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Back to Healthy News Comentary by Kevin Lamb Medical scientists are turning out to be wrong about a lot of things they used to know absolutely for sure. What's a person to do? Easy as it is to blame an excess of studies, the bigger problem is a lack of good research. The last two weeks, for example, have brought bad news about the value of hormone-replacement drugs for cardiovascular health, low-fat diets for weight loss and knee surgery for arthritis. None of those presumed benefits had convincing evidence behind them. They had been taken largely on intuitive faith and buttressed by growing industries. What we can do is apply more caution to research reports and health claims. Besides looking for the basics of large study populations and randomly assigned placebo-control groups, we can remember: * Just because the prototypical surfer is blond doesn't mean they all are. And just because people on hormone drugs have more heart problems than people who aren't, that doesn't mean everyone on hormones will have heart problems. Nor did news this spring that the three most popular antidepressants are equally effective mean HMOs can save money by covering only one of them. They're equally effective for a large group, but individual members of that group will have different results. * There are two ways to express increased risk. Suppose that 10,000 people took Medication X for a year and had eight more heart attacks than 10,000 similar people who didn't take the medicine. That's an increase in absolute risk of eight-100ths of a percent, low enough that most people wouldn't worry about it. But if the raw numbers are 16 heart attacks for the first group and eight for the second, that's an increased relative risk of 100 percent, enough to scare everyone off of Medication X. One reason it's hard to draw firm conclusions from the hormone-drug data is it showed low absolute risk and high relative risk. We need to consider both. Relative risk is significant because no research can prove X causes anything. It can only prove X and something else are associated. Smoking is associated with a 3,000 percent increased relative risk in lung cancer, so we're fairly certain it's a cause. If the relative risk grows by less than 50 percent, it's very possibly a coincidence. * New information doesn't overturn the old. It was big news a few years ago that bacteria caused most peptic ulcers, but the mistaken conclusion of many was that stress had nothing to do with them. Stress weakens the immune system that neutralizes bacteria. Both could play a role. Science is rarely either-or. * Studies almost never yield sweeping conclusions. The arthritis news didn't say arthroscopic knee surgery doesn't work. It said scoping the knee isn't any more effective for osteoarthritis than pretending to operate. Again, that was true for the group and not every individual. Orthopods say the surgery can repair some specific arthritic conditions. It's just used too often for things it's not likely to help. * Researchers have biases. `The moment a person forms a theory,' Thomas Jefferson said, `his imagination sees, in every object, only the traits which favor that theory.' And Jefferson wasn't even doing research funded by drug companies. Preliminary research indicates heart disease might have more to do with high homocysteine levels than high cholesterol. It's been preliminary for years, though, because homocysteine responds to B vitamins and cholesterol responds to $15-billion-a-year drugs. * Accept uncertainty. One reason studies frustrate us is we want answers, and we want them now. Life doesn't work that way. * Question the premise. Another reason studies frustrate us is we want convenient solutions. Pills. Cures. Medical research still tends to start with the prevailing premise that solving problems requires the intervention of drugs or surgery, if only because drugs and surgery (and fat-free cookies) are where the money is. That's a defeatist premise. It says we're passive receptacles, powerless to change our health. Another premise is that we can intervene in some ways to strengthen our bodies. It's harder that way, but all these false facts making news came from the prevailing premise.   FDA Takes Close Look at Bioengineered Food Healthy News WASHINGTON, Aug 12, 2002 (United Press International via COMTEX) -- Concerns about the potential for future genetically engineered foods to cause allergic reactions has spurred the Food and Drug Administration to hold a meeting to look into the best methods for determining whether these foods pose an allergic risk. The meeting, to be held Tuesday and Wednesday, is the first of the newly developed food biotechnology subcommittee, an FDA spokeswoman who requested anonymity told United Press International. The subcommittee, which includes representatives from industry and a consumer interest group, will "discuss different approaches to assess whether proteins in bioengineered foods would be likely to cause allergic reactions or not," the spokeswoman said. The meeting will be used to develop guidance for the tests industry should conduct on the products they are developing to "ensure the safety of new bioengineered foods for consumers," she said. Asked whether the agency was concerned about the allergic potential of these foods, she said, "We're looking into it." Gregory Jaffe, director of Center for Science in the Public Interest's biotechnology project, said the potential for bioengineered foods to cause allergic reactions "is definitely of concern." So far none of the bioengineered foods currently on the market appear to be causing allergies or other adverse reactions in people, Jaffe said. However, there are concerns about future generations of bioengineered crops because they are likely to contain more complicated genetic modifications, he said. "The next generation will be more complex and may raise additional safety concerns," he said. "Toxicities and unintended effects are of concern too." Mike Rodemyer, executive director of the Pew Initiative on Food and Biotechnology, which does not take a position on genetically modified foods but seeks to stimulate dialogue and debate about the issues pertinent to this new field, concurred with Jaffe. "The issue really is trying to look ahead at next generation of products where we really haven't had experience before," Rodemyer told UPI. The next generation may have proteins that have not been in the food supply before, so "it's really an unknown and the question is how do you screen for that ahead of time," he said. Jaffe said the FDA should have been advising companies on the appropriate tests to rule out allergenicity "a lot earlier." This is because several bioengineered foods are already on the market and in the food supply, including Monsanto's Roundup Ready corn and soybeans, which have a gene that makes them resistant to herbicides. Rodemyer said the real concerns regarding bioengineered foods are about allergenicity rather than toxicity. There "isn't really a good scientific test to predict ahead of time whether a protein causes allergies," he said, but "we know how to screen for the kind of obvious changes in toxicity." Allergen screening involves comparing proteins from genetically modified food plants to known allergens and testing for digestibility -- a characteristic of allergens is that they do not readily break down in the digestive tract. But these tests may not always reliably indicate whether a bioengineered food will cause allergies. Rodemyer said some companies have bioengineered products they believe are safe but because the tests are so crude they cannot prove they are safe. Thus they are prohibited from bringing them to market. A lack of good allergen tests is one factor that kept the genetically modified corn StarLink from being approved for use in humans, Rodemyer noted. There was no indication that it caused allergies, but it had flunked some of the crude tests so authorities had to reject it, he said. StarLink was approved for use in animal feed and in 2000 it accidentally got into the human food supply and untold number of people consumed the bioengineered corn. Although numerous people claimed to have developed reactions as a result of eating products containing the StarLink corn, there is no credible evidence that it caused any allergic reactions in people, Rodemyer said. Jaffe criticized the current approval system for bioengineered foods because it is voluntary and does not require companies to submit safety data to the FDA. "I don't think that instills a lot of consumer confidence nor does it give us a chance to check what industry is doing to make sure what they are doing really safeguards the consumer." The General Accounting Office issued a report in May that "found that FDA's evaluation process (of bioengineered foods) could be enhanced." The GAO recommended that FDA randomly verify test data provided by the companies and clarify its evaluation process of these products. In 2001, the FDA proposed making the approval process mandatory but so far it has not made a final decision on that proposal. Although the current system is voluntary, companies have largely complied with it and every company that has brought bioengineered foods to the market has submitted safety data to the FDA. Bryan Hurley, spokesman for Monsanto, said the company already focuses a lot of attention on ensuring their bioengineered foods do not cause allergic reactions. But he added that there have been improvements in tests in recent years and Monsanto would "certainly" want to improve their allergen testing by incorporating the latest technology. Hurley said Monsanto has not received any reports of allergic reactions to their bioengineered corn or soy. The company has a number of bioengineered crops in development. The furthest along is a new insect-resistant corn, which goes before an advisory panel to the Environmental Protection Agency this month. It already has FDA approval and the U.S. Department of Agriculture is in its final stages of reviewing the product, Hurley said. The Effect of EEG Neurofeedback Training in a Clinical Sample of Patients with Fibromyalgia Earl Franklin Winter, PhD. Scope of Study: This study evaluated EEG neurofeedback training (neurotherapy) as a possible treatment option for patients with fibromyalgia. The neurotherapy treatment protocol consisted of a sensing electrode placed on the midline of the head of the patient, directly over the sensory motor cortex. The training protocol required the patient to inhibit theta waves, augment SMR waves, and inhibit high beta waves in order for the patient to be rewarded. In addition, TOVAâ tests of variables of attention were administered to the patients after completion of every 10 sessions of neurotherapy. Purpose of these tests was to determine if they could be used to track treatment progress. Data was obtained from 15 fibromyalgia patients who received a minimum of 40 sessions of neurotherapy. The average number of sessions for the group was 58, with a range of 40-98 sessions. This treatment protocol was attempted only after other medical treatment protocols had failed to relieve patient symptoms. Data from these 15 patients was compared to another group of 63 fibromyalgia patients who had not received EEG neurofeedback training. For that comparison group, symptoms changed very little: global pain decreased 6%, fatigue decreased 5%, anxiety increased 4%, and depression increased 3%. Findings and Conclusions: This neurotherapy protocol appears to offer a significant improvement for patients with fibromyalgia: 93% felt improved, there was a 74% average reduction in tender point pain, a 39% average reduction in global pain, and a 40% average reduction in fatigue in amounts that were statistically significant. Also, there was a reduction in stiffness and mood/depression scores, but the amount was not statistically significant. In addition, the TOVAâ tests did not give results that were reliable as monitors of neurotherapy treatment progress. Delayed Cognitive Deficits May Develop After Coronary Artery Bypass Graft By Pam Harrison STOCKHOLM (Reuters Health) Jul 23 - Patients undergoing coronary artery bypass graft (CABG) surgery for severe coronary heart disease are at risk for both acute deficits in memory and attention, as well as delayed cognitive decline starting about 1 year after surgery. Dr. Guy M. McKhann, of Johns Hopkins University School of Medicine in Baltimore, and colleagues collected data on 3300 patients who underwent CABG between 1997 and 2001. Following the procedure, the Baltimore group observed a 2.6% risk of stroke and a 6.8% risk of encephalopathy, the main symptoms of which were acute confusion and short-term memory deficits. After developing predictive models for stroke, encephalopathy and the combination of the two outcomes, Dr. McKhann and colleagues identified hypertension, diabetes, carotid bruit, prior stroke and age as the predominant risk factors predisposing CABG patients to adverse outcomes. For every hour patients spent on the bypass pump, "there was a 50% increase in the probability [of patients developing] encephalopathy," they report. The researchers also evaluated changes in cognition 1 month, 1 year and 5 years after surgery. In general, short-term deficits in memory and attention usually improve within a year, Dr. McKhann explained in an interview with Reuters Health. However, 1 year after the procedure, executive function and the domain of visuo-construction in particular often decline, especially among patients with more severe cerebrovascular disease at baseline, he said. This decline appears to persist up to 5 years. "After CABG, it is very important for patients to pay more attention than they normally do to control risk factors," Dr. McKhann said. "There is a great tendency for patients to say, 'I've had my surgery, I'll go back to what I was doing before'." "But there are studies which suggest that if you really go after these [risk factors], patients do much better. And [for high-risk patients], it may be beneficial to consider alternative cardiac interventional techniques in addition to carefully managing diabetes, hypertension and other related risk factors." Reuters Health Information 2002. © 2002 Reuters Ltd.

