“You are going to like it”, Stefanie’s Australian colleagues ensured her when they spoke about their project: “Once you come Down Under, you can try it yourself”. Some months later, when Stefanie arrived at her temporary Australian office, they showed her their project: playing Super Mario hands-free. On the computer screen the well-known Mario figure could be recognized and on the table there was a headband device with electrodes. Stefanie enthusiastically put the headband on and received the instructions: “If you want to jump, just blink; if you want to walk, you have to relax“. It was amazing to see how indeed Mario could be moved just with the mind, without pressing any buttons.
The Mind over Mario game is an example of a brain-computer-interface (BCI), programmed to pick up measured brain activity and translate specific signals into computer commands to control a device (here the movement of the Mario figure). Other types of BCIs convert measured brain activity into sensory representations as a form of real-time feedback, designed to inform the user about their current brain activity (Enriquez-Geppert et al., 2017). The movement of a curser ball towards a target on the computer screen for example could indicate changes of the current brain activity into an intended direction. Individuals can thus learn to self-regulate their brain activity, an approach known as neurofeedback. The backbone of neurofeedback is an empirically confirmed relation between certain features of brain activity and specific cognitive functions (Herrmann & Knight, 2001). Currently, neurofeedback attracts growing interest in scientific and health care communities, for instance as potential non-invasive therapeutic tool for patients (Enriquez-Geppert et al., in press).
“One such patient who could benefit from neurofeedback is Patient K.”
Diede met K during her practical work at a center for patients with cognitive impairments. One morning, while in the crafts room, K suddenly realized that he lost his lower dentures. Being absolutely sure he had his dentures in his mouth just a moment before, he alarmed a staff member. Within minutes, a group of patients and staff started a thorough search. Even the toilet drain was searched in case the patient accidentally flushed his teeth – to no avail. Upon returning to his room to take a nap, however, K suddenly felt something underneath his pillow: his lower dentures! It turned out he had put them there the night before when reading a new book. K put the dentures where he would have normally put the book, and the book where he would have put the dentures. Thus, instead of the dentures being in the bathroom, the book was there, right above the sink on a tray. While such incidents can occasionally happen to any of us, for example when we are tired or distracted, K suffers from them on a daily basis because of his cognitive impairments.
Part of the cognitive impairments of K can be described as impairments of so-called executive functions. Executive functions are separable but inter-related higher cognitive functions, which control primary processes – such as memory and attention – and enable flexible and successful goal-oriented behavior and thoughts (Snyder et al., 2015). Executive functions allow us to react controlled when automatic and habitual reactions are inappropriate, make decisions, evaluate risks, prioritize and sequence our actions, and cope with novel situations. Patients with executive dysfunctions can experience severe daily problems with planning, time management, evaluating ideas, and keeping track of multiple tasks at the same time.
“Currently, available treatments for executive dysfunctions have only small to moderate effect sizes (Stamenova & Levine, 2018; Webb et al., 2018) and are therefore insufficient to clinically improve cognitive abilities, daily functioning, and well-being of patients. One option to increase the clinical armamentarium is by enhancing executive functions through modulation of their neural underpinnings, e.g., via neurofeedback.”
Research has shown a relationship between executive functioning and theta oscillations measured at the frontal-midline (fm) scalp regions. Fm theta oscillations are even considered as the neural working language of executive functions (Cavanagh & Frank, 2014). Oscillations reflect the rhythmic activity of neurons that can be picked up with electroencephalography (EEG). Deviating theta oscillations have been associated with age-related performance declines (Enriquez-Geppert & Barceló, 2018) and abnormal theta activity as well as impairments of executive functions are found in various psychiatric and psychological disorders (Basar et al, 2016; Koerts et al., 2011, Huepen et al., 2016). Scientific findings show the feasibility of self-regulation of fm-theta by neurofeedback and as a result of improving executive functioning in healthy participants (Enriquez-Geppert et al., 2014). Fm-theta neurofeedback thus is a potentially viable treatment option for patients like K.
Although games like Mind over Mario might not yet be suitable for patients, Diede, Stefanie and colleagues currently develop the newest state-of-the art neurofeedback trainings as clinical interventions for patients with executive problems.
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NOTE: Image by Dave Hunt, licenced under CC BY 2.0.