Martina D. Liechti

First clinical trial of tomographic neurofeedback in attention-deficit/hyperactivity disorder : evaluation of voluntary cortical control

OBJECTIVE Tomographic neurofeedback (tNF) training was evaluated as a treatment for attention-deficit/hyperactivity disorder (ADHD). To investigate the specificity of the treatment, outcomes were related to learning during tNF. METHODS Thirteen children with ADHD trained over 36 lessons to regulate their brain activity in the anterior cingulate cortex (ACC) using both theta-beta frequency and slow cortical potential (SCP) protocols. Thirty-channel electroencephalogram (EEG) was used to calculate low-resolution electromagnetic tNF and to assess the course of the training. Pre- and post-assessments included questionnaires, tests of attention, EEG recordings, and cognitive event-related potentials. RESULTS Despite behavioural improvement and EEG artefact reduction, only partial learning was found for ACC parameters. Successful regulation was observed only for a simple feedback variant of SCP training, but with ACC-specific effects. Over training, resting EEG analysis indicated individual frequency normalisation rather than unidirectional changes across subjects. CONCLUSIONS These results indicate that clinical improvement after ACC-tNF training can parallel artefact reduction without substantial learning of improved cortical control. However, individual normalisation of resting EEG activity and partial SCP control proved possible in this specific brain region affected in ADHD using tNF. Further studies are needed to clarify which critical aspects mediate region-specific learning in neurofeedback. SIGNIFICANCE This study is the first to systematically investigate tNF in children suffering from a psychiatric disorder.

Comparing tomographic EEG neurofeedback and EMG biofeedback in children with attention-deficit/hyperactivity disorder

Two types of biofeedback (BF), tomographic electroencephalogram (EEG) neurofeedback (NF) and electromyographic biofeedback (EMG-BF), both with phasic and tonic protocols, were compared for treatment effects and specificity in attention-deficit/hyperactivity disorder (ADHD). Thirteen children with ADHD trained their brain activity in the anterior cingulate cortex (ACC), and twelve trained activity of arm muscles involved in fine motor skills. In each training session, resting state 24-channel EEG and training performances were recorded. Both groups showed similar behavioral improvements and artifact reduction in selected conditions, with no significant advantages despite medium effect sizes on primary outcomes for NF. Only the EMG-BF group, however, showed clear improvement in training regulation performance, and specific motor coordination effects. The NF group tended to present individual normalization of trained frequency bands in the ACC during rest across training. The results provide evidence for some specific effects in our small sample, albeit only to a small extent.

Vestibulospinal responses in motor incomplete spinal cord injury

OBJECTIVE Postural instability limits ambulatory capacity in patients with spinal cord injury (SCI). Galvanic vestibular stimulation (GVS) was used to investigate the integrity of vestibulospinal pathways and related changes in postural responses in SCI. METHODS Binaural bipolar galvanic stimuli of 400 ms duration and 3 mA intensity were applied in 8 motor incomplete SCI and 8 control subjects who stood facing towards the left. EMG responses were recorded from the right soleus muscle and the trajectory of the centre of pressure (CoP) was measured with a force plate. RESULTS There was no difference in excitability and amplitude of the responses between the groups. However, the latency and duration of the medium latency EMG response and all CoP responses were significantly longer in the SCI group. Additionally, postural stability was reduced in the SCI group, as shown by a greater tendency to fall due to GVS. CONCLUSIONS Despite early EMG responses proving the basic connectivity of the direct vestibulospinal pathways, the delayed GVS responses suggest a vestibulospinal deficit in the SCI subjects. SIGNIFICANCE GVS can be applied in incomplete SCI to supplement the neurological examination by revealing changes in vestibulospinal responses and impairment of postural stability.