Moody Brains By Melissa Lee Phillips A group of scientists has identified an area of the brain that seems to be associated with negative moods. The researchers, led by David H. Zald, Ph.D. of Vanderbilt University, found that people who tend to experience high levels of anxiety, irritability, anger and other unpleasant moods are more likely to have a high level of activity in the ventromedial prefrontal cortex (VMPFC). Individuals differ in the range of negative moods and emotions that they experience. Over time, some people experience negative mood states more consistently and more severely than others. The purpose of Zald's study was to identify a relationship between negative moods and activity in a specific area of the brain. Study participants were given a questionnaire that asked them to rate their negative emotions during the previous month. Researchers then measured the resting blood flow in each person's brain using the brain imaging technique called positron emission tomography (PET). When the scores from the questionnaire were compared with the PET scan images, the researchers found that people who reported experiencing frequent negative emotions over the past month usually had higher levels of activity in the VMPFC. The scientists also looked for a correlation between activity in the VMPFC and positive emotional states, but they found none. Activity in this brain area seems to be linked only to the negative aspects of mood. These results agree with data from other studies that have implicated the VMPFC in emotional processing. For example, patients with damage to the VMPFC lack emotional responses to various situations. Also, the VMPFC has been linked with emotional disturbances in people with certain psychiatric conditions. Zald and his colleagues emphasize that although the study suggests a correlation between chronic negative moods and activity in the VMPFC, it is not known what causes the changes. It may be that people experience negative mood states because they have high activity in the VMPFC, or it could be possible that negative moods cause increased activity in the VMPFC. Other factors not measured in the study may also be the actual cause of the observed results. A correlation means that two variables are related, but it does not provide any information about what causes the relationship. Reference: 1. Zald, D.H., Mattson, D.L., and Pardo, J.V., "Brain activity in ventromedial prefrontal cortex correlates with individual differences in negative affect," Proc. Natl. Acad. Sci. USA, Vol. 99, Issue 4, February 19, 2002, pp. 2450-2454. Are Brain Waves the Key to Treating Fibromyalgia? By Dr. Horst H. Mueller, CPsych, CRHSPP, BCIAC Fibromyalgia Syndrome (FMS) is a common chronic pain disorder that effects approximately one million Canadians — mostly women. Common symptoms of FMS are: chronic wide-spread or all-over-body pain with numerous painful tender points in specific locations on the body, disturbed and nonrestorative sleep, morning stiffness, persistent fatigue and exercise intolerance, and reduced ability to think clearly (mental clouding or "fibro-fog"). Other health problems frequently associated with FMS include: depressed and irritable mood, irritable bowel and bladder, headaches, premenstrual syndrome, multiple allergies and chemical sensitivities, and cold hands and feet. Fibromyalgia is especially confusing and often misunderstood because almost all its symptoms are also common to other conditions. There is no single test or laboratory finding that is uniquely diagnostic for FMS. In addition, FMS probably has more than one cause. It can develop over a few months as a result of a traumatic muscle injury from a fall or minor motor vehicle accident, or it can start with a viral illness like the flu or mononucleosis. In some women it appears to develop after sudden hormonal change such as occurs after a hysterectomy, child birth or menopause. While FMS can be associated with irritable and depressed mood and is frequently made worse by psychological stress, most research does not support the notion that FMS is psychologically caused. Moreover, FMS and chronic fatigue immune deficiency syndrome (CFIDS) are closely related conditions confused in diagnosis. It has been estimated that approximately 65% of persons with FMS also meet all diagnostic criteria for CFIDS and, similarly, nearly 85% of those with CFIDS also have FMS. Common medical and physical therapy treatments for chronic body pain have not proven very successful in alleviating FMS. Commonly prescribed low dose antidepressant drugs, painkillers, and aerobic exercise generally help only a minority of FMS sufferers to obtain minimal to moderate remission. "What we believe happens in FMS is that the continued bombardment of the brain by the pain stimulus in the periphery causes the brain to shift patterns." (Dr. Stuart Donaldson, Director of Myosymmetries in Calgary, 1997) Recent research increasingly points to the brain as key to understanding FMS and CFIDS. Physiological arousal is under the management of the brain, which also regulates the sleep-wake cycle and modulates the pain response. When the brain and central nervous system are presented with a constant barrage of pain signals, over the course of time a number of physical and chemical changes occur within the brain centres that process bodily sensations to increase their sensitivity to stimulation and decrease their sensitivity to location. More and more, the brain interprets previously nonpainful stimulation as painful and loses its ability to pinpoint exactly where stimulation is coming from. There is growing consensus among neurological researchers that FMS and CFIDS patients show abnormalities in brain blood flow and electrical activity (EEG) that appear to be associated with a number of core symptoms. These changes include evidence of reduced blood circulation (hypoperfusion) in various areas of the brain and excessive amounts of low frequency electrical activity from primarily central and frontal areas of the cortex. A promising new therapy for FMS and CFIDS uses EEG neurotherapy to train the brain to reduce low frequency EEG activity and increase the amount of higher frequency activity. This training appears to normalize the brain's functioning and results in increased mental clarity and energy, improved mood, deeper and more restful sleep, decreased physical fatigue, and a reduction in "all-over-body" pain. Once these changes begin, FMS patients are able to benefit from specific physical therapy treatments that focus on decreasing activity of painful myofascial trigger points and obtaining myofascial release, reinstating muscle balance, gentle muscle stretching, correcting poor posture and movement patterns, and increasing physical stamina. Only a small number of pioneering clinicians in the United States and Canada are currently using EEG neurotherapy with Fibromyalgia and Chronic Fatigue patients. However, as their positive clinical outcomes become more broadly reported and research on the connection between brain wave patterns and various physical disorders continues, EEG neurotherapy will become a relatively common treatment. Myosymmetries clinics in Calgary and Edmonton, Alberta are the Canadian pioneers in the use of combined EEG Neurotherapy and sEMG Neuromuscular Retraining and specialized myofascial physical therapies to treat persons with Fibromyalgia and Chronic Fatigue Syndrome, and other forms of generalized chronic pain. New Discoveries May Help Doctors Defeat Depression Judy Foreman At McLean Hospital in Belmont, brain researchers have hit upon what could become a totally new way to treat depression: blocking a brain chemical called dynorphin, the "evil cousin" of endorphin (the chemical that triggers a "runner's high"). At the University of California, Los Angeles, psychiatrists have modified the standard EEG (or electroencephalogram) to predict which depressed patients will get better with drugs and which won't--weeks before the patients can detect any changes in mood. If one key region in the "emotional brain" is overactive, depressed people improve with drug therapy. If it's not, they don't. At the University of Toronto, scientists are mapping "depression circuits" in the brain and have found that one key region in the "emotional brain" is crucial. If that's overactive, depressed people improve with drug therapy. If it's not, they don't. At the Beth Israel Deaconess Medical Center in Boston, researchers are trying yet another approach--transcranial magnetic stimulation (TMS), which uses magnets placed on the scalp to stimulate the prefrontal lobes of the brain, which are often sluggish in depression. Depression, in other words, is no longer believed to be a mere deficiency of key brain chemicals--norepinephrine, dopamine, and perhaps most important, serotonin. Balance the Brain The hallmark of depression is now believed to be too little activity in the right and left prefrontal lobes (behind the eyes) and the right and left parietal lobes (on the side of the brain, toward the top), and too much activity in the limbic system. But the limbic system and prefrontal lobes, which govern thinking, are wired together, notes Dr. Helen Mayberg, a professor of neurology and psychiatry at the University of Toronto who uses PET (positron emission tomography) scans to map depression in the brain. In healthy people with sad feelings, the brain can quickly shift back to equilibrium. "The phone rings, the baby cries, the boss calls, and you immediately disengage from the sadness and the thinking part of the brain turns back on," Mayberg says. With depressed people, this ability to shift back to equilibrium is altered. In some people, that may be because area 24a, a monitoring center for emotions, is stuck in the "on" position, Mayberg says. Curiously, however, depressed people with high activity in area 24a often get better with drug treatment, while those with low activity in 24a don't. Dr. Andrew Leuchter of UCLA can predict which patients will respond to drugs with a simpler tool. Using a system called QEEG (for quantitative EEG), Leuchter studies depressed people with low activity in their prefrontal lobes. Then he looks at what happens when they start taking Prozac, which typically takes 6 weeks to improve mood. (Crossroads Institute uses the same objective measues but instead of medications strengthens the effected areas through neurotherapy, neurodevelopment exercises and Chinese Medicine.) In the first few days, some people show a further decrease in prefrontal lobe activity followed by an increase about 1 week later. When Leuchter follows the patients over time, those who respond best to drugs are those who show the initial decline, a clue that may help doctors predict for whom the drugs will work. Today, brain researchers view depression, which strikes about 19 million Americans, as a malfunction of circuits that connect the limbic system ("emotional brain") to the prefrontal cortex ("thinking brain") and the brain stem and hypothalamus, which control basic functions such as sleep, appetite, and libido. In truth, there never was much proof that depression was merely a serotonin deficiency. That was an inference from data showing that people who are aggressive or suicidal often have low serotonin. But now, despite the obvious efficacy of serotonin-boosting drugs like Prozac (fluoxetine), it's clear that when a person is depressed, there's a lot more going wrong in specific areas of the brain than just low levels of serotonin. Depression can be treated by getting the electrical circuits back to normal. The brain works by chemical and electrical signals. When an electric current passes through one cell, the cell releases a neurotransmitter, which floats to the next cell, causing it to "fire up electrically," notes Dr. Alvaro Pascual-Leone, director of the transcranial magnetic stimulation lab at Beth Israel Deaconess.

