Sinha ClinicNeurofeedback Technician Course

Course created:Jennifer Rodgers-Skeens, MBAMarketing Director Sinha Clinic 2019

Module 2

Course Module Outline:Module 1: Welcome

● About the Sinha Clinic● Technician Role● Contact Information

Module 2: Neurofeedback basics ● Biofeedback● Neurofeedback● Fundamentals of Brainwaves● Measuring 10-20 Electrode Placements

Module 3: qEEG BrainMapping● Pre-qEEG● qEEG● Post-qEEG

Module 4: Baseline tests● Beck’s Depression and Anxiety Inventory

Module 5: Application & Amplifiers● Brainmaster 2.5● Brainmaster 3.7● Discovery Unit● BrainAvatar

Module 6: Protocols● Alpha Theta● SMR● ZScore● Single,dual 4 channel training

Module 7: Setting up a chart● Ipad● Brainmaster

Module 8: Running a session● Pre session● During session● Post Session

Module 9: Icanotes and supervision ● Inputting non-Rx notes● Supervision

Module 10: Admin & Troubleshooting● Administration● Troubleshooting

Module Test:

● Neurofeedback Test● Neurofeedback Answer Sheet

Module 2: Neurofeedback Basics❏ Review video❏ Biofeedback ❏ Neurofeedback ❏ The Difference of Biofeedback & Neurofeedback in Practice❏ Fundamentals of Brainwaves

❏ Frequency, Amplitude, Symmetry, Coherence❏ Measuring 10-20 Electrode Placements

❏ Measuring by tape and hands❏ Conversion chart❏ Headmap of Functions

What is Biofeedback?Biofeedback is a technique you can use to learn to control your body's functions, such as your heart rate. With biofeedback, you're

connected to electrical sensors that help you receive information (feedback) about your body (bio). This feedback helps you focus on

making subtle changes in your body, such as relaxing certain muscles, to achieve the results you want, such as reducing pain. In

essence, biofeedback gives you the power to use your thoughts to control your body, often to improve a health condition or physical

performance.

Types of Biofeedback● Brainwave. This type of method uses scalp sensors to monitor your brain waves using an electroencephalograph (EEG).

● Breathing. During respiratory biofeedback, bands are placed around your abdomen and chest to monitor your breathing

pattern and respiration rate.

● Heart rate. This type of biofeedback uses finger or earlobe sensors with a device called a photoplethysmograph or

sensors placed on your chest, lower torso or wrists using an electrocardiograph (ECG) to measure your heart rate and

heart rate variability.

● Muscle. This method of biofeedback involves placing sensors over your skeletal muscles with an electromyography

(EMG) to monitor the electrical activity that causes muscle contraction.

● Sweat glands. Sensors attached around your fingers or on your palm or wrist with an electrodermograph (EDG) measure

the activity of your sweat glands and the amount of perspiration on your skin, alerting you to anxiety.

● Temperature. Sensors attached to your fingers or feet measure your blood flow to your skin. Because your temperature

often drops when you're under stress, a low reading can prompt you to begin relaxation techniques.

Biofeedback Devices:You can receive biofeedback training in physical therapy clinics, medical centers and hospitals. A growing number of biofeedback

devices and programs are also being marketed for home use, including:

● Interactive computer or mobile device programs. Some types of biofeedback devices measure physiological changes

in your body, such as your heart rate activity and skin changes, by using one or more sensors attached to your fingers or

your ear. The sensors plug into your computer.

● Using computer graphics and prompts, the devices then help you master stress by pacing your breathing, relaxing your

muscles and thinking positive thoughts. Studies show that these types of devices might be effective in improving

responses during moments of stress, and inducing feelings of calm and well-being.

● Another type of biofeedback therapy involves wearing a headband that monitors your brain activity while you meditate. It

uses sounds to let you know when your mind is calm and when it's active to help you learn how to control your stress

response. The information from each session can then be stored to your computer or mobile device.

● Wearable devices. One type of wearable device involves wearing a sensor on your waist that monitors your breathing

and tracks your breathing patterns using a downloadable app. The app can alert you if you're experiencing prolonged

tension, and it offers guided breathing activities to help restore your calm.

Why it Biofeedback used?Biofeedback, sometimes called biofeedback training, is used to help manage many physical and mental health issues, including:

Anxiety or stress, Asthma, Attention deficit hyperactivity disorder (ADHD), Chemotherapy side effects, Chronic pain, Constipation,

Fecal incontinence, Fibromyalgia, Headache, High blood pressure, Irritable bowel syndrome, Motion sickness, Raynaud's disease,

Ringing in the ears (tinnitus), Stroke, Temporomandibular joint disorder (TMJ), Urinary incontinence,

What is Neurofeedback?● Neurofeedback retrains brain waves through auditory and/or visual stimulation in a video, ambient music, or video games.

During a session, three electrodes are placed on the head. One electrode is placed on the left earlobe, one on the right earlobe, and one on the scalp at a particular brain site. The electrodes measure the electrical patterns coming from the brain (much like a physician listens to your heart from the surface of your skin). No electrical current travels into your brain. Your brain wave patterns are relayed to the computer and recorded. Sessions should be completed 2 times per week but once a week is fine as long as the training is consistent. A session runs for 1 hour, but we work two different brain sites (protocols) for 30 minute each within the hour. Usually, one brain site (protocol) will be completed between 10-20 sessions. The average number of sessions per person is between 45 to 55 sessions, but it varies depending on the patient’s history and recommendations through a QEEG (aka, brainmap).

● Neurofeedback is completed through a process called operant conditioning, where the computer program reconditions and retrains the brain to retrain brainwaves to their most optimal level. Neurofeedback can be compared to strength training for the brain, enhancing cognitive flexibility and control. Neurofeedback is an alternative treatment to medication, it is long lasting, painless, non-invasive, and some patients are able to reduce their medication once their brainwaves are retrained and are now functioning more optimally. Neurofeedback can help patients with ADD/ADHD, a learning disability, a stroke, head injury, deficits following neurosurgery, uncontrolled epilepsy, cognitive dysfunction associated with aging, depression, anxiety, obsessive-compulsive disorder, autism symptoms, or other brain-related conditions.

The Difference between Biofeedback & Neurofeedback in Practice

● Excerpts are taken from James Thomas, Ph.D. within this manual, “Biofeedback is a type of training and treatment that uses monitoring instruments attached to the body to “feedback” biological information about body functioning. People are able to view information about their bodies normally outside of their awareness such as hand temperature, blood pressure, number and depth of breaths being taken, level of muscle tension in any target muscle, or the electrical activity of their brains. It has been discovered that once people have more detailed information as to what their bodies are doing, they are able to either consciously or subconsciously control those functions.

● The form of biofeedback that enables people to alter brain electrical activity is called “neurofeedback” (or EEG biofeedback). The reason that neurofeedback is of special concern to psychologists is that the brain is a central contributor to the emotions, physical symptoms, thoughts, and behaviors that define many problems for which people seek psychological consultation. The kinds of problems which have been addressed through neurofeedback include anxiety, depression, attention deficit/hyperactivity disorder, memory difficulties, general cognitive functioning, learning disabilities, head injury, obsessive compulsive disorder, chronic pain, epilepsy, immune system disturbances, panic attacks, sleep disturbances, and more. Scientists have identified specific patterns of brain waves that contribute to many of these disorders, and this is done by obtaining a QEEG evaluation (quantitative electroencephalogram) in order to determine the pattern of brain wave relationships” (Retrieved 2014).

Fundamentals of Brainwaves:“Quantitative analysis of brainwaves produces measurements of frequency, amplitude, symmetry, coherence, and others (these measures are described below). The report of the analysis provides a value for each of these variables for each of the 19 sites at which the brainwaves have been measured. Each value represents how much the activity at a given site differs from usual. Values that are positive (e.g.,+2.4) represent activity that is higher than usual, and values that are negative (e.g., –2.4) represent activity that is lower than usual. Because each value represents how different a site is from usual, the number “0” represents a close match with the brains to which an individual’s brain has been compared.

We will be discussing: ● Frequency● Amplitude● Symmetry● Coherence

FrequencyFrequency is one of the parameters of brain functioning that has to do with the speed of the brainwaves or how many times it repeats itself per second. All sites of the brain show all frequencies of activity. However, the amount of a particular frequency that is desirable depends on where it is located in the brain. In general, concentrations of alpha are found at the back of the head, and faster waves are more prominent at the front of the head. Thus, no brain wave is good or bad. It is simply more or less adaptive, depending upon where it is concentrated in the brain.

Frequency refers to the rate at which a brainwave repeats its cycle within one second. The number of cycles per second is called “hertz” (Hz). The more times a brainwave repeats its cycle per second, the FASTER it is said to be. The most common way practitioners divide the frequency of brainwaves into categories is:

• 1-3 Hz Delta• 4-7 Hz Theta• 8-12 Hz Alpha• 12-15 Hz Lo-Beta• 15-18 Hz Mid-Beta• 18-30 Hz High-Beta• 30-40 Hz Gamma

Brainwaves Explained:● Delta waves occur primarily during sleep; however, they are also present to various degrees throughout normal brains when

awake.● Theta waves are also slow waves, and are often associated with twilight states such as that between sleep and wakefulness.

Theta is much more complicated than this simple explanation, as it has also been shown to be important in memory consolidation. In many people with Attention Deficit Disorder, there is more Theta in various parts of the brain (particularly frontal areas) than in normal people.

● Alpha waves are thought of as an idling rhythm, sometimes associated with relaxation or meditation. Alpha is also associated with multi-tasking. For example, a person is multi-tasking when he is focused on many things at once such as ironing a shirt, listening to the weather report, and wondering what is for breakfast. Alpha is produced by large groups of neurons that are not engaged in any particular task, but rather, are standing ready to serve a function should they be called upon. Alpha may be likened to “the ready position” in volleyball, or a car sitting in neutral.

● Beta waves are the fastest and most active form of brainwaves, and are associated with focus and concentration. When excessively present, Beta waves can contribute to anxiety. Consider how much focus and concentration one may have while driving down a busy freeway in a snowstorm: This is focus that is heightened to the point of possible anxiety.

AmplitudeThe amplitude of the EEG is defined as the voltage in microvolts. Another way to think of amplitude is in terms of "power" or how much energy is being manifested in a particular brainwave. Put simply, the amplitude can be thought of as the “volume” of the brainwave. A high amplitude theta signal at a particular site means that there is a lot of energy or power of theta at that site.

SymmetrySymmetry is the degree to which the activity at a particular site on one side of the brain is similar to the corresponding site on the other side. In this way, a person can serve as his or her own reference. For the most part, the activity at one site should look similar to the activity at the corresponding site on the opposite side of the head. Recording data simultaneously from each of the 19 sites enables the symmetry between left and right to be calculated.

CoherenceCoherence is a measure of how closely each site communicates with each other site. There is an ideal amount of communication that should take place among sites. With too much communication, the brain is devoting too much energy to doing the same thing – and this is not a good use of resources. With too little communication between sites, the brain also is not using its resources most optimally. Communication in the brain may be thought of in the context of the crew on a sailing vessel. If the captain issues an order for some of the crew to solve a problem on one side of the ship, it would not be wise for the entire crew to rush over and leave the rest of the ship unattended. Similarly, if none of the crew communicated with each other, the running of the ship would quickly become disorganized. Recording data simultaneously from each of the 19 sites enables calculation of the coherence, or level of communication between each pair of sites” (Thomas, 2014).

Measuring 10-20 Electrode Placement:How to Measure 10-20 Placements:

● Measure Front to Back (Nasion to Inion) to obtain measurement. ● Measure Side to Side break in ear to opposite break in ear to obtain second measurement. ● This is how one will be able to find 10%, 20%, 50% placements on scalp.

Check out this Youtube Video: https://www.youtube.com/watch?v=IwGIF5aCnqg

Skull Landmarks

Skull Landmarks

1. Nasion – The bridge of the nose or lowest indentation point between nose and forehead

2. Inion – Bony ridge at the base of the back of the skull. Have patient tilt head up and down to feel it better.

3. Pre-auricular points – Indentations just above the cartilage that covers the external ear openings

4. Mastoid Process – bony area located just behind the ear. Where M1 and M2 reference electrodes are placed.

Measure if CentimetersMeasurements (always measured in centimeters) (1 inch = 2.5 cm)

Nasion – Inion: Measure from Nasion to Inion.Example 40 cm total. Follow the measurement chart using the correct percentages.Example:

Find the Nasion and go up 10% o(4 cm) to FZ.

If you are looking for Fp1 - count 4 cm to over the left eye right over the pupil for Fp1. If you are looking for Fp2, go back to FZ and go 4cm over right eye over the pupil.

To find the midline - Start at nasion, and go up 10% to FpZ. Go up toward the hairline, 20% or 8cm, from Fz and you have found Cz.-Go up another 20% (8 cm) from Cz and mark this point as Pz.-Go up another 20 % (8 cm) from Pz and mark this point as Oz.The measurement between Oz and the Inion mark should be 10% or 4 cm.

Where to Start?Front to Back Measurement - Measure from the break in the nose that meets forehead (naison) to the top of the bump (Inion) where the occipital lobe is located to obtain the front to back measurement. Write it down.

Side to Side Measurement – Measure from the break in the ear close to the start of the ear canal to opposite break to obtain the side to side measurement. Write it down.

While standing behind the patient -

Finding CZ - Take half (50%) of each measurement, write it down. Find CZ first by using the centimeter guidelines and locate the center most point by starting at the naison and use tape measure to find the 50% center, hold spot. Do the same for side to side measurement. The intersection of both 50% measurements is CZ.

When locating FZ, C3, C4, or PZ - use 20% using the front to back or side to side measurements.

● Find FZ - Find CZ, then move 20% using front to back measurement forward to FZ ● Find PZ - Find CZ, then move 20% using front to back measurement backward to PZ ● Find C3 - Find CZ, then move 20% using side to side measurement to left to C3 ● Find C4 - Find CZ, then move 20% using side to side measurement to right to C4

Where to Start?While standing behind the patient -

Finding CZ - Take half (50%) of each measurement, write it down. Find CZ first by using the centimeter guidelines and locate the center most point by starting at the naison and use tape measure to find the 50% center, hold spot. Do the same for side to side measurement. The intersection of both 50% measurements is CZ.