Differential EMG Biofeedback for Children with ADHD: A Control Method for Neurofeedback Training with a Case Illustration

The objective of the present paper was to develop a differential electromyographic biofeedback (EMG-BF) training for children with attention-deficit/hyperactivity disorder (ADHD) matching multiple neurofeedback training protocols in order to serve as a valid control training. This differential EMG-BF training method feeds back activity from arm muscles involved in fine motor skills such as writing and grip force control. Tonic EMG-BF training (activation and deactivation blocks, involving bimanual motor tasks) matches the training of EEG frequency bands, while phasic EMG-BF training (short activation and deactivation trials) was developed as an equivalent to the training of slow cortical potentials. A case description of a child who learned to improve motor regulation in most task conditions and showed a clinically relevant reduction of behavioral ADHD symptoms illustrates the training course and outcome. Differential EMG-BF training is feasible and provides well-matched control conditions for neurofeedback training in ADHD research. Future studies should investigate its value as a specific intervention for children diagnosed with ADHD and comorbid sensorimotor problems.

Sensory evoked potentials of the bladder and urethra in middle-aged women: the effect of age.

To investigate feasibility, reproducibility and age dependency of sensory evoked cortical potentials (SEPs) after electrical stimulation of different locations in the lower urinary tract (LUT) in a cohort of middle‐aged healthy women.

Sensory function assessment of the human male lower urinary tract using current perception thresholds

To evaluate the feasibility and reliability of current perception threshold (CPT) measurement for sensory assessment of distinct locations in the male lower urinary tract (LUT).

A novel infusion-drainage device to assess lower urinary tract function in neuro-imaging.

To evaluate the applicability and precision of a novel infusion‐drainage device (IDD) for standardized filling paradigms in neuro‐urology and functional magnetic resonance imaging (fMRI) studies of lower urinary tract (LUT) function/dysfunction.

Identifying barriers to help-seeking for sexual dysfunction in multiple sclerosis

BackgroundSexual dysfunction (SD) is common in multiple sclerosis (MS), however, under-reported.ObjectiveThe aim of this study was to identify barriers faced by patients with MS and healthcare professionals (HCPs) in discussing SD.MethodsThis was a two-part prospective study carried out at a tertiary care centre. Patients with MS were surveyed using a 29-item questionnaire and SD was assessed using the MSISQ and ASEX questionnaires; depression screened with PHQ-2. HCPs were surveyed using a 23-item questionnaire.ResultsSeventy four patients (mean age 42.4 ± 10.7, 54 females) and 98 HCPs (mean age 45.8 ± 8.9, 90 females) participated. SD was significant, with primary (36.4%), secondary (27%) and tertiary (29.8%) contributory factors. Commonest barriers reported by patients were dominance of neurological symptoms (N = 30, 40.5%), presence of family or friends (N = 28, 37.8%), and not being asked (N = 25, 33.8%), while HCPs reported presence of family or friends (N = 34, 34.7%), lack of knowledge about SD (N = 30, 30.6%), and inadequate time during the consultation (N = 27, 27.6%).ConclusionsBarriers to discussing SD are similar between patients and HCPs. The most common barriers are addressable through modifications in the clinic environment, raising awareness and providing training opportunities.