The role of complementary and alternative medicine in attention-deficit hyperactivity disorder. Journal of Developmental & Behavioral Pediatrics Author/s: Eugenia Chan Issue: Feb, 2002 ABSTRACT. The use of complementary and alternative medicine (CAM) in pediatrics has become widespread. Parents of young children with developmental and behavioral problems such as attention-deficit hyperactivity disorder (ADHD) are particularly drawn to CAM interventions to avoid or decrease use of psychotropic medications. This paper reviews the epidemiology of CAM use for ADHD, describes a conceptual model of CAM, discusses a variety of commonly used therapies for ADHD, and introduces a systematic, pragmatic approach to discussing CAM therapy use with parents. Index terms: complementary and alternative medicine, attention-deficit hyperactivity disorder. The mother of a little girl you have diagnosed with attention-deficit hyperactivity disorder (ADHD) calls you. "I know you said she has ADHD and should be on medicine, but I don't want to put my child on drugs. What if she gets addicted? My husband found out that cutting down on sugar and food dyes can help calm her down. Also, I read on the Internet that pycnogenol and blue-green algae can cure ADHD and they don't have any side effects. Is that true? How come you didn't tell me about these treatments for ADHD?" For many parents and clinicians, choosing an acceptable therapy for the young child with ADHD is very difficult. First, clinicians have generally avoided prescribing stimulants except as a last resort for very young children, although in recent years the use of psychotropic medications for preschoolers has increased dramatically, (1,2) Unlike evidence demonstrating the benefits of stimulant therapy for school-aged children, data supporting the effectiveness of stimulants in children under 6 years of age are sparse. (3) Second, parents often are concerned about giving their child a "mind-altering" drug without knowing how long the child will need to be treated and what long-term side effects there might be. Understandably, then, parents may search for what they consider to be more "natural" therapies, hoping either to lessen the need for stimulant therapy (i.e., as adjunctive or "complementary" therapy) or to avoid stimulants altogether (i.e., as "alternative" therapy). Thus, it is important for clinicians caring for children with ADHD to be familiar with complementary and alternative medicine (CAM) and its role in ADHD. This paper will review the epidemiology of CAM use in ADHD, discuss a conceptual model of CAM as well as selected therapies used to treat ADHD, and suggest ways to incorporate CAM into pediatric practice. WHAT IS COMPLEMENTARY AND ALTERNATIVE MEDICINE? A DEFINITION In 1993, "unconventional medicine" was defined as "medical interventions not taught widely at United States medical schools or generally available at United States hospitals." (4) In the year 2001, as more medical schools offer courses in alternative medicine, more hospitals and clinics offer therapies such as acupuncture, hypnosis, and massage, and third party payors are increasingly willing to reimburse for such therapies, this definition has become quite dated. A more recent definition used by the Cochrane collaboration defines complementary and alternative medicine (CAM) as "... a broad domain of healing resources that encompasses all health systems, modalities, and practices and their accompanying theories and beliefs, other than those intrinsic to the politically dominant health systems of a particular society or culture in a given historical period." (5) Implicit in this definition is the reality that the boundaries between CAM and mainstream medicine are often unclear, as what was once considered alternative (e.g., acupuncture for management of pain) moves into conventional medicine. COMPLEMENTARY AND ALTERNATIVE MEDICINE USE IN CHILDREN: EPIDEMIOLOGY Adult use of complementary and alternative medicine (CAM) has increased significantly in the past decade. (6) Although there are no similar national epidemiologic studies in children, a series of regional studies over time suggests that CAM use in general pediatric populations is also increasing, with more recent estimates of 20% to 21% of children in the Bath (United Kingdom) and Washington, DC areas. (7-9) Among children with serious or chronic medical and psychosocial conditions, rates of CAM use are much higher (e.g., 66% in children with cystic fibrosis, 70% in patients with juvenile rheumatoid arthritis, and 70.1% in homeless youth), (10-12) One would expect that CAM use in attention-deficit hyperactivity disorder (ADHD), a highly prevalent chronic condition, would be similarly common. There are remarkably few systematic studies of the prevalence of CAM use in ADHD. A developmental referral center in western Australia found that approximately 64% of their patients diagnosed with ADHD had used "other" therapies in addition to stimulants, most commonly dietary restriction, multivitamins, and occupational therapy. (13) Data from our institution suggest that over half of the parents of children referred for ADHD evaluation have used some form of CAM therapy for treatment of ADHD (E. Chan, L.A. Rappaport, and K.J. Kemper, unpublished manuscript, May 18, 2001). In a 1997 American Academy of Pediatrics Ambulatory Care Quality Improvement Program self-assessment exercise, 38% of pediatricians reported being asked about alternative therapies by their patients with ADHD. (14) CONCEPTUAL MODEL: THE THERAPEUTIC WHEEL OF COMPLEMENTARY AND ALTERNATIVE MEDICINE What complementary and alternative medicine (CAM) therapies are children with attention-deficit hyperactivity disorder (ADHD) using? The answers depend on geography, the availability and types of CAM practitioners in a given area, and the current fads at any given time. The diversity of CAM therapies is remarkable; it is well beyond the scope of this paper to review the majority of CAM therapies and their effectiveness in ADHD. Several other articles on this subject have recently been published. (15,16) However, learning a comprehensive model for CAM helps one to organize an understanding of CAM therapies and to develop a practice of discussing CAM with families. One useful conceptual model, proposed by Kemper, (17) also demonstrates how conventional therapies for ADHD integrate into a holistic therapeutic approach. Kemper's model takes the form of a wheel of therapies, with the patient at the center and different therapies at the rim (Fig. 1). Specific therapies are grouped into one of four broad healing modalities roughly based on the proposed mechanism of action: biochemical, lifestyle/mind-body, biomechanical, and bioenergetic. For ADHD, the most commonly used therapies fall into the biochemical and lifestyle/mind-body groups. Lifestyle/Mind-Body Therapies These interventions are often common-sense therapies all of us incorporate into our daily lives, including exercise, nutrition, environmental changes, and mind-body techniques such as hypnosis, psychotherapy, and biofeedback. Parents often encourage their children with ADHD to engage in exercise, whether to improve their overall well being or (consciously or unconsciously) to "tire them out." Common activities include gymnastics, martial arts, and team sports. Although it is doubtful that exercise alone can "cure" ADHD, exercise can certainly provide opportunities to develop social skills and to help improve the motor incoordination so often present in children with ADHD. Mind-body therapies are geared toward invoking the mind's ability to influence body function and symptoms. The key principle is that thoughts or emotions ("stresses") have an important impact on health. By improving awareness of one's own bodily systems, one develops a sense of self-efficacy and control and is more able to move from a state of internal disorder to one of homeostasis. Probably most relevant for children with ADHD is that mind-body therapies can help reduce autonomic hyper-arousal to stress by eliciting the relaxation response. Several mind-body therapies are commonly used for ADHD. Many of these are readily recognized and are considered established interventions: professional counseling, parenting skills training, and behavioral therapies such as positive rewards for desired behaviors. Electroencephalogram (EEG) biofeedback therapy was developed after it was observed that a subset of children with ADHD appear to have excessive theta (slow) wave and decreased beta (fast) wave activity on EEG. Teaching children to alter their EEG pattern through biofeedback thus may help normalize their cortical function. One study, using a pre/post-training design, found a correlation between decreased theta wave activity and improvements in visual attention, ADHD behavior scores, and intelligence scores. (43) However, studies with more rigorous methodology need to be done. EEG biofeedback can be an unwieldy therapy requiring 35 to 50 training sessions, although results can be observed after 15 to 20 sessions. (44) Bioenergetic Therapies The underlying principle of bioenergetic interventions is that they restore the harmonious balance of an invisible energy or spirit that surrounds and flows through the body. These therapies are often not based on known scientific laws, but several have been shown to be effective for certain conditions in well-conducted studies. Examples of bioenergetic therapies include acupuncture, therapeutic touch, prayer, and homeopathy. Acupuncture is based on the theory that illness arises when the body's flow of energy (Qi or Chi) is no longer in balance. To restore the proper flow of energy, points along the meridians that carry Qi are stimulated with needles, heat (moxibustion), vigorous massage (shiatsu), or electrical current. Studies of acupuncture in ADHD are ongoing. Tourette's, Other Tic Disorders Far More Common Than Once Thought University Of Rochester Medical Center One out of four students in special-education classes has a tic-related disorder like Tourette syndrome, and the rate of Tourette’s among students in the general population is 50 to 75 times higher than has been traditionally thought by doctors, according to a study published in the Oct. 23 issue of the journal Neurology. The neurologists who did the study say that Tourette’s comes in many forms, including variations much milder than the profanity-spewing, limb-jerking characters seen on TV shows like Ally McBeal and LA Law. Doctors say the findings should raise awareness among teachers and doctors that children who are performing poorly in school and who have tics may need medical treatment, and that such treatment could ease school difficulties for these students. “Most people view Tourette’s as a very rare, unusual disorder with bizarre symptoms, but it’s really very common, usually with mild symptoms,” says Roger Kurlan, M.D., a professor of neurology at the University of Rochester Medical Center and lead author of the Neurology paper. “The cases you see on TV are the most severe cases, and they’re just the tip of the iceberg. Most cases of Tourette’s are much milder and don’t progress to the severe form.” In the study of 1,596 children in Rochester, N.Y., 8 percent of children in special education met the criteria for Tourette’s, and about 27 percent had some tic disorder. In the general population, 3 percent had Tourette’s, and 20 percent had a tic disorder. The rate of 3 percent in the general population is about 50 to 75 times higher than typical estimates. While tics like barking obscenities or jerking one’s head are easy to spot, there are a slew of other repetitive and involuntary movements or vocalizations – tics – that are usually overlooked by family, friends and co-workers as strange or annoying habits, Kurlan says. Common tics include rapid eye-blinking, scrunching up one’s nose, little jerks of the head, facial twitches, or even constant sniffing or clearing one’s throat repeatedly. “The fact that a child has tics probably signifies a subtle brain developmental disorder. It’s like a window into the brain: When you see a child with tics, it’s a sign that the wiring isn’t quite right,” says Kurlan, chief of the Cognitive and Behavioral Neurology Unit at the university’s Strong Memorial Hospital, where he treats more than 400 Tourette’s patients regularly. “Tics are observable markers that this person is more likely to have problems in school.” Researchers have linked Tourette syndrome to an area of the brain known as the basal ganglia, which is involved in controlling movement and plays an important role in attention, concentration, and decision-making. The same part of the brain is affected in people with obsessive-compulsive disorder, attention deficit-hyperactivity disorder (ADHD), and some learning disabilities. So it’s no surprise that the same factors that affect children with ADHD and these other disorders are also stumbling blocks for children with Tourette’s. Students with the disorder are five times as likely as others to end up in special education. People with Tourette’s typically are impulsive, have trouble concentrating and are easily distracted; friends or colleagues might say they’re filled with nervous energy or seem to fidget continually. Kurlan says that with a little training, teachers should be able to recognize most tics and thus identify some students more likely than their peers to have difficulty in school. “A good proportion of these kids has a recognized medical condition that's amenable to treatment. Many of the symptoms of Tourette’s are treatable, so that if you recognize it, you can treat it and perhaps improve the child’s school performance and their ability to make friends. “If a child is doing well, there certainly wouldn’t be much to do in terms of intervening,” Kurlan says. “On the other hand, maybe a child isn’t doing all that well. If the child is struggling in school or having trouble making friends, perhaps causes like ADHD or Tourette’s should be evaluated, and treatment should be considered for that student.” Kurlan thinks that the rate of Tourette’s has been underestimated because the patients who seek out treatment in a doctor’s office are usually those with the most severe symptoms. In past studies, doctors have relied on questionnaires and a review of medical records to identify patients without conducting direct interviews or exams. “Our eyes were opened by going out into the community, when we explored what Tourette’s is like in the real world. It’s not a severe illness with bizarre symptoms; most people had relatively mild symptoms and did not go to their doctors for help. Most live a pretty normal life and are not disabled by tics.” The Neurology study, funded by the National Institute of Neurological Disorders and Stroke, was done in the city of Rochester and in 10 suburban school districts and included students ages 8 to 17. Teachers and parents answered questions about the students, and then students were interviewed for an hour by technicians trained to assess tics and separate out possible causes like boredom, hyperactivity, or simple restlessness. His results back the findings of two recent smaller studies which estimated Tourette’s in about 1 percent of people, significantly higher than previous estimates. Every day – in airports, at the office, and in the hospital – Kurlan sees people who likely have Tourette’s, just like anyone with a trained eye would see among any large group of people, he says. He likes to tell the story of famed neurologist and author Oliver Sacks, who often said that on the day he recognized his very first patient with Tourette syndrome, he saw several more cases on the way home from work.

