Why we use Neurofeedback at Sydney Neuro & Integrative Health
When patients first see a QEEG brain map, there is often an understandable fascination with the colours, Z-scores and patterns of electrical activity displayed on the screen. The technology is visually impressive, but the brain map itself is only the beginning of the story.
The more interesting question is what we do with that information.
At Sydney Neuro & Integrative Health, we use QEEG as part of a broader investigation into how the brain is functioning. We are interested in patterns of electrical activity, the timing and coordination of that activity, and how those findings may relate to the person’s clinical presentation. Neurofeedback takes us from observation into training.For patients searching for neurofeedback in Sydney, the important question is not simply what the brain map shows, but how that information can be used to guide a structured brain-training process.
Neurofeedback is best understood as a form of closed-loop learning. The brain produces electrical signals which are measured by EEG. A computer analyses selected features of the EEG in real time and when particular criteria are met, provides immediate visual and/or auditory feedback. The feedback may be subtle such as a sound that will be heard or a visual display may respond. This may seem deceptively simple, however a complex learning process is taking place.The brain is gradually detecting a relationship between its own activity and the feedback it receives. Neural patterns associated with successful feedback become more likely to occur again. With sufficient repetition, the brain may become more efficient at accessing and maintaining those patterns.
This is why we often explain to patients that neurofeedback is not something being done to the brain. The brain is learning – and learning takes repetition.
The Brain May Be Learning Even When You Cannot Explain What You Are Doing
One of the most fascinating aspects of neurofeedback is that patients often cannot consciously describe how they are changing their brain activity. If we ask, “What did you do to change that EEG pattern?” the answer may simply be, “I don’t know.”
That does not necessarily mean that learning isn’t happening.
Think about learning to ride a bicycle. An experienced cyclist can maintain balance, continuously adjust posture, respond to changes in speed and make hundreds of tiny motor corrections without consciously calculating the physics involved. The skill becomes procedural.
Neurofeedback may involve a similar form of implicit learning. The brain learns from the relationship between its activity and the feedback signal without the person necessarily developing a verbal explanation for the process. Modern theories of neurofeedback therefore extend well beyond the idea that we are simply “increasing alpha” or “reducing theta”. Neurofeedback appears to involve several overlapping learning mechanisms, including operant conditioning, reinforcement learning, procedural learning, attention, error-based adaptation and neuroplastic changes within neural networks.
The precise contribution of each mechanism remains an active area of neuroscience research. What is increasingly clear however, is that neurofeedback is not simply a computer showing someone their brainwaves. It is an interaction between measurement, timing, reward and the brain’s extraordinary capacity to adapt.
Rewarding Brain Activity: The Principle of Operant Conditioning
The classical explanation for neurofeedback comes from operant conditioning. The basic principle is familiar: behaviours followed by a meaningful reward become more likely to occur again.
In neurofeedback, the “behaviour” being reinforced is not necessarily a visible movement or conscious action. It is a pattern of brain activity. Imagine, for example, that we are training a particular sensorimotor rhythm. The EEG system continuously monitors the relevant electrical activity. When the brain moves towards the training criterion, the computer immediately provides feedback.
Neurofeedback Sydney: Why Brain Training Needs Repetition
The brain receives information that in effect says: that pattern was successful. This may happen hundreds or thousands of times during a course of training. Over time, repeatedly reinforced patterns may become easier for the brain to reproduce.
At a physiological level, reward-based learning involves networks that include dopaminergic pathways, the basal ganglia and areas of the prefrontal cortex. Dopamine is particularly important in reinforcement learning because it participates in signalling the difference between an expected and actual outcome—a concept known as reward prediction error. The basal ganglia are also deeply involved in learning which actions or patterns are worth repeating. This is well recognised in motor learning, habit formation and procedural learning.
Neurofeedback applies a similar principle to the brain’s own electrical activity. Rather than consciously practising a tennis serve or a piano sequence, the brain is repeatedly exposed to information about its own physiological state.
Why the Timing of Feedback Matters
For the brain to learn efficiently, it must be able to associate an event with its consequence. If you press a button and a light illuminates immediately, the relationship is obvious. If the light illuminates several seconds later, the brain has far more difficulty determining exactly what caused the response.
The same principle applies to neurofeedback.
EEG activity is changing from moment to moment. The closer the feedback occurs to the brain activity being reinforced, the clearer the learning signal may be. Experimental work examining feedback delay supports the importance of latency in neurofeedback system design.
