1. The Efficacy of HRV Biofeedback and Neurofeedback for Chemotherapy Induced Peripheral Neuropathy (CIPN). Dr. Morayo Jimoh CPsychol 17 th Meeting and Scientific Sessions of the Biofeedback Federation of Europe, Venice, Italy

2. Introduction  Peripheral neuropathy occurs when the peripheral nerves which are located a distance away from the brain and spinal cord are damaged.  It could arise as a result of immune system disease, diabetes, fatal injury, excessive alcohol consumption use of medication such as the use of chemotherapy drugs to treat cancer patients (Hughes, 2002).

3. Introduction contd. Chemotherapy-Induced Peripheral Neuropathy (CIPN) is a common and potential side effect of many chemotherapy drugs. CIPN affects not only sensory functions but also motor and autonomic functions of an individual giving rise to a number of symptoms such as: pain; numb, burning and tingling sensation; loss of balance; shrinking and weak muscles; bowel and bladder difficulties; blood pressure changes and temperature sensitivity (Biedrzycki,2010)

4. Is HRV Biofeedback effective? Is Neurofeedback effective?

5. Objective The main objective of this study is to ascertain the suitability of HRV Biofeedback and Neurofeedback treatment as alternative therapies for CIPN

6. Method  Study Design: Case study  Client description: A 51 year old male diagnosed with cancer. He developed peripheral neuropathy which affected his feet and resulted in excruciating pain.  Symptoms: Insomnia, Anxiety, Chronic Pain (70 on McGill’s Pain Questionnaire), numbness and tingling sensation on his feet which restricted movement.  Previous diagnosis: Hypertension and Diabetes ( At the time of therapy, his blood pressure and blood sugar were under control).

7. Method Contd.  Other therapy: Anodyne therapy  Medications: Vitamin B based supplements, Neurotonin, Iboprufen and Norvasc.  Instruments:  McGill’s Pain questionnaire was used to assess level of pain at onset, during and after therapy  Equipment:  Wild Divine and Hearthmath for Heart Rate Variability (HRV) Biofeedback training  Biograph Infiniti EEG System was used for Neurofeedback assessment and training

8. Method Contd.  High Beta (rumination beta) was high in most of the points measured as the diagonal line swerves upwards at the end. This may have indicated high stress levels resulting from his cancer diagnosis.  Asymmetry was noted at Fp1 and F3 as beta readings was higher on the left aspect of the hemisphere than the right apart from the higher Beta 3 recording at Fp2.  His recording also showed higher Theta and SMR at FP1 and higher SMR was also recorded at F3. This may have indicated anxiety and/or depression.  An over active cingulate was recorded at Fz which could be indicative of emotional instability.  At the occipital region of the brain, his readings showed Beta to be high may have indicated of high stress levels. Quantitative Electroencephalogram (QEEG) Assessment

9. QEEG Trend Report

10. Neurofeedback Training Sessions  Client underwent a total of 42 sessions (3 times a week).  Neurofeedback training was aimed at enhancing SMR ( 12– 15 Hz) at the sensorimotor cortex which corresponds with the legs using the Penfield’s homunculus (Figure 2) (Penfield & Jasper., 1954).  Based on the somatotopic representation of the different body parts in the primary motor cortex, the leg area is located close to the midline Cz and corresponds with C1 and C2.  Training started with SMR training at C3 and C4 for 25 minutes to increase sleep spindles while high beta and theta was inhibited.  This protocol was varied with SMR training on C1 and C2 to target his legs.

11. Fig 2: Penfield’s Homunculus

12. HRV Biofeedback Training Sessions  The client underwent a total of 30 sessions of HRV Biofeedback (5 sessions using Wild Divine and 25 sessions using Heartmath).  After a few sessions of Neurofeedback, HRV biofeedback was introduced using Wild Divine while he learnt progressive relaxation to enable him distinguish between tense and relaxed muscles. He was also encouraged to practice diaphragmatic breathing three times a day for at least 10mins.

13. Results Following treatment, client reported:  Reduced Pain relative to pre-treatment on pain qualities (Figure 3)  Better Sleep  Reduced anxiety as indicated by the Heart Rate Coherence (Figure 4 )  Additional improvement was seen in his ability to partake in simple exercises and his walking pace, although this was not measured by any standard means, the client reported a reduction in the frequency of falls.

14. Results

16. Discussion  Penfield’s Homunculus proves useful in providing treatment protocols to alleviate CIPN symptoms. By locating the aspect of the sensorimotor cortex that corresponds with the affected body part, effective neurofeedback protocols can be developed (Tolle et al., 1999).  This is in consonance with Ibric (1996) who treated a client with reflex sympathetic dystrophy exhibiting right eyelid spastic ptosis. After Neurofeedback Training, the client was able to open her right eye while she also experienced reduced pain in her arms and shoulder.

17. Conclusion  The client’s pain level substantially reduced after complementing sessions of EEG Biofeedback with HRV Biofeedback.  Client also recorded greater degree of high coherence than when therapy commenced.  In addition, motor ability slightly improved. Thus, evidence from this study suggests that HRV Biofeedback and Neurofeedback are effective alternative therapies to managing CIPN

18. Recommendations  Further research is needed to determine the relative contribution of Neurofeedback and HRV Biofeedback training to Chemotherapy Induced Peripheral Neuropathy  Larger sample size in further studies.  Longitudinal studies with longer number of sessions may provide more significant results in using this treatment modality for CIPN.

19. References Biedrzycki, B. A. (2010). Peripheral neuropathy. In Brown CG, ed. A Guide to Oncology Symptom Management. Pittsburgh, PA: Oncology Nursing Society:405-421. Hughes, R. A. C. (2002). "Clinical review: Peripheral neuropathy". British Medical Journal, 324(7335): 466–469. Ibric, V. L. (1996). Components in Long Term, Comprehensive Care of patients with Myofascial Pain Syndrome: Part II – The Usefulness of Biofeedback. In Contemporary Management of Myofascial Pain Syndrome Symposium, sponsored by the Division of Continuing Medical Education, Discovery International, IL Beverly Hills, CA, pp. 29 – 39. Penfield, W. G. and Jasper, H. H. ( 1954 ). Epilepsy and the functional anatomy of the human brain. Boston: Little Brown. Tolle, T. R., Kaufmann, T., Siessmeier, T., Lau tenbacher, S., Berthele, A., Munz, F., Zieggansberger, W., Willoch, F., Schwaiger, M., Conrad, B. and Bartenstein, P. ( 1999 ). Region-specific encoding of sensory and affective components of pain in the human brain: a positron emission tomography correlation analysis. Annals of Neurology,45 ( 1 ), 40 – 47.

21. Questions

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