Auditory Cortical Responses to the Interactive Effects of Interaural Intensity Disparities and Frequency Julie R. Mendelson and Keith L. Grasse1 Cerebral Cortex, Vol. 10, No. 1, 32-39, January 2000 © 2000 Oxford University Press Department of Speech-Language Pathology, Faculty of Medicine, University of Toronto, Toronto, Ontario M5S 3H2 and 1 Department of Psychology, Centre for Vision Research, Institute for Space & Terrestrial Science, York University, North York, Ontario M3J 1P3, Canada   Under natural conditions, stimuli reaching the two ears contain multiple acoustic components. Rarely does a stimulus containing only one component (e.g. pure tone burst) exist outside the realm of the laboratory. For example, in sound localization the simultaneous presence of multiple cues (spectral content, level, phase, etc.) serves to increase the number of available cues and provide the listener with more information, thereby helping to reduce errors in locating the sound source. The present study was designed to explore the relationship between two acoustic parameters: stimulus frequency and interaural intensity disparities (IIDs). By varying both stimulus frequency and IIDs for each cell, we hoped to gain insight into how multiple cues are processed. To this end, we examined the responses of neurons in cat primary auditory cortex (AI) to determine if their sensitivity to IIDs changed as a function of stimulus frequency. IIDs ranging from +30 to –30 dB were presented at different frequencies (frequency was always the same in the two ears). We found that approximately half of the units examined exhibited responses to IIDs that varied as a function of stimulus frequency (i.e. displayed some form of IID x Freq dependency). The remaining units displayed IID responses that were not clearly related to stimulus frequency. Studies have shown that cortical cells are sensitive to a variety of stimulus parameters such as interaural intensity, temporal and frequency when they are examined individually (Kitzes et al., 1980; Phillips and Irvine, 1981, 1983; Reale and Kettner, 1986; Mendelson, 1992). Under natural conditions, these cues rarely arise in isolation. In fact, in sound localization if only one of the available cues is present, spatial ambiguity often occurs, causing the organism to mislocalize. This ambiguity stems from the fact that sounds arising from different locations may produce identical values of a given cue. Thus, the presence of additional cues (spectral, temporal, level, etc.) helps to disambiguate the location of the sound source. The goal of the present study was to further our understanding of how the auditory cortex processes the interaction of multiple acoustic parameters. To date, relatively few studies have examined the interaction of two or more parameters (Kitzes et al., 1980; Takahashi et al., 1984; Semple and Kitzes, 1987; Wenstrup et al., 1988a,b; Fuzessery et al., 1990; Brainard et al., 1992; Irvine et al., 1996; Park et al., 1997). In general, these studies have shown that the response of some neurons to one parameter can be modulated by the simultaneous manipulation of a second parameter. For example, Irvine et al. (1995) studied the relationship between interaural intensity and temporal differences as would be predicted by the time–intensity trading phenomenon observed in psychophysical studies (Deatherage and Hirsh, 1959). They found that for the majority of units in the inferior colliculus, the response to interaural intensity disparities (IIDs) could not be predicted from the response to interaural temporal disparities (ITDs). The effect of sound pressure level (SPL) has also been shown to modulate the response of units in the inferior colliculus (Semple and Kitzes, 1987; Wenstrup et al., 1988a,b; Fuzessery et al., 1990) and auditory cortex (Irvine et al., 1996) to IIDs. Park et al., on the other hand, have shown that stimulus duration has no effect on the IID response of lateral superior olive (LSO) neurons (Park et al., 1997). Collectively, one point these studies clearly demonstrates is that the way in which neurons in the auditory system treat multiple parameters is by no means a simple matter. Two other parameters that warrant examination because of their intimate relationship are the intensity and spectral components of the signal. Recent studies have shown that IID-azimuth functions display different patterns of non-monotonicity/monotonicity at different frequencies (Irvine, 1987; Martin and Webster, 1989; Rice et al., 1992). However, the way in which the interaction of these parameters is encoded by the auditory cortex is not well understood. Thus, in the present study we investigated the relationship between IIDs and stimulus frequency in an attempt to explore how the response of a cortical unit to one parameter can be modified by the manipulation of a second parameter. The primary goal of the present study was to explore the functional relationship between changes in stimulus frequency and IID in the responses of auditory cortical neurons. To this end, approximately half of the units examined exhibited responses to IIDs that varied as a function of stimulus frequency (i.e. displayed some form of IID x Freq dependency). The remaining units displayed IID responses that were, for the most part, invariant to stimulus frequency. Comparison with Other Studies Monotonicity In the present study ~66% of the units exhibited monotonic response profiles when tested with IIDs at CF. This is consistent with what has previously been reported (Phillips and Irvine, 1981; Schreiner et al., 1992). In addition, the fact that monotonicity appeared to be independent of CF has also been observed by other investigators (Phillips and Irvine, 1981; Schreiner et al., 1992). Collectively, these studies and the results of the present study support the suggestion that multiple cues interact in complex ways that, at present at least, are poorly understood. In the present study, the IID response of almost 50% of the units was modulated in some manner by the stimulus frequency. This suggests that perhaps up to half the cortical units may be providing the organism with spatial information in addition to whether or not the sound source is located in a hemifield or central region. However, accurate sound localization is most likely achieved by the presence of more than two cues. It is certainly the case that under natural conditions there is typically an array of acoustical cues available which allow the organism to derive an accurate representation of sound source location. In accord with this multiple-cue requirement, Brainard et al. reported that the value of IID for a single frequency is not sufficient to specify the exact location of a sound source because, given other conditions, several locations may share similar IIDs (Brainard et al., 1992). A closely related alternative view of the function of AI is that it is primarily involved in the spectral analysis of sounds rather than in sound location per se. For example, AI may perform a first-order spectral analysis of sound stimuli, which would be useful for processing such stimuli as species-specific communication signals or characteristic sounds generated by prey. The results of this first-order spectral analysis could be conveyed to other cortical fields where, as suggested above, it might be refined further in a manner useful for more specific functions such as sound localization and/or acoustic pattern recognition. Additional research is necessary before either the role of AI or the role of higher auditory cortical areas can be comprehended within a single theoretical framework. Functional Role of Auditory Cortex in Frequency Processing and Pitch Perception Mark Jude Tramo,1,2,3 Gaurav D. Shah,1,2 and Louis D. Braida2 The Journal of Neurophysiology Vol. 87 No. 1 January 2002 by the American Physiological Society  1Department of Neurology, Harvard Medical School and Massachusetts General Hospital, Boston 02114-2696;  2Research Laboratory of Electronics, Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge 02139; and  3Eaton-Peabody Laboratory of Auditory Physiology, Department of Otology and Laryngology, Harvard Medical School and Massachusetts Eye and Ear Infirmary, Boston, Massachusetts 02114 Microelectrode studies in nonhuman primates and other mammals have demonstrated that many neurons in auditory cortex are excited by pure tone stimulation only when the tone's frequency lies within a narrow range of the audible spectrum. However, the effects of auditory cortex lesions in animals and humans have been interpreted as evidence against the notion that neuronal frequency selectivity is functionally relevant to frequency discrimination. Here we report psychophysical and anatomical evidence in favor of the hypothesis that fine-grained frequency resolution at the perceptual level relies on neuronal frequency selectivity in auditory cortex. An adaptive procedure was used to measure difference thresholds for pure tone frequency discrimination in five humans with focal brain lesions and eight normal controls. Only the patient with bilateral lesions of primary auditory cortex and surrounding areas showed markedly elevated frequency difference thresholds: Weber fractions for frequency direction discrimination ("higher""lower" pitch judgments) were about eightfold higher than Weber fractions measured in patients with unilateral lesions of auditory cortex, auditory midbrain, or dorsolateral frontal cortex; Weber fractions for frequency change discrimination ("same""different" pitch judgments) were about seven times higher. In contrast, pure-tone detection thresholds, difference thresholds for pure tone duration discrimination centered at 500 ms, difference thresholds for vibrotactile intensity discrimination, and judgments of visual line orientation were within normal limits or only mildly impaired following bilateral auditory cortex lesions. In light of current knowledge about the physiology and anatomy of primate auditory cortex and a review of previous lesion studies, we interpret the present results as evidence that fine-grained frequency processing at the perceptual level relies on the integrity of finely tuned neurons in auditory cortex.   NYU Neuroscientist Explores Changes In The Brain Following Hearing Loss In the United States alone, 28 million people have some degree of hearing impairment. The problem is particularly severe in childhood, when deafness can have a profound impact on intellectual and emotional development. NYU neuroscientist Dan H. Sanes works to understand how deafness affects the growth and function of the central nervous system, and how these effects might be averted or reversed. Sanes' research focuses on the development of inhibitory synapses. Although much is known about how malfunction of the excitatory synapses affects the auditory system's development, there is a dearth of such information on the inhibitory synapses. Sanes is trying to fill this void. Previously, he has demonstrated that a developing organism's central auditory system can undergo striking changes when the inhibitory synapses malfunction for as little as 24 hours. For example, nerve cell dendrites produce extra branches, and excitatory connections from the intact ear become stronger than normal. Sanes said, "We're trying to figure out what happens to the connections between nerve cells when they're deprived of stimulation during development, as occurs in hearing loss. Changes in the strength of inhibitory synapses can fundamentally alter how the central nervous system processes speech sounds or the location of a moving car. Broken inhibitory synapses probably play a pivotal role in many developmental disorders, including dyslexia and epilepsy." Sanes lab is now examining how the activity of inhibitory synapses might influence neural development, and why the loss of this activity is so harmful. Dr. Vibhakar Kotak, a collaborator in Sanes's lab, discovered that the inhibitory synapses release a unique neurotransmitter during early development. This neonatal signal (an amino acid called GABA) activates a specific type of receptor, and it can depress the strength of neighboring connections. Understanding the normal signals that help inhibitory synapses form will be crucial to understanding how to deal with their loss or damage. A second interest in Sanes' lab is the restoration of function following traumatic injury to nervous system pathways. For adult mammals, including humans, a major obstacle is that neuronal processes, called axons, will not regrow across the site of injury. In collaboration with Dr Aziz Hafidi, Sanes' lab has generated a model system to study this phenomenon. Relatively large pieces of the rodent central auditory system are kept alive in an incubator, where axon regeneration can be followed more easily. Although cut axons show some ability to grow, they are unable to cross the injury site, similar to the situation in the living animal. Sanes' lab is currently working on methods to modify the injury site in order to permit axons to grow across it.

Age Differences in Language Processing By Melissa Lee Phillips June 17, 2002 The human brain undergoes extraordinary changes from embryo to adult. One way to examine such changes is by studying differences in how the brain functions in adults and in children. Although adults' and children's brains work similarly for some tasks, even small physiological differences can shed light on how the brain develops. Understanding these processes may be important for treating childhood disorders such as dyslexia. A recent study from Washington University in St. Louis, Missouri, shows that children and adults sometimes use different parts of their brains for the same task. The research team led by Bradley Schlaggar used functional magnetic resonance imaging (fMRI) to measure brain activity during a single-word verbal response task. In this task, the subjects looked at individual words on a computer screen. They then responded by speaking a new word, such as a related verb, a word that rhymed, or a word with the opposite meaning of the word seen on the screen. Each person's brain blood flow was measured while performing this task. The scientists observed 21 adults (ages 18-35) and 19 children (ages 7-10) and looked for differences in brain activity. One problem with some experiments designed to test differences between children and adults is that children tend to be slower and less accurate at language tasks. Therefore, it is difficult to know if the results are due to age differences or simply due to differences in ability. To get around this problem, the researchers looked at children and adults whose abilities were the same. They assumed that if the adults and the children were equally good at the task, then any variations in brain activity would be due only to age. The scientists found two major differences in the brain activity of children and adults. The children had more activity in the left extrastriate cortex and the adults had more activity in the left frontal cortex. Both of these areas are known to be important in language processing. This is the first study to show that adults and children may be using these brain areas differently. Studies such as these are important to learn how adult human brains develop. By comparing young and old brains, researchers can begin to piece together a timeline of brain development. This knowledge may someday help in understanding and treating many developmental brain disorders. Approximate location of differences in brain activity between adults and children. References: 1. Reference: Schlaggar B.L., Brown, T.T., Lugar, H.M., Visscher, K.M., Miezin, F.M. and Petersen, S.E. Functional neuroanatomical differences between adults and school-age children in the processing of single words. Science, 296(5572): 1476-1479, 2002. 2. Casey, B.J., Windows into the Human Brain. Science, 296(5572): 1408-1409, 2002.

THE HUMAN VISUAL SYSTEM IS 'SMART,' DRAWING ON EXPERIENCE TO INTERPRET VISUAL INFORMATION IN THE MOST LIKELY WAY American Psychological Association (APA) 3-Jun-02 New research shows that what falls below the horizon line in ambiguous figure-ground pictures is most often seen as the 'figure' WASHINGTON -- Every student of introductory psychology has seen figure-ground pictures, those ambiguous illustrations that demonstrate the flexibility of human perception. Is it a light goblet or two dark profiles? An elegant lady with a feather in her hat, or a vase? These figure-ground pictures are important to understanding how people make sense out of their visual environments, and act on what they perceive. Now, three University of Iowa psychologists have systematically documented that people usually see what falls in the lower region of a figure-ground picture as the "figure," not the "ground." They report their findings in the June issue of the Journal of Experimental Psychology: General, published by the American Psychological Association (APA). The article covers eight experiments whose results consistently confirmed that people pick what constitutes the lower, not upper, region of a display as the "figure," not the "ground," at rates greater than chance. The findings reveal the ongoing power of perception to guide us through a world in which everyday visual scenes contain multiple objects that often overlap and partly occlude one another. The perceptual system gives figures special treatment: People hold figures in short- and long-term memory longer than grounds; figures seem more salient than grounds; figures have a definite shape but grounds are shapeless; and figures are perceived as being closer to the viewer. The researchers, led by Shaun Vecera, Ph.D., ran groups of five to 12 participants through a series of eight experiments that used two-color figure-ground displays to assess figure-ground preferences and investigate their source. The researchers found that lower-region preference was independent of whether the figure-ground display was placed in the upper or lower visual field; participants continued to defined "lower" relative to the horizon line. Vecera and his colleagues suspect that the lower-region preference arose because in the real world, regions that fall below the horizon are physically closer. The perceptual system then uses this knowledge to interpret figure-ground displays. "The shared contour that separates upper and lower regions acts as a horizon," says Vecera, "and we perceive the lower region as the figure because it falls below the horizon line." He adds, "Many perceptual phenomena are easily overlooked in everyday life because our visual systems are extraordinarily efficient. The lower-region preference provides a glimpse at one part of this behind-the-scenes work." Visual Cortex Activity in the Blind By Melissa Lee Phillips May 20, 2002 Scientists used to believe that each area of the human brain was specialized only for particular tasks. It was assumed that an area of the brain that processes a certain type of information can process only that type of information and can never change its function. Over the past few years, it has become apparent that the brain actually exhibits more plasticity -- the ability to change and form new and different neural connections -- than originally thought. For example, the occipital cortex is thought to be used mainly for visual processing. If someone is blind, though, what happens to this area? Is it simply not used? Can the brain adapt and use these neurons for something else? A study by Dr. Harold Burton and his colleagues at Washington University in St. Louis has attempted to answer some of these questions. Sixteen blind people were studied: nine were blind from birth ("early-blind") and seven became blind later in life ("late-blind"). Using functional magnetic resonance imaging (fMRI), the scientists measured cerebral blood flow while the subjects read Braille words and while they read sequences of nonsense Braille. The major activity detected while the subjects read real words occurred in the visual cortex, even though all the subjects were completely blind. The early-blind subjects had even more activity in the visual cortex than the late-blind subjects. More specifically, the people who were blind from birth had more activation in occipital-temporal cortex areas called V5/MT and V8 and in the occipital cortex on the side of the brain opposite their reading hand. The researchers think it is possible that the traditionally visual areas might have been recruited for some other function, possibly for processing touch input they receive by reading with their hands. This might explain why the early-blind subjects had more activation in the visual areas: they didn't have the "normal" neural connections to begin with, so these brain areas were free to develop for some other type of input. The late-blind subjects, though, already had many visual connections. It may be more difficult for the visual cortex to adapt to another type of input if these neurons were originally dedicated to visual input. A second possibility is that these areas are not used solely for processing visual information but are used more generally for encoding information that will later be processed by the brain's language centers. Sighted people often encode visual information for this purpose, but blind people would encode touch information instead. In both cases, the activity is essentially the same: coding information for later use. The scientists stress that more studies will be needed to determine which -- if either -- of these hypotheses is correct. Reference and more information: * Burton, H., Snyder, A.Z., Conturo, T.E., Akbudak, E., Ollinger, J.M., and Raichle, M.E., Adaptive changes in early and late blind: A fMRI study of Braille reading, Journal of Neurophysiology, 87:589-607, 2002.

Fibromyalgia Traditional Chinese Medicine (TCM) categorizes fibromyalgia as a blockage in the smooth flow of Qi and Blood throughout the energetic pathways in the body. Accordingly, the disorder is classified as a type of Bi, or impediment, syndrome affecting the muscles: Muscle Bi. Because pain in TCM indicates the presence of a blockage, conditions such as fibromyalgia are called Painful Obstruction Syndromes. The immediate cause of Bi syndromes is environmental: pathogenic influences of Wind, Cold, and Dampness, are said to penetrate the body’s defenses and lodge in the muscles, tendons, and joints, creating obstruction and causing pain, stiffness and other symptoms. The confluence of these pathogens also can lead to the generation of Heat in the affected areas, manifesting as inflammation. While the Qi usually is strong enough to resist invasion by environmental pathogens, several internal disharmonies in the Qi and the Blood can predispose a person to Bi syndrome. * People under stress often suffer from obstructed flow of Qi and Blood in the body because stress affects the Liver, which is responsible for the smooth flow of Qi. Obstruction creates an environment in which pathogens can invade and lodge. * Insufficient Blood and Qi can lead to the body’s energetic pathways being incompletely filled, allowing pathogens to invade. * Genetic predisposition, poor diet, overwork, or insufficient exercise can weaken the Zang Organs, such as the Kidney or Spleen – responsible for supplying the kinds of Qi that maintain overall resistance – allowing Pathogenic Influences to invade as well. Traditional Chinese Medicine Categories of Fibromyalgia TCM diagnoses Muscle Bi syndrome based on the predominance of Wind, Cold, or Damp symptoms. All three pathogenic factors usually are found together; Wind is said to carry the others into the body. Each, however, has a separate set of symptoms, with one factor playing a primary role. Accordingly, Muscle Bi is differentiated into the following categories: * Wind Bi: Wind predominates when a patient exhibits pain that begins and ends rapidly, limits the range of comfortable movement, and moves among different parts of the body. Windy weather can make symptoms worse. A patient afflicted with Wind Bi also may have an aversion to wind, a floating pulse, and a tongue of normal color with a thin, white coat. Because this type of Bi moves from area to area, it is also known as "Wandering Bi." * Cold Bi: Cold predominates when the pain is severe, limits the range of comfortable movement, and has fixed locations. Cold temperatures worsen the condition and warmth improves it. A patient afflicted with Cold Bi may have an aversion to cold, a tight pulse, and a white coat on the tongue. Because this type of Bi usually results in severe pain, it is also known as "Painful Bi." * Damp Bi: Damp predominates when the pain is characterized by soreness, limits the range of comfortable movement, and is accompanied by feelings of heaviness and sometimes numbness. Pain tends to be fixed in areas of the body. Dampness worsens the condition, and there may be swelling of affected areas. Patients afflicted with Damp Bi usually have an aversion to damp weather, a slippery pulse, and a greasy tongue coating. Because this type of Bi is characterized by fixed areas and sensations of heaviness, it is also known as "Fixed Bi." Chinese Medicine Overview by Healthcommunities.com, Inc. Chinese medicine is an ancient medical system based on the Daoist view of a universe where everything is interrelated. Through thousands of years of observation and practice, the Chinese have developed a unique method of understanding the structure of the internal organs and the body’s physiological processes. Today that medicine is called Traditional Chinese Medicine (TCM). Chinese medicine is designed to promote and maintain health through diet and exercise. If illness occurs, it is treated with acupuncture, herbs, and Qigong. Chinese medicine practitioners diagnose and treat all types of illness and disease. It is undeniably a valid and effective form of medicine. Chinese medicine is very complex and intricate. Practitioners study for many years to grasp its concepts, which differ from Western medicine. It is important to have a basic knowledge of these concepts to understand how Chinese medicine practitioners diagnose and treat illness. Many of the concepts can be difficult to understand because they have no counterpart in Western medicine. Chinese medicine practitioners view the mind and body as an energetic system that cannot be separated from one another or the universe. Organs are not separate structures, but are interconnected organ systems that work together to keep the body functioning well. Chinese medicine practitioners treat the patient, not the disease. Yin and Yang The most fundamental concept of Chinese medicine is Yin and Yang. All things in the Universe are either Yin or Yang. However, nothing is ever all Yin or all Yang, but a balance between the two that is ever changing. They are opposites, yet complementary. They are not independent of each other but change into each other. For example, the day (Yang) turns into night (Yin) and winter (Yin) turns into spring (Yang.) Illness is caused by an imbalance of Yin and Yang in the body. In Chinese Medicine, treating illness is the process of rebalancing Yin and Yang. This is done through acupuncture, herbs, and Qigong. The Yin-Yang symbol is a representation of Chinese medicine philosophy. The symbol is a circle divided by a curved line into a black (Yin) side and white (Yang) side. The curve represents the constantly changing balance between Yin and Yang. Each side contains a small circle of the opposite color which symbolizes that there is some of Yin in Yang and some of Yang in Yin (i.e., Yin exists in Yang and Yang exists in Yin.) Listed below are examples of Yin and Yang. Yin Yang Female Earth Night Moist Cold Winter Death Structure Small Solid Chronic Male Heaven Day Dry Hot Summer Birth Function Large Hollow Acute Vital Substances Vital Substances interact with each other to nourish and sustain the body. Together they form the mind and body. The Vital Substances – Qi (pronounced chee), Blood, Body Fluids, Jing, and Shen – are described below. * Qi The body has an energy force (also referred to as life force or vital force) running through it known as Qi. Qi travels through the body along channels or meridians. It is both energy and substance. The Chinese say, “When Qi gathers, so the physical body is formed; when Qi disperses, so the body dies.” Qi nourishes, protects, and supports all systems and functions of the body. The other Vital Substances are manifestations of Qi. Health is affected by the flow of Qi through the body. If the flow of Qi along channels (pathways that connect all parts of the body) is disrupted, insufficient, or stagnant, then Yin and Yang become unbalanced, which may result in illness. * Blood Blood has a different meaning in Chinese medicine than it does in Western medicine. Blood not only transports nourishment, but also vitality. Blood is a material form of Qi. The Zang Fu organs form blood from food and drink. Blood is the basis for the formation of our skin, bones, muscles, and organs. Illness may be caused by Deficient Blood, Stagnant Blood, or Heat in the Blood. * Body Fluids Bodily Fluids, also known as Jin Ye, are formed from food and drink and serve to moisten, lubricate, and nourish the body. Jin fluids are light and watery fluids that lubricate the skin and muscles and exterior of body (sweat, tears). Ye fluids are heavy and thick fluids that lubricate the joints and brain and interior of body. Illness can be caused by Deficient Body Fluids or Accumulation of Body Fluids. * Jing Jing gives the body vitality and health. It is the Essence or vital force. If the Jing is strong, the person’s constitution is strong. If the Jing is weak, the person’s constitution is weak and more susceptible to illness. Jing is the root of existence and reproduction. Jing is also responsible for growth and development. Illness presents as constitutional or developmental problems. * Shen Shen is the Mind or Spirit. Internal Organs As the Chinese observed the world around them, they organized it into five primal powers or elements: Wood, Fire, Earth, Metal, and Water. The body was organized into corresponding systems known as Organ Networks. Solid organs are Zang and hollow organs are Fu. Zang Fu deals more with an organ’s relationship to the body rather than to a specific function. The Organs have different functions, yet depend on each other to function properly. Each Organ is predominantly Yin or Yang. Yang organs transform and digest. Yin organs store, in particular the Vital Substances. The Zang Fu organs are associated with specific body tissues and emotions. A Chinese medicine practitioner understands these relationships and uses them to diagnose and treat illness. The following table lists these relationships. Element Zang Organ Fu Organ Orifice Tissue Emotion Wood Liver Gallbladder Eyes Tendons Anger Fire Heart Small Intestine Tongue Blood Vessels Joy Earth Spleen Stomach Mouth Muscles Pensiveness Metal Lungs Large Intestine Nose Skin Grief Water Kidney Bladder Ears Bones Fear The Zang Organs and their functions are described below. * The Lung governs respiration, the extraction of Qi from the air, and plays a role in fluid metabolism. * The Spleen governs the transportation and transformation of nutrients. * The Heart governs the circulation of blood and is the residence of Shen. * The Kidney is mainly responsible for fluid metabolism and the storage of Jing. * The Liver stores the Blood and is responsible for maintaining the free flow of Qi throughout the body. * The Pericardium, not always considered a Zang Organ, protects the heart. The Fu Organs and their functions are described below. * The Stomach is responsible for initiating the metabolism of food and drink. * The Large Intestine and Urinary Bladder are responsible for excretion of feces and urine. * The Gallbladder governs the storage and secretion of bile. * The Small Intestine and Triple Burner (a Fu Organ that has no corresponding physical organ) assists the process of water metabolism and fluid flow. Extraordinary Organs are less important organs to the processes of the body. Their names and functions are listed below. * The Uterus regulates conception, pregnancy, and menstruation. * The Brain plays a role in sensory functions, memory, and intelligence. * The Bones provide structure to the body. * The Bone Marrow fills the Bones and Brain. * The Blood Vessels circulate the Blood. * The Gallbladder, a Fu Organ, is also considered an Extraordinary Organ because it stores the Liver’s bile. Meridians The organs and all components of the body are connected by channels or Meridians. They are pathways for the flow of Qi throughout the body. There are Twelve Regular Meridians running vertically up and down the surface of the body with many branching channels. The Meridians are paired (the same on both sides of the body). Each Meridian is associated with a Zang Fu organ. Acupuncture points are Qi access points along the Meridians. There are Eight Extraordinary Vessels, which do not connect to the Zang Fu Organs. Only two of these channels have acupuncture points. They mostly function as reservoirs of Qi and Blood for the Twelve Regular Meridians.

Preliminary assessment of intrahemispheric QEEG measures in bipolar mood disorders. Oluboka OJ, Stewart SL, Sharma V, Mazmanian D, Persad E. Clinical Rehabilitation Evaluation Unit (CREU), Acute Care Program, North Bay Psychiatric Hospital, OBJECTIVE: This study assessed the quantitative electroenchephalographic (QEEG) absolute power and coherence differences between a group of patients with bipolar I mood disorder (BMD I) and a group of patients with schizophrenia. We also examined the correlation between QEEG measures and family history of BMD. METHOD: Using the National Institutes of Mental Health (NIMH) Global Rating Scale, we rated 18 adult inpatients with a DSM-III-R diagnosis of BMD I for the severity of the current episode. We also collected data on the family history of the illness. This group was then matched for age, sex, and handedness with an equal number of inpatients with a DSM-III-R diagnosis of schizophrenia. QEEG absolute power and coherence was calculated for the alpha bandwidth (8.0 to 12.0 Hz), assessed at 18 pairs of electrodes in both hemispheres during resting, eyes-closed condition in all the patients. RESULTS: The patients with schizophrenia showed significantly higher coherence (P = 0.047) at 6 pairs of electrodes on the right side. The group with BMD showed significantly higher power (P = 0.042) at 2 pairs of electrodes on the right side. Correlational analysis showed that QEEG measures were significantly correlated (P = 0.01) with positive family history of BMD. CONCLUSION: These findings suggest that the patients with BMD are more disorganized in the right anterior hemisphere and that there is a significant positive correlation between the QEEG measures and the presence of family history of BMD. EEG-Driven Stimulation in Fibromyalgia Patients by Source: Fibromyalgia Frontiers A report on the presentations given by Mary Lee Esty, Ph.D., & Theodora Quinn, B.C.I.A.C., [Reprinted from Fibromyalgia Frontiers, Vol. 6, #4, July/August 1998] If you have fibromyalgia syndrome (FMS) and have ever confided to a friend or family member that your brain seemed to be stuck in "low gear" and you just couldn't "think straight", you might have been close to the truth. New research from Calgary, Canada, suggests that in fibromyalgia patients the most powerful electrical activity in the brain is in the slowest brain waves .1 The condition is known as "EEG slowing". Why this occurs is not yet known, however, it is possible that trauma or severe viral illness (the triggers commonly associated with fibromyalgia syndrome) are at least partially responsible for altering the biochemistry of the brain which in turn produces the many symptoms that FMS patients know so well. The powerful, slow brain waves also seem to prevent FMS patients from maintaining the effects of rehabilitative treatments over the long-term.2 Mary Lee Esty, Ph.D., President of the Neurotherapy Center of Washington (DC) and of Myosymmetries Washington, sums it up this way: As long as the brain is stuck in that condition where the slowest waves have more power in them than the rest of the spectrum, the symptoms will continue. You cannot get rid of them. People will try and try and try, but the control room up there is set at one speed, and it is almost impossible to change it.3 Dr. Esty and Theodora Quinn, B.C.I.A.C. (Clinical Director of Myosymmetries Washington) recently joined patients and medical professionals at FMAGW's June 6, 1998, Saturday Series to discuss the theory behind the newly published study by Calgary researchers Stuart Donaldson, Ph.D.; Gabriella Sella, M.D., M.P.H., M.Sc.; and Horst Mueller, Ph.D. which used a procedure called "EEG-Driven Stimulation (EDS)--also known as the Flexyx Neurotherapy System (FNS) or EEG Neurotherapy--along with several follow-up treatment modalities, in an attempt to "reset" the brains of FMS patients and restore normal functioning. Dr. Esty, who has had a great deal of experience with EDS in the treatment of traumatic brain injuries, attention deficit disorder, migraines, panic disorder, post-traumatic stress disorder, fibromyalgia and chronic fatigue syndromes, as well as several other conditions, worked closely with the Calgary research team. Some Background on EEG-Driven Stimulation EDS was first pioneered by Len Ochs, F.N.S., of Walnut Creek, CA, as part of a NIH study involving learning disabled children. Through his collaboration with Esty and Ochs, Calgary researcher Dr. Stuart Donaldson, already highly experienced in EEG technology and the study of musculoskeletal problems, was able to apply EDS technology to fibromyalgia research. Using a type of brain mapping called QEEG (quantitative electroencephalogram), Donaldson soon discovered a signature spike unique to the brain waves of FMS patients. Of particular interest was the fact that no such spike appeared in the mappings of patients with myofascial pain syndrome, a condition frequently confused with fibromyalgia. Also, by using the QEEG, a patient's brain wave pattern could be assessed and different brainwaves' intensities and locations identified. "EEG slowing" shows up in the brain map (the delta and theta waves of the brain are the slowest). The good news is that both Dr. Esty (at Myosymmetries Washington) and Dr. Donaldson (at Myosymmetries Calgary) have reported success treating fibromyalgia syndrome using EEG-Driven Stimulation. Dr. Esty describes the usual EDS treatment protocol this way. A patient first has a QEEG map made through the scalp to document electrical activity emanating from 21 sites around the brain. The QEEG is used to create a schematic picture of the brain which is then colorized to show the relative functioning of different brain sites. The patient is then asked to sit in a comfortable chair with eyes closed and to put on a special pair of dark glasses. A sensor is placed on the head; a clip is attached to one ear; and a ground is secured to one hand. The sensor transmits data concerning the areas of strongest brain wave activity through a processor to a computer. A rhythmic stimulus (a non-light emitting diode) is then sent through the glasses into the eyes and brain to essentially draw power from the slowest brain waves up to faster waves. The brain should then be more flexible and shift as needed in response to stimuli.4 Once the brain has been coaxed into a flexible, new state which allows it to perform its integrative functions in an optimal way, neuro-muscular re-education can begin. Theodora Quinn, who coordinates soft tissue rehabilitation programs at Myosymmetries Washington, described the supplemental treatment protocols designed by Dr. Donaldson. During the time period when brain wave neurotherapy treatments are being applied, a multi-disciplinary team of specially trained clinicians conduct both static and dynamic evaluations of posture and muscle functioning as well as assessments of a client's work and home environments to produce an individualized treatment plan which helps the patient regain the use of deconditioned muscles and develop new awareness of inappropriate postures, work habits, or muscle-guarding.5 Surface Electromyography (sEMG) is one technology frequently used to record abnormal muscle activity in various locations around the body and to identify muscles that are working in-effectively together as a team. Often, micro-exercises are prescribed to re-establish proper muscle function. Trigger point therapy and myofascial release are also commonly performed in careful symmetry with EDS therapy to help restore muscle health.6 The Calgary Study In a newly published article, "Fibromyalgia: A Retrospective Study of 252 Consecutive Referrals", (Canadian Journal of Clinical Medicine, June 1998), Donaldson et al report on the success of the EEG Neurotherapy treatment protocol (i.e., EEG-Driven Stimulation, sEMG neuromuscular retraining, and physical and massage therapy) on 44 FMS patients from their larger study whose progress had been followed for up to a year. Of the 44, only four patients rated themselves as worse after receiving treatment. Dr. Donaldson notes that these patients had also experienced problems with medication interactions or had other undiagnosed medical problems in addition to fibromyalgia syndrome. The other 40 patients reported improvement. Interestingly, those who indicated slight improvement (n=14) tended to be those whose FMS was thought to be triggered by viral infection. Those who reported being either greatly improved or symptom-free (n=26) tended to have developed fibromyalgia syndrome after a trauma.7 It should be noted that symptom-relief did not come all at once. In all cases, "fibro-fog" (i.e., decreased ability to concentrate, decreased short-term memory, difficulty with multiple tasks) disappeared first, generally within 20 days from the start of treatment. Pain symptoms seemed to change from being generalized to being site-specific and somewhat more intense. Mood and irritability symptoms lessened or resolved in approximately 20 to 30 days, while fatigue decreased after one to two months. Sleep improved in two to three months. During this same period, specific pain decreased, and muscle function and range of motion improved.8 Unfortunately, the study makes no mention of other symptoms commonly associated with FMS such as irritable bowel, gastrointestinal complaints, genito-urinary symptoms, environmental sensitivity, and others. Admittedly, research on EEG-Driven Stimulation is in its infancy, and much more work and observation need to be done. Nevertheless, the new body of work surrounding EDS undoubtedly raises some interesting questions about the effect of physical trauma on the brain and how that effect differs from stresses imposed by viral illness. Also exciting is Dr. Donaldson's identification of a signature spike in the brain waves of FMS patients. If this finding can be corroborated by double-blind, controlled studies, it may mean, at last, that there is an accurate tool for the differential diagnosis of FMS. Unfortunately, there is also a down side to the neurotherapy protocol, at least for the present. Not surprisingly, it is quite expensive and not yet covered by many insurers. However, Dr. Esty and Ms. Quinn promise that they are working hard to educate insurers. Overview of EEG and qEEG Jay Gunkelman (Often Crossroads Institute is asked to detail what we do, how we do it and why we do it. This paper gives a thorough overview into the history of EEG and where it is as a field today. It is lengthy but well worth reading if you are interested in what EEG and qEEG is all about.) -Crossroads Institute- The purpose of this paper is to give a concise introductory review of the EEG and the quantitative analysis of the EEG. This will entail a summary of the EEG and signal sources as well as the recording and processing of the EEG to generate a qEEG and report. This should serve as a basic starting point, but not as an end to the study of this field. As an introduction, it will not have all the detail that is needed for a depth understanding in this rapidly evolving field. EEG The EEG was discovered in the 1920's and applied in humans by Hans Berger, a psychiatrist. The field was touted as likely to give the psychiatric professionals an insight into the brain's function, though failed in producing this. The electrical patterns were found to have neurological correlates in the 1930's for some disorders, such as epilepsy and tumors in work by Frederick Gibbs, MD, and Charles Yeager, MD as well as others. The 1940's and 50's found the instrumentation advancing, with commercially available equipment fostering establishment of laboratories throughout the nation. The field established standards of electrode placement in 1949 when Rasmussen convened an international committee and designed the international 10-20 electrode placement system. The details of this system are outside the scope of this paper, but are essential to the proper practice of EEG. The reader unfamiliar with this system should study this elsewhere, with the ASET organization being a good source of these details. The frequency patterns seen in the EEG have been divided into bands, with somewhat arbitrary division into the standard bands of delta, theta, alpha and beta. The frequency bands, however, are to this day still not set as a standard, with the resultant confusion if the names and not the detailed frequency parameters are used. The delta band starts as low as the bandpass filter will allow, with the upper limit set at 3.5 or 4. Theta starts at 4 and goes to 7 (or less properly to 8). Alpha starts at 7-8 and goes to 12-13, with beta being the desynchronized faster activity above alpha, occasionally divided into beta subtypes. Gamma, or "40 Hz", is an area of current interest, and is being associated with neural network "binding". The field of neurology does not use the detailed frequency bands to determine the limits of alpha, but rather defines it as the rhythmic posterior activity that attenuates with sensory stimulation, regardless the frequency limits. It is commonly referred to as the background activity, not as alpha. Other frequency bands are also seen in the literature, including Mu, a motor rhythm seen focally at C3 and C4 at 9-11 Hz, which is monomorphic or wicket shaped and is eliminated with the movement of a contra-lateral limb. Lambda is also seen in the literature, being the posterior waveform elicited by visual scanning. SMR or sensory motor rhythm is a frequency pattern seen in the sensory motor strip. The pattern was studied by Sterman in the 1970's, and was found to correlate with a focused non-movement state. It was subsequently used in treatment of epileptics and shown in well constructed and replicated studies to be efficacious in cases where medications were unable to control the epileptic ictal events (seizures) for tonic-clonic or motor expressions of epilepsy. In the 1960's and the 1970's the digitizing of the EEG was undertaken, with the subsequent computer analysis of this data. The original aspiration of Berger and the psychiatric community only then began to see the correlation of the EEG with psychiatric conditions, as well as the brain's detailed response to medication intended to treat these disorders. Though medication effects in the EEG were previously reported, their presence was merely an artifact in the interpretation of the EEG, not able to be systematically studied. Physiology The EEG is the summation of the cortex's pre and postsynaptic potentials, but not all the cortical activity. EEG is only able to measure the radially oriented dipole of the pyramidal cells of the cortex and hippocampal cortex, with recent evidence from E.Roy John's work that the radially oriented discharges of the cingulate (a structure residing deep within the longitudinal fissure) also showing activity in the EEG. The radially oriented discharges comprise only about 30% of cortical activity, with the laterally oriented discharges being invisible to EEG, though seen in magnetoencephalography (MEG). The lateral activity may only be inferred by looking at measures of coherence and phase in the EEG. These covariance phenomenon are associated with the 'connectivity' of distant or adjacent areas. The details of the cellular discharges are outside the scope of this chapter, requiring the study of a neurophysiology text for appropriate detail. The cortex is the source of the voltages seen in the EEG, though the slower rhythms of alpha and theta all require a rhythm generator subcortically to be present. Delta also has subcortical genesis of some of its activity, in that the cortically generated delta is suppressed by activity reaching the cortex. The delta frequencies in an intact brain are derived from the cortex, though there is some evidence of it associated with the limbic system, with recent work suggesting these rhythms are seen related to the hypothalamus in the slow waves of sleep. The delta pattern is normal in slow wave sleep during stage 3 and 4 sleep, and in early life. Delta may also be seen from white matter damage including demyelination, or even compressive changes from pressure induced from adjacent structures. The initiation of delta frequencies from artifacts is common and will be discussed later in this chapter. Theta is produced in the limbic system, more specifically in the septal nucleus (hedonic theta and frontal midline theta) and with the septal cholinergic stimulation, in the amygdala (emotional processor) and hippocampus (memory processor). The propagation to the cortex from the limbic system is fairly direct temporally, with frontal projection via the medial forebrain bundle and also to the vertex and posteriorly via the thalamus and its projections. Theta frequencies may also be seen during the hyperpolarizing of the thalamus, though this is deemed 'slowed alpha' in many schools of thought, and is eliminated with the norepinephrine increases of brain stem stimulation. The thalamic projections and cortical-cortical fasciculi are also used in the distribution of these and other frequencies. Alpha is generated as a rhythm in the thalamus due to the cholinergic input via the reticular nucleus of the thalamus. It is projected to the sensory areas via the specific thalamic projection system, with diffuse projection via the diffuse thalamic projection system. The specific projection system is a point by point projection of all the sensory systems except smell, which directly enters the limbic system. The diffuse projection system sets the tone of the cortex and is the projection system for the reticular activating system (RAS). The cortex interacts with the thalamus to set the spatial and temporal distribution of the alpha (see Steriade's model of alpha generation and distribution). Beta is generated cortically. The brain stem generators disturb the thalamic alpha genesis, thus the commonly held misperception that there is a reciprocal relationship between alpha and beta. Beta also has faster frequencies historically described with the term 'Gamma'. This activity, which brackets 40 Hz, is ubiquitous throughout the brain, and is described as a "carrier wave", a "binding" mechanism connecting neural networks, as well as an "encoding" rhythm by various schools of thought. SMR and Mu are generated in the thalamo-cortical system, more related to alpha than beta. Lambda is likely a thalamic relay phenomenon from the lateral geniculate nucleus, related to a visual evoked potential, with a focal occipital phase reversal deep in the calcarine fissure of the occipital lobes cortically. Electrodes The EEG recording electrodes and their proper function are critical for acquiring appropriately high quality data for interpretation. The electrode is not merely the metal disk or cap sitting at the end of a wire. It is these pickup surfaces and their interaction with the patient or client's skin surface. The metal pickup may be made from a variety of materials, each performing adequately. Gold disks are more expensive, and work well, though silver and tin is also able to provide a high quality report. The gold disks must be disposed of when their plated gold is scratched through revealing the underlying metal substrate. The scratching provides a bi-metallic pickup and introduces artifacts into the EEG system. This same bi-metallic effect may be introduced by using more than one type of metal in the same recording; thus all metals must be similar in the recording of any EEG. Plated chloride on silver is a very stable electrode, though a small scratch will obviate this advantage. More modern silver-silver chloride pellets of amalgamates small pieces avoids this problem. Proper skin contact and preparation is required for quality recordings in this highly