This is one reason the quality of EEG acquisition and real-time processing matters. The amplifier, software, signal processing, artefact management and feedback system all form part of the learning loop. Neurofeedback is not simply a matter of placing electrodes on the scalp and playing a video. The technical integrity of the feedback loop influences what information the nervous system is actually receiving.
“Neurons That Fire Together Wire Together”
Many patients have heard the phrase “neurons that fire together wire together”. It is a simplified description of Hebbian plasticity, but it captures an important concept. Repeatedly activating neural pathways can alter the strength of connections between neurons. Processes including long-term potentiation and NMDA-receptor-mediated synaptic plasticity are fundamental to how the nervous system learns and adapts.
Neurofeedback attempts to harness these existing biological learning systems. When particular patterns of neural activity are repeatedly produced and reinforced, the relevant networks may become more efficient at reproducing those states. This does not mean that a single neurofeedback session permanently “rewires the brain”. That is an oversimplification of neuroplasticity. Neuroplastic change develops through repeated exposure, adaptation and consolidation. The brain must encounter the learning opportunity enough times for a newly reinforced pattern to become increasingly accessible and, ideally, more stable.
This is the reason we place such importance on the frequency and consistency of neurofeedback training.
Why We Recommend at Least Two Sessions Per Week
We are sometimes asked whether a patient can attend neurofeedback once every few weeks or simply book a session whenever symptoms become particularly difficult. Technically, a neurofeedback session can be performed at any interval. Clinically, however, that is not how we prefer to approach a structured neurofeedback program.
At Sydney Neuro & Integrative Health, when neurofeedback is recommended as part of a treatment plan, we generally recommend a minimum of two sessions per week for approximately ten weeks. That recommendation is based on a simple principle: we are trying to facilitate learning and consolidation, not provide an occasional passive treatment.
Twenty sessions should not be interpreted as a magical number at which every brain suddenly changes. There is no universal session number that guarantees an outcome and patients differ considerably in their ability to learn EEG self-regulation. However, meaningful neurofeedback research and clinical protocols commonly involve repeated training across many sessions. Studies of established neurofeedback protocols frequently use treatment courses extending to 20, 30 or 40 sessions, depending on the population and the neurological target. Our minimum twice-weekly structure is intended to maintain continuity in the learning process.
A useful comparison is neurological rehabilitation. If someone is retraining gait following a neurological injury, we would not expect substantial motor learning from practising once every three weeks. Similarly, a musician learning a technically difficult movement does not practise once a month and expect the motor cortex to consolidate the skill.
The brain changes in response to what it repeatedly experiences. For some patients, changes are noticed within the first few weeks. Others progress more gradually. Some may require modifications to their protocol as their EEG and symptoms evolve. Our concern is not to chase a dramatic response after every individual session. We are looking for a trajectory of change.
Not All Neurofeedback Is the Same
The term “neurofeedback” is often used as though it describes one treatment. It does not. There are several different approaches to EEG neurofeedback and they differ considerably in what is being measured and reinforced. One of the oldest and most extensively studied approaches is traditional amplitude or power training. In this form of neurofeedback, the system trains the amplitude of selected EEG frequency bands. For example, a protocol may aim to increase sensorimotor rhythm, commonly referred to as SMR, or modify the relationship between theta and beta activity. The training threshold can be adjusted according to the individual’s EEG activity during the session. The brain is rewarded when the selected rhythm moves in the desired direction.
Traditional protocols involving SMR, theta/beta training and slow cortical potentials have a substantial research history, particularly in ADHD and epilepsy. Their relative simplicity is not a disadvantage. In neuroscience, more complicated does not automatically mean more effective. A well-selected amplitude training protocol may be precisely what a patient needs.
Z-Score Neurofeedback: Training in Relation to a Normative Database
Z-score neurofeedback approaches the problem differently. A Z-score is a statistical measure of how far a value differs from the mean of a reference population. In QEEG analysis, an individual’s EEG measures may be compared with an age-referenced normative database. If a particular measure is two standard deviations above or below the normative mean, that deviation can be quantified. Live Z-score neurofeedback uses this information during training. Rather than simply rewarding an increase or decrease in one frequency band, the system can reinforce movement of selected EEG features towards a defined normative range.