PD06-11 REPRODUCIBILITY OF SUPRASPINAL RESPONSES TO AUTOMATED, REPETITIVE BLADDER FILLING - AN FMRI STUDY

INTRODUCTION AND OBJECTIVES: Recent functional magnetic resonance imaging (fMRI) studies revealed supraspinal networks in response to bladder filling involved in perception and processing of bladder distension. However, reproducibility of blood-oxygenation-level dependent (BOLD) signal changes during bladder filling has not been proven yet. Therefore, our aim was to investigate BOLD signal changes in response to bladder filling to provide evidence for repeatability using a standardized filling paradigm, i.e. a magnetic resonance (MR)compatible and MR-synchronized infusion-drainage system. METHODS: 20 right-handed healthy subjects, 10 women and 10 men, mean age 39 years (range 22-54) with no history of urinary urgency and/or urinary incontinence were included. Visit 1: After catheterization and bladder pre-filling with body warm saline until persistent desire to void, we performed in a 3T MR scanner automated, repetitive bladder filling of 100mL body warm saline over 15s, i.e. block design study. Visit 2: Within 8 weeks from visit 1, a second MR scan was performed in the same manner. Using SPM8, BOLD signal changes during bladder filling were compared to rest, i.e. pre-filled condition. For within-group whole-brain (WB) analysis, a voxel-threshold was set at p<0.001 using the false discovery rate (FDR) correction to adjust for multiple comparisons. Differences between both visits were investigated using a paired t test. In addition, regions of interest (ROI) were defined using the Wake Forrest University Pickatlas and included as a mask in order to restrict the voxel-by-voxel statistical analysis (familywise error (FWE)-correction) to pre-specified brain areas. RESULTS: Within-group WB analysis revealed activation in the following brain areas for visit 1: bilateral prefrontal gyrus (PFG); anterior cingulate cortex (ACC), mid and posterior cingulate cortex; left insula; hippocampus; temporal and parietal gyrus; and for visit 2: bilateral PFG; ACC; bilateral insula; bilateral basal ganglia. No statistical differences in BOLD signal changes were detected between both visits. ROI analyses, a more sensitive approach, detected reproducibility of BOLD signal changes in the following areas: PFG, ACC and insula. CONCLUSIONS: This study confirms that automated, repetitive bladder filling of body warm saline using a MR-compatible and MRsynchronized infusion-drainage system shows reproducible BOLD signal changes in specific areas, known from previous neuroimaging studies to be involved in supraspinal lower urinary tract control.

PD1-10 SUPRASPINAL CONTROL OF LOWER URINARY TRACT FUNCTION IN PATIENTS WITH SPINAL CORD INJURY: AN FMRI STUDY

INTRODUCTION AND OBJECTIVES: The control of the lower urinary tract (LUT) is a complex, multilevel process involving both the peripheral and central nervous system. Most patients with spinal cord injury (SCI) suffer from neurogenic LUT dysfunction and LUT symptoms severely impair the patients’ health-related quality of life. Although there are several concepts regarding neuronal control and perception in the normal and pathological LUT condition, the exact mechanisms involved remain to be elucidated. METHODS: In this functional magnetic resonance imaging (fMRI) study, we prospectively assessed 20 patients (mean age 43 years old, range 25e75) with cervical and thoracic SCI (12 with complete and 8 with incomplete lesion) suffering from neurogenic detrusor overactivity. All subjects underwent data acquisition in a 3 Tesla scanner. The scan paradigm (SP) comprised 3 different bladder stimulations: (1) repetitive bladder filling of 100mL body warm saline starting with an empty bladder, (2) repetitive infusion and withdrawal (100mL) of body warm saline starting with a pre-filled bladder and (3) repetitive bladder filling of 100mL cold saline. Date was analysed using SPM8. Second-level random effects group analysis (at a voxel-threshold of P<0.001 using false discovery rate correction at cluster level) was performed to account for between subject variability. Only subjects with significant activity (first-level analysis, P1⁄40.05 familywise error rate) were included. RESULTS: 6 subjects had to be excluded from certain analysis due to excessive head motions, autonomic dysreflexia or urinary incontinence during data acquisition. At first-level analysis, we found significant activation in 67% (12/17), 56% (9/15) and 66% (10/15) for SP (1), (2) and (3), respectively. At second-level analysis, significant activation was found in all 3 SP. (1): right inferior frontal gyrus (BA 45), left middle frontal gyrus (BA 10/46), left superior medial frontal gyrus, dorsal posterior cingulate area (BA 31) and bilateral middle temporal gyrus (BA21); (2): anterior left insula and inferior parietal lobe; (3): right precentral gyrus (BA 6) and left superior parietal lobe (BA 7). Activations were seen in both complete and incomplete SCI patients. CONCLUSIONS: In our patients with SCI, significant brain activation similar as reported for healthy subjects, non-neurological and other neurological patients with detrusor overactivity was detected. SP (1) showed activation in more brain areas than (2) and (3). Our findings suggest that extra-spinal sensory pathways might also be involved in LUT control.