technical field, regardless the types of electrodes or EEG manufacturer's instructions. Electrode contact below 10,000 ohms, or 10K ohms is essential, with impedance readings below 5K and balanced within 1K being required to pass the EEG registry exams and advised by this author to those wishing to do quality work. Skin preparation may be done with any commercially available surface cleaner and an abrasive preparation such as Nuprep or Redux. This must be done after locating the site and before the application of the electrode when using disk electrodes. With the Cap systems, there is a small hole to apply gel through. The skin preparation may be accomplished following the application of a moist gel, which will hydrate the skin and help avoid skin damage. The blunt tip needle used for applying the gel is recommended by the manufacturer as an instrument to prep the skin. I personally see too many patients' skin surfaces lacerated with this use, switching my use to a wooden q-tip applicator stick, which may be dipped into the Nuprep to assist when difficulty skin areas are encountered. I have done thousands of EEGs with this technique and have never found contact difficult to achieve, nor have I seen skin damage with this gentle technique. Electrodes must be held in place with either the cap systems or a commercial paste. Elefix or 10-20 Paste is commonly used modern pastes, which are hot water soluble. The electrodes must be secure and stable for the recording, so the wires should be secured to reduce cable movement inducing electrode contact changes. The recessed electrode in cap systems is more stable with movement and in peer reviewed studies has shown to be more reliable in placement when used properly. Electrode artifacts are a major concern for EEG recordings, and even more of a concern in qEEG, where the visually detectable difference may be eliminated. The impedance mismatches may alter amplitude, which will change the data for computer analysis and may influence database comparisons in ways undetected by the user and interpreting professional. Amplifiers and filters All of the frequency patterns must be amplified from the few millionths of a volt measured at the skin surface, to a higher level via an amplifier. This is done as the "gain" of the amplifier, with small changes after this done to scale the result in the display. This later change is the "sensitivity" of the display, measured in microvolts per millimeter. All amplifiers in current commercial use are differential amplifiers. Differential amplifiers amplify the difference between the two inputs, and must additionally have a patient or client ground contact to be able to work. These amplifiers may have the electrodes applied to the skin in various fashions, either in reference to a point, or alternatively in sequential chains of electrodes running from one area to another. Referential electrode mountings, or "montages", that are commonly used include the same side (ipsilateral) or opposite side (contralateral) ear, linked ears, the vertex or CZ electrode and more complex forms using all the electrodes (common average or weighted average) or the adjacent electrodes (local average). The general use of these complex references is referred to as the "source derivation", virtual, Laplacian and Hjorth references. Amplifiers need to have their own inputs shielded from current flow from a patient, so they have input impedance which keep the client's direct currents and static from entering the recording or damaging the amplifiers. This input impedance must be high enough to make the electrode impedance less of an influence, but not so high that there is an increase in sensitivity to field effects and movement near the patient. The input impedance trade-off is made by each manufacturer with their client's application in mind, so the appropriate thing to do is ask the manufacturer what their values are and to test the instrument thoroughly prior to purchase to evaluate their choices in your application. Amplifiers have a common mode rejection ratio, which should be 10,000:1 or greater. This effectively reduces the environmental influences common to the inputs to allow the recordings to occur in the modern 60 Hz filled environment we all live in without the need to electrically shield the room (50 Hz may be seen in countries that have a different tuning for their electrical grid, like Mexico). The EEG ranges from D.C, or 0 Hz to well over 1000 Hz, so the amplifier needs to filter out the unwanted bandwidths at the high frequency and low frequency ends of the EEG spectrum. This is accomplished with filters. The lower frequencies are stopped with a filter that will allow the higher frequencies to pass through, or a "high pass" filter. The high frequencies are conversely filtered with a "low pass" filter. Combining these two filters gives a "band pass" filter, which lets the frequency band of interest be seen without the unwanted frequencies. Within some bandpass filters, there is the ability to exclude specific frequencies such as 60 Hz electrical interference. This type of filter takes a narrow notch out of the bandpass at the desired frequency, and is called a "notch" filter. The frequencies that are left out of the actual full range when the filters are combined can be plotted. The plot of the remaining amplitude or voltage is called a "frequency response curve" when graphed. A frequency response curve is an ideal way to evaluate the frequency response profile of any EEG instrument's amplifier(s), and to compare one to another. Recording techniques The recording of the EEG is the art of this science. The clients are sometimes cooperative, and occasionally even virtually impossible to record. Clients may come in prepared, though sometimes are totally unprepared for a recording. They are on and/or off medications, moody, argumentative, hyperactive, lethargic, sleepy, and even occasionally awake, alert, cooperative and friendly, with clean hair and a smile. Regardless their condition or state, the recording of their EEG is the goal. Instructions to the patient prior to the arrival in the laboratory should be given in writing. Areas to include are: clean hair (without cream rinse or gels), a case for contact lenses if worn, a meal within an hour of arrival (unless ordered as a hypoglycemia study by the physician), a listing of medications or the medications in their original containers, a good nights sleep (unless done for epilepsy, when 24 hours of sleep deprivation may be ordered, which will increase the diagnostic yield of the EEG by 50-70%). Medications should not be altered unless ordered as such by the prescribing or attending physician. Directions to the laboratory and the telephone number as well as any other pertinent information such as a cancellation policy are appropriate as well. Artifacts Artifacts in EEG are any activity recorded that have a non-cerebral genesis. They fall into two broad categories: physiological and exogenous. Physiological artifacts include eye blink, eye movement, muscle, pulse, cardioballistic, electrodermal and "breech rhythm" (lack of skull in an area). Movement, electrode, 60 Hz, field effect, IV drip, and instrument related artifacts are exogenous, or from non-subject related sources. The eye movement and blink artifacts are due to the movement of the electrical field of the eye. There is an approximately 100 Millivolt difference between the aqueous and vitreous humors, the fluid filling the front and back of the eye. These fluids are separated by a membrane, which when damaged can 'short' these charge gradients and eliminate eye movement artifacts, as seen in eye surgery for cataracts. The elimination of eye movements in an EEG laboratory entails the placing of fingertips gently on the surface of the eye lids, restricting the rotation of the convexity of the cornea past this slight pressure. The eyes must be free of contact lenses, and it is best to ask your subject's permission to place the fingertips for this task. Electrode artifacts may occur following careful preparation of the skin and placement of the electrodes securely on the head if there is a significant impedance difference or mechanical disturbance even in low impedance balanced placements. These discharges have an incredibly fast rise time and decay at the rate of the time constant associated with the high pass filter. Muscle artifacts have biphasic morphology, with a very high frequency spike as each phase. The muscle artifacts may be seen easily as a 'buzz' of fast wild activity during a contraction associated with tension of a muscle like chewing, or as a single biphasic spike as in lateral rectus muscle used to turn the eye to the side. Trains of EMG spikes are seen as a single motor unit discharge, which forms a train of spikes seen with a characteristic "HHHHHHH" configuration. The EMG will be seen as fast activity in qEEG mapping, with some frequency content as low as 10 Hz, but building to a power peak above 70 Hz, though resolution may be lost with slower sampling rates like 128/sec. Pulse artifacts are due to the mechanical movement of the electrode and the "half cell" effect of the electrode/electrolyte/skin interface. This movement is the mechanical arrival of the pulse pressure wave with each heartbeat, with a slight phase delay from the electrical beat of the heart. EKG monitoring makes identification of pulse artifacts more easily done in EEG. Cardioballistic artifacts are the apparent sharp wave associated with the EKG, but seen in the EEG. These are reduced with linking of the ears, and with well-balanced ear impedances, but are difficult to eliminate in some individuals. Sequential montages and the Hjorth montage are better at rejecting this artifact than referential montages. Electrodermal artifacts are seen when the ecrine glands on the facial, palmar and plantar skin surfaces receive a signal from the sympathetic nervous system, causing the myoepithelial cell to contract and excrete "sweat", which is then passively reabsorbed and evaporated. The electrolytic salty solution of the sweat causes direct current sway to the EEG baseline during this excretion and dissipation of the sympathetically initiated event. Thermally induced sweating can usually be avoided by air conditioning and is not a significant problem in modern times and well appointed laboratories, but the emotionally induced artifacts are more difficult to deal with. Hyperventilation tends to reduce the incidence of this artifact following the hyperventilation, but occasionally even this old standby trick will not suffice. If in an appropriate circumstance, an injection of atropine, a sympathetic blocking agent, will be used as a last resort. The last physiologic artifact is the breech rhythm. This high amplitude focal fast activity is seen when there is a decrease attenuation of these activities due to a breech in the presence of the skull. This can be seen in the area of burr holes residual from brain surgery, and in fractures. The same hyperfocal activity is seen in premature infant recordings and in very young infants. It may also be noted in congenitally non-formed skull and in skull decreased density due to a vascular insufficiency, though these later conditions are very rare. Movement by the patient causes both the half-cell sways, similar to those seen with the pulse artifacts, as well as the EMG and electrode pops described elsewhere. With imbalanced electrode impedances and extremely high input impedances designed in some amplifiers without the correction of shielded cables movement artifact may also be a swaying of the baseline due to exogenous movements near the patient. Electrode artifacts include a variety of types, from mismatched electrode metals causing polarization of the amplifiers input stages, bad electrodes causing intermittent spiking, unstable placements and impedance problems causing pops and even wires that are broken, causing a lack of input to the amplifier. These problems all have solutions, but whenever there is a suspected electrode problem, a proper replacement of the wire will be one solution. 60 Hz and field effect artifacts are exogenous artifacts seen when there is a source of the artifact too close to the client, or when the electrode impedances are not balanced. The 60 Hz notch filters should only be used as a last resort in removing the 60 Hz artifact. The source should be identified and eliminated through removal or by redoing the electrodes whose impedances were mismatched. IV drip is seen in clinical settings and is difficult to deal with, suggestions include a grounding wire from the solution to the patient, though this usually has to be rigged with a sterile needle inserted into the IV and a clip attaching the wire to this and the patient/amplifier grounding point. Instrument related artifacts are most easily identified by their stability to the electrode input regardless the electrode used, and their other presentation as being stable to the channel, when the input is assigned to another channel during remontaging. The scope of this chapter is exceeded by the details of instrumentation trouble shooting and repair. I will simply say when it remains after redoing the electrodes carefully and does not track the input when switched to another channel, it is the eq