Depending on the system and protocol, these features may include power, asymmetry, coherence and phase relationships. This provides us with with the ability to consider several dimensions of EEG activity simultaneously. It is an elegant concept, but it is important to understand its limitations.
A normative database represents statistical characteristics of a reference population. “Statistically average” is not automatically synonymous with “optimal for every individual”. The quality of the normative database, the quality of the EEG recording and the clinical interpretation of the findings all matter. There is also ongoing scientific debate regarding the strength of evidence for live Z-score neurofeedback compared with more established traditional protocols.
At Sydney Neuro & Integrative Health, we do not assume that a technology is clinically superior simply because it can process more data.
The question is always: What are we trying to train in this particular patient and why?
sLORETA and the Challenge of Understanding Brain Networks
The brain does not function as a collection of isolated electrodes. An electrode positioned at the front of the scalp is measuring electrical potentials at the scalp surface. It is not directly “looking at” one specific brain structure underneath. This is where source localisation methods such as sLORETA (standardised Low Resolution Electromagnetic Tomography) become relevant. sLORETA uses mathematical inverse modelling to estimate the cortical sources most likely to have contributed to electrical activity measured at the scalp.
The word estimate is important. EEG cannot directly image deep brain structures in the same way that MRI provides anatomical images. Source localisation is a mathematical reconstruction based on the electrical data and an underlying head model. Nevertheless, source-based approaches provide an interesting way to consider distributed cortical activity and large-scale functional networks. These may include networks involved in attention, salience detection, executive control and internally directed thought. The Default Mode Network, Salience Network and Executive Control Network are frequently discussed in contemporary neuroscience because cognitive and neurological function depends heavily on how networks coordinate, switch and communicate.
In selected patients – particularly those with complex network dysfunction, traumatic brain injury or multifaceted cognitive presentations – there may be a clinical rationale for considering connectivity or source-based training. But again, complexity must serve the patient. We do not believe that every patient requires the most technologically elaborate neurofeedback protocol available.
The QEEG Does Not Choose the Treatment by Itself
This is perhaps one of the most important points we can make. A brain map should never be interpreted in isolation from the person sitting in front of us. QEEG can provide valuable information about electrical activity, frequency distribution and statistical deviations. Depending on the analytical method, we may also examine measures related to asymmetry, coherence, phase and estimated cortical source activity.
But a coloured map is not a patient.
At Sydney Neuro & Integrative Health, we are particularly interested in complex presentations involving dysautonomia, POTS, cognitive fatigue, concussion, dizziness, migraine, attention difficulties and neurological symptoms that may cross several functional systems. The EEG findings need to make sense in the context of the clinical history. We consider the patient’s symptoms, neurological examination, autonomic findings, medication use, sleep, fatigue, cognitive demands and response to previous treatment. The protocol is selected from that broader clinical picture.
Sometimes the most appropriate approach may be traditional amplitude training. In another patient, Z-score information may provide useful targets. In a complex neurological presentation, connectivity or source-based information may contribute to protocol design. The sophistication lies not in selecting the most complicated software option. It lies in choosing an appropriate training target.
Medication Matters More Than Many People Realise
One of the most under-discussed considerations in QEEG and neurofeedback is medication. The EEG is a recording of the brain’s electrical activity under the physiological conditions present at the time of the recording. If a patient is taking a stimulant, antidepressant, benzodiazepine or antiepileptic medication, that medication may influence cortical excitability and EEG rhythms. This does not mean that patients taking medication cannot undertake neurofeedback. Many neurofeedback studies have included patients taking stable medication, and neurofeedback may be used alongside pharmacological care. The more important issue is consistency.
Consider a patient taking stimulant medication for ADHD. Stimulants may alter theta and beta activity and influence cortical signal stability. If the patient completes their baseline QEEG while taking medication, attends several neurofeedback sessions without medication, restarts medication, changes the dose and then completes a follow-up QEEG under another set of conditions, interpretation becomes considerably more difficult.
Are we observing neurofeedback-related learning? A medication effect? A change in dose? Or an interaction between all three? For this reason, we ask patients to tell us about their medication and any changes occurring during their training program. Where QEEG is being used to monitor change, we generally want the recording conditions to be as consistent as clinically feasible. We do not advise patients to cease prescribed medication for the purpose of neurofeedback unless this has been discussed with the prescribing practitioner. Medication decisions belong with the clinician responsible for prescribing that medication. Our role is to understand the physiological context in which the EