Report on the AAPB Conference in Daytona Beach, FL

by Siegfried Othmer | May 22nd, 2008

Musk OxOur migraine symposium was the last scheduled item on the program. It was to be conducted by Frank Andrasik, Jeff Carmen, Deborah Stokes, and me, but Frank was unable to be there. The attendance was huge, given the late positioning in the schedule. On the previous occasion, in 2004, we were crowded into a smaller room and the audience overflowed into the hallway. After the debacle last time, we were braced for the reappearance of the tantruming Rumpelstiltskins, Steve Baskin and Richard Sherman, but they chose not to show up. They did, however, succeed on the previous occasion in suppressing interest in the new approaches to migraine. It was reported to me recently that Steve Baskin updated attendees at the BFE Conference in Salzburg on migraine work and mentioned neither pIR nor EEG feedback as having any application to migraine. That’s just mind-boggling if true. Apparently Jeff Carmen’s paper on 100 clients doesn’t count.

One marvels at the degree to which an ostensible fealty to scientific standards ends up so incredibly perverted. The efficacy of thermal biofeedback for migraine is not, after all, in question any longer, and hasn’t been for some decades. Now over most of those decades the late Marjorie Toomim chose to place the thermal sensors over the temporal arteries, no doubt under the influence of the ruling paradigm that migraines were a vascular phenomenon. I don’t know of a publication that sanctified this new placement, but this approach was surely at least as effective as other biofeedback approaches, or one suspects that Marjorie would have noticed and gone back to hand-warming.

An organic science builds upon what is already known. Proving out the placement at the temples does not require that one start over from ground zero. One can move incrementally from one hypothesis to another in an A/B comparison. It should be a relatively trivial matter to find out whether placement at the temples is superior to hand warming, for example.

Also, in the clinical world one is not restricted to a single approach. Marjorie might have chosen to try working with the temporal arteries in first instance, and if that didn’t work, she might well have moved on to something else. The pantheon of biofeedback techniques that have been usefully applied to the subjugation of migraines is the usual complement of techniques: thermal training, EMG training, blood volume pulse, heart rate variability, GSR, and biofeedback-assisted relaxation training. No one technique is categorically superior for each individual, even if research were to indicate a statistical superiority for one of them. The target is self-regulation, any way you can get there. Each individual ultimately presents a unique challenge. Often stress-profiling is used to determine which of the standard biofeedback techniques is likely to be the most effective with a particular individual, and that one is tried first.

Siegfried Othmer speaks at AAPB
Left: EEG Info Booth at AAPB in Daytona Beach, FL
Siegfried Othmer spoke as part of a panel discussion on neurofeedback and migraine headaches.

Now in this situation Jeff Carmen found that the use of an infrared thermometer on the forehead was preferable to the use of a contact measurement with a thermistor. At a minimum, the response was more rapid, making for more engaging feedback, and one had the impression from infrared imagery that one could even discern the differential activity of the two cerebral hemispheres. He then found that reinforcement at the central placement of Fpz was the best tolerated. And migraines responded better than they had before when he was using conventional thermal training. The A/B comparison is quite sufficient to establish the claim of efficacy for this new kind of thermal training for migraine.

Now Marjorie Toomim apparently never published her approach to migraine suppression, most likely because she simply regarded it as an obvious variation on conventional thermal training. Similarly Jeff Carmen’s method could be considered a simple variant of thermal training not requiring independent proof. Jeff chose to publish because the results were manifestly superior to what he had gotten before. The results were so superior that an in-situ A/B comparison was not even necessary. Jeff never looked back to his years of doing hand-warming. It would be ridiculous to insist that proof requires going back to ground zero with a controlled design as if thermal training had not already been proved out.

