TITLE: Effects of neurofeedback training on the brain wave of adults with forward
head posture

  ABSTRACT:
[Purpose] The purpose of the present study was to examine the effects of neurofeedback
training on electroencephalogram changes in the cervical spine in adults with forward head
posture through x-ray. [Subjects and Methods] The subjects of the study were 40 college
students with forward head posture, randomly divided into a neurofeedback training group
(NFTG, n=20) and a control group (CG, n=20). The neurofeedback training group performed
six sessions of pottery and archery games, each for two minutes, three times per week for
four weeks, while using the neurofeedback system. [Results] There were significant effects
within and between groups in terms of the Delta wave, the Theta wave, the Alpha wave, the
Beta wave, or the sensory motor rhythm. Especially, the Delta wave, Beta wave, and the
sensory motor rhythm were showed significant effects between the groups. [Conclusion] It
is thought that neurofeedback training, a training approach to self-regulate brain waves,
enhances concentration and relaxation without stress, as well as an increase in attention,
memory, and verbal cognitive performance. Therefore an effective intervention method to
improve neck pain and daily activities.

BODY.INTRODUCTION:
Owing to the prevalence and popularity of computers, students and workers are increasingly
experiencing musculoskeletal abnormalities in their neck and shoulders1). Using computers and smart phones for many hours, coupled
with lack of exercise, may cause stiffness of the muscles in the neck and shoulders,
inducing weakness in the soft tissues. Such postural and lifestyle habits lead to forward
head posture (FHP), which can cause relative compensation such as increased lordosis in the
junction of the skull and neck, and abnormal, consistent muscular contraction inducing
changes in the craniocervical junction2).
Attention is a basic cognitional function necessary for learning and information processing,
and it serves as a basic ability essential for educational activity, information
acquisition, and social adjustment3).
Attention and memory are the most basic elements of human cognition; issues with either may
affect the seamless acquisition of new information and consistent performance in learning
and tasks4). Posture affects people in
terms of psychological, physical, structural, and functional changes. Specifically, bad
posture is thought to increase the possibility of a decline in learning efficiency,
attention, and memory. The collum and the brain, in particular, are closely situated in
terms of anatomical structures. According to previous research, FHP may induce a reduction
in proprioceptive sensibility, in addition to interference between the nerves and the
muscles. These problems may, in turn, affect an individual's mind and emotions5). Neuro-feedback (NFB) is a type of brain
training—based on biofeedback—in which brainwaves are induced and feedback of the induction
is provided so that users can control their own brainwaves. It has been researched in
various fields, including brain activation training for the elderly and training for sports
requiring concentration, such as golf, archery, and shooting6). Learning processes, thought, and activity are controlled by
cerebral functions, which depend on the activities of many cranial nerves. These activities
can be identified with the help of electroencephalogram (EEG). When compared to other
neuroimaging techniques for research, the EEG is a short-term, noninvasive method that
directly shows changes in cerebral function. From a cost perspective, it has the advantage
of being able to provide various useful data based on a short-term test.  In this study, a neuro-feedback training program to a study sample with unstable postures
and identified the influence of neuro-feedback training program on the subjects by means of
an EEG, on the assumption that the FHP was due to malalignment of the cervical joints and
was possibly affecting the subjects' attention.

BODY.SUBJECTS AND METHODS:
The subjects of this study were students from a university located in Gyeongsangbuk-do,
South Korea, whose cervical lordosis angle was 21° or less7), whose anterior weight bearing (AWB) of the head was 15 mm or
more8), and whose cervical extension
range of motion (ROM) was 70° or less. They understood the purpose and method of the study,
and voluntarily provided consent before the experiment. Those who were periodically
undergoing treatment or taking drugs for pain reduction, and those with neurological
problems were excluded from the experiment. Table
1Table 1.General characteristics of each group (Mean ± SD)NFTG (n=20)CG (n=19)Male/Female9/119/10Age (years)20.9 ± 3.322.8 ± 4.4Height (cm)168.5 ± 9.2167.6 ± 8.7Body weight (kg)59.3 ± 11.559.5 ± 11.4NFTG: neurofeedback training group; CG: control group shows the general characteristics of the subjects. All patients understood the
purpose of this study and provided written informed consent prior to participation in
accordance with the ethical standards of the Declaration of Helsinki.  The subjects were randomly divided into a neuro-feedback group and a control group, and
underwent a radiographic check and a nondestructive inspection (NDI). After a four-week
application of intervention three times per week for each group, the subjects underwent
another radiographic check and NDI. Neuro-feedback training was applied to the
neuro-feedback group using the Neuro-Feedback System (Braintech Corp., Korea) developed by
the Korean Research Institute of Jungshin Science. The training was performed in a place
where light and noise were blocked. After taking a rest for ten minutes, each subject wore a
headband in such a way that the FPz, as the center electrode, adhered to the middle of the
forehead above the prefrontal region, and the reference electrode adhered to the left
earlobe. As a training exercise for improving attention, the subjects performed a cup-making
game and a mind arrow game. In the cup-making game, the subject had to collect glass pieces
to make a cup; the more cups made, the higher the score. When the brainwaves were stable
enough to satisfy the training conditions, a signal sound indicated that a cup was complete.
If the brainwaves were unstable, the program stopped. The game was performed six times for
two minutes each time. The mind arrow was a game of archery using brainwaves. When the
brainwaves of the subject satisfied the training conditions and a signal sound was made, the
subject could shoot an arrow with the aim of hitting the target in the center. Fifteen
arrows could be shot for two minutes, and the total score indicated the results of the
brainwave training after six sessions, each lasting twelve minutes.  Radiographic inspection was conducted to identify the following: the absolute rotation
angle (ARA)9) for measuring lordosis of the
neck; anterior weight bearing (AWB)10) to
investigate forward head posture; and range of flexion and extension motions(PFEM)11) to identify the angle of flexion and
extension. In general, it is the brainwaves of the frontal lobe that are used for recording
purposes. In this study, we measured the Delta (δ) wave, the Theta
(θ) wave, the Beta (β) wave, and the sensory motor
rhythm (SMR) for recording purposes. We followed the international 0–20 system to locate
scalp electrodes for the brainwave recording. When the total ratio is determined as 50, the
ratio of the electrodes is 20:20:10 between the parietal region and the nasion in a forward
direction, between the parietal region and the inion in a rearward direction, and between
the parietal region and the upper point of both auricles laterally12).  SPSS 14.0 for Windows was used to statistically process the data in this study. An
independent t-test was performed for pretest-posttest within-group comparison and for
pretest-posttest difference comparison between the groups. For level of statistical
significance, p=0.05.

BODY.RESULTS:
As seen in Table 2Table 2.Comparison of the change of brain wave between the neurofeedback training group
and the control group (mean ± SD)NFTG CG Pre-testPost-testPre-testPost-testDEF17.3 ± 0.514.9 ± 3.6*a17.2 ± 0.717.1 ± 3.7TEF29.5 ± 0.227.8 ± 3.5*29.4 ± 0.728.6 ± 3.7ALF33.0 ± 0.436.0 ± 7.3*33.2 ± 0.735.7 ± 6.8BEF20.2 ± 0.427.3 ± 8.2*a20.2 ± 0.421.3 ± 2.3SMRF2.5 ± 0.111.2 ± 7.2*a2.5 ± 0.14.7 ± 0.2*Significant difference from the pre-test at<0.05. aSignificant
difference in gains between the two groups. p<0.05. NFTG: neurofeedback training
group; CG: control group; DEF: delta frontal; TEF: theta frontal; ALF: alpha frontal;
BEF: beta frontal; SMRF: sensory motor rhythm frontal, the neuro-feedback group showed significant differences in the
δ wave, the θ wave, the α  wave, the
β wave, and the SMR (p<0.05) in the pretest-posttest within-group
comparison, while the control group showed no significant difference in the
δ wave, the θ wave, the α  wave, the
β wave, or the SMR in the comparison (p>0.05). As for the
pretest-posttest difference comparison between groups, significant differences were found in
the δ wave, the β wave, and the SMR (p<0.05) (Table 2).

BODY.DISCUSSION:
Jang13) reported that neuro-feedback
training using brainwaves may generate positive brainwaves due to the force of one's will to
feedback one's own physical reactions with a view to modifying behavior. Brainwave
examination by EGG is a noninvasive method that displays functional changes in the cerebrum
and provides various useful data within a short time14). A β wave faster than 13 Hz is activated when a
normal person is excited or concentrates on a certain task, and this is usually displayed in
the frontal and parietal regions. The SMR becomes predominant when a person pays attention
to a relatively simple task, while the activities of the sensory motor cortex are minimized
without physical movement. The α wave is a basic brainwave reflecting the
stability of the brain, and it can be observed when the balance of brain activities is
focused or attention is needed. Conversely, the β wave is prominent when a
person is experiencing worry or anxiousness. The δ wave is induced, not in
a conscious state but in an unconscious state, and it is associated with intuition. As seen
in a patient with a head injury, the δ wave in an arousal state slows down
data processing in the brain to interrupt conscious activities15). Penistone15) reports that regular relaxation or meditation training may reduce
the low frequency potential and increase the activation potential of the α 
wave to induce a stable mentality.  In this study, the neuro-feedback training group showed significant increases in the
δ wave, the θ wave, the α wave, the β
wave, and the SMR after the intervention, while the control group showed no significant
increase. As for the pretest-posttest difference comparison between the groups, significant
differences were observed in the δ wave, the β wave, and
the SMR. After the intervention, the neuro-feedback training group showed significant
changes in the α  wave and the δ wave, indicating that
their attention was enhanced because the brainwaves were stabilized by the brain training.
The results of this study were supported by Penistone15) in research reporting that regular relaxation or meditation
training increases the activation potential of the α  wave to induce a
stable state of the brain. The θ wave and the β wave also
showed significant changes in the neuro-feedback training group, results that were similar
to those of Lee16) who reported a reduced
θ wave in the frontal lobe and the parietal lobe after training, and
those of Seo and Park17), in which
cognitive anxiety declined and attention increased in normal people when training to maximum
performance competency. Such changes may be common characteristics of brainwave types
inducing increased mental attention. In the performance of a task, the θ
wave and the β wave tended to be reduced, indicating an increase in
attention and favorable achievement14).
Sterman18) reports that the SMR is
closely related to attention and indicates that an increase in the SMR may induce changes to
a state of attention. The results of this study are similar to those of Sterman. In this
context, neuro-feedback training may be helpful in stress relaxation, enhancement of
attention, and a more stable, efficient state of brain functions that will optimize brain
performance.  In this study, brainwave changes by means of neuro-feedback training in adults with forward
head posture (FHP). After the neuro-feedback training, the subjects showed significant
increases in the δ wave, the θ wave, the α
 wave, the β wave, and the SMR. FHP induces muscular tension and
malalignment of the cervical structures, causing stress and a decline in attention due to
transformation of the body structure. Our assumption was that after the neuro-feedback
training, the subjects with FHP might experience a stable mentality and relaxation without
stress, as well as an increase in attention, memory, and verbal cognitive performance. We
sought to verify these assumptions based on changes in their brainwaves during the training.
Although direct effects on attention were not measured in this study, it might be said that
the training positively affected attention. Consistent studies may be needed in the future
to identify various methods for measuring brainwaves in many parts of the brains of patients
with different disorders.

Question: Compared to baseline what was the result of neurofeedback training group (NFTG) on δ wave, the θ wave, the α wave, the β wave, and the sensory motor rhythm (SMR)?
Evidence: the control group showed no significant difference in the
δ wave, the θ wave, the α  wave, the
β wave, or the SMR in the comparison (p>0.05). 
Answer: significantly increased