if recovery occurs by whatever therapeutic intervention—including in particular the placebo---it will most likely have been accompanied by the re-normalization of network functional connectivity.

Most recoveries from mental disorders occur outside of institutional settings and even in the absence of standard therapeutic interventions. Clearly the brain is capable of achieving autonomous re-normalization of network function even in cases of challenging clinical conditions. With instrumental support we can now harness and guide this process systematically toward the resolution of clinical syndromes. This level of broad-based effectiveness would imply a powerful agent at work.

It must therefore be said emphatically that there is no agency here outside of the brain itself. The instrumentation serves merely to reflect physiological activity back to the brain. What our work amounts to is guided self-recovery, but only the brain itself is in a position to assign meaning to the information being provided.

Since the mechanism of recovery relates to the spontaneous reorganization of resting state networks, infra-low frequency EEG training reduces ultimately to nothing more than instrumentally-mediated relaxation training. Success in a training session nearly always means that the trainee walks out in a state of lower arousal level than prevailed when he walked in. Eventually the brain acquires new habits of functioning.



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