The same case can be made for the EEG training protocol that we employ. To put this into play one simply needs to show that EEG reinforcement is another viable pathway to self-regulation, and should therefore be considered along with the peripheral biofeedback techniques. We are choosing to make our point by showing superiority in those very areas where peripheral biofeedback has not been strong to date: hormonally mediated migraines; migraines involving comorbidities; and chronic migraine. The pièce de résistance is that with EEG feedback (as with pIR) the ongoing migraine can frequently be aborted right within the session. This is not commonplace with thermal training, so this finding stands as prima facie evidence of efficacy, on the one hand, and superiority to prior methods on the other.

It turns out that hormonally mediated migraines are only marginally more troublesome with EEG feedback than others. And with EEG feedback, the same protocols often address the common comorbidities of migraine as well as the migraine susceptibility. As for the chronic migraine history, this is most likely tied up with a trauma history that likewise needs to be addressed. Again, we are fortunate in EEG feedback that the same protocol that is used for migraine will also place the person on the path of recovery with respect to trauma. This may be one of the significant advantages accruing to EEG feedback. It renormalizes the whole neuronal regulatory regime. The most difficult cases seem to respond to training at the lowest EEG frequencies, and these tie in efficiently to autonomic regulation as well as emotional stabilization.

When one goes top-down from the periphery as a pathway in to central regulation, there may be some particularity in the results because of selective engagement with one system (sympathetic arousal in the case of thermal training). When one goes bottom-up with EEG-based regulation, the regulatory regime is challenged more as an integrated whole.

As it happens, we have been working effectively with migraine for nearly twenty years now, over most of which time the Grand Poobah’s of migraine work could not be interested in EEG feedback for migraine because they were convinced it was a vascular phenomenon, and what does the EEG have to do with that? Now that this primitive view of migraine mechanisms has been finally demolished, one might have hoped for more humility and openness on their part. Instead, their irrational opposition has gotten even more strident, as has also been the case with Russell Barkley.

EEG Feedback versus Peripheral Biofeedback

The contention between the domains of EEG feedback and peripheral biofeedback continues as a live issue at the AAPB. A number of people came to our booth saying they knew nothing of EEG feedback. They were most likely either students or biofeedback techs somewhere. With information about neurofeedback now increasingly available “out there,” it appears that biofeedback people are almost uniquely sheltered from this information.

The topic also came up in a Symposium conducted by Judith Lubar, Carol Schneider, and Elizabeth Stroebel. Unsurprisingly, Judith saw EEG feedback mainly in connection with ADHD. The higher frequency training (SMR and low beta) addresses dysregulation of cognitive arousal and deficits in executive function, leaving the domains of autonomic regulation to the conventional biofeedback techniques. Typically the latter should come first in the hierarchy of needs, so one might well want to do peripheral feedback first.

This is indeed the approach that Elizabeth Stroebel takes with her children. She then sends them on for EEG feedback if necessary. I found this discussion illuminating. Even the ostensible advocate of EEG feedback, Judith Lubar, gave it a very restrictive role in the overall scheme of things. The compartmentalization of function that has plagued this field since forever was alive and well. The thought that EEG feedback is perfectly capable of addressing autonomic disregulation as well just cannot get purchase with this audience.

I often rail against such apparent obtuseness in these newsletters. When contradictory facts are so unavailing, one must no doubt look to the sociology of therapeutic communities for understanding. When the factual or theoretical basis of a field is in flux, sanctuary is sought in the community of belief. There is comfort in shared belief, even if everyone will turn out to have been wrong in the end. Given the uncertainties that prevail in empirical studies, a refuge is found in the provisional truth claims of a professional community. A lone therapist strays from that provisional consensus at his peril.

Inevitably, the community belief system will lag the clinical reality, and if the rate of change is great, the lag may even look like a complete disconnect. We find ourselves in one of those rare historical moments where the emerging clinical facts are outrunning our models. Many simply cannot make the leap. I am thankful for the many clinicians who have decided to cut their moorings to convention and come along for the journey of discovery.

Siegfried Othmer Ph.D.

Share your thoughts in the comments section below.

Leave a Reply