When locating FpZ, T3, T4, or OZ

● Find FpZ - Find CZ, then move 40%(or use 20% twice) using front to back measurement forward to FpZ ● Find OZ - Find CZ, then move 40% (or use 20% twice) using front to back measurement backward to OZ ● Find T3 - Find CZ, then move 40% using side to side measurement to left to T3 ● Find T4 - Find CZ, then move 40% using side to side measurement to right to T4

While standing behind the patient -

Finding CZ - Take half (50%) of each measurement, write it down. Find CZ first by using the centimeter guidelines and locate the center most point by starting at the naison and use tape measure to find the 50% center, hold spot. Do the same for side to side measurement. The intersection of both 50% measurements is CZ.

Two Options: Locate Fp1, Fp2, O1, or O2

● Find Fp1 - Find CZ, then move 40%(or use 20% twice) using front to back measurement forward to FpZ, then use side to side at 10% to left to Fp1.

○ Alternative option - Use F2B measurement from naison(nose break) 10% back to FZ, then 10% S2S to left to Fp1● Find Fp2 - Find CZ, then move 40%(or use 20% twice) using front to back measurement forward to FpZ, then use side to side

at 10% to right to Fp2. ○ Alternative option - Use F2B measurement from naison(nose break) 10% back to FZ, then 10% S2S to right to Fp2

● Find O1 - Find CZ, then move 40%(or use 20% twice) using front to back measurement forward to OZ, then use side to side at 10% to left to O1.

○ Alternative option - Use F2B measurement from inion (back of head bump) 10% up to OZ, then 10% S2S to left to O1● Find O2 - Find CZ, then move 40%(or use 20% twice) using front to back measurement forward to OZ, then use side to side at

10% to right to O2.○ Alternative option - Use F2B measurement from inion (back of head bump) 10% up to OZ, then 10% S2S to right to O2

While standing behind the patient -

Finding CZ - Take half (50%) of each measurement, write it down. Find CZ first by using the centimeter guidelines and locate the center most point by starting at the naison and use tape measure to find the 50% center, hold spot. Do the same for side to side measurement. The intersection of both 50% measurements is CZ.

Two Options: Locate F3, F4, P3, or P4 -

● Find F3 - Find CZ, then move 20% using front to back measurement forward to FZ, then use side to side at 20% to left to F3 ○ Alternative option - Use S2S measurement from left prearcurial point (A1) 10% to right to T3, then 20% S2S to right to

F3● Find F4 - Find CZ, then move 20% using front to back measurement forward to FZ, then use side to side at 20% to right to F4

○ Alternative option - Use S2S measurement from right prearcurial point (A1) 10% to left to T4, then 20% S2S to left to F4● Find P3- Find CZ, then move 20% using front to back measurement backward to PZ, then use side to side at 20% to left to P3

○ Alternative option - Use F2B measurement from inion (back of head bump) 10% up to OZ, then 10% S2S to left to P3● Find P4- Find CZ, then move 20% using front to back measurement backward to PZ, then use side to side at 20% to right to P4

○ Alternative option - Use F2B measurement from inion (back of head bump) 10% up to OZ, then 10% S2S to right to P4

While standing behind the patient -

Finding CZ - Take half (50%) of each measurement, write it down. Find CZ first by using the centimeter guidelines and locate the center most point by starting at the naison and use tape measure to find the 50% center, hold spot. Do the same for side to side measurement. The intersection of both 50% measurements is CZ.

Two Options: Locate F7, F8, T5, or T6

● Find F7 - Find CZ, then move 40%(or use 20% twice) using front to back measurement forward to FpZ, then use side to side at 30% to left to F7.

○ Alternative option - Use F2B measurement from naison(nose break) 10% back to FpZ, then 30% S2S to left to F7● Find F8 - Find CZ, then move 40%(or use 20% twice) using front to back measurement forward to FpZ, then use side to side at

30% to right to F8. ○ Alternative option - Use F2B measurement from naison(nose break) 10% back to FpZ, then 30% S2S to right to F8

● Find T5 - Find CZ, then move 20% using front to back measurement backward to PZ, then use side to side at 40% to left to T5. ○ Alternative option - Behind the patient, use S2S measurement from A1 (left ear) 10% up to T3, then 20% F2B back to T5.

● Find T6 - Find CZ, then move 20% using front to back measurement backward to PZ, then use side to side at 40% to right to T6. ○ Alternative option - Behind the patient, use S2S measurement from A2 (right ear) 10% up to T4, then 20% F2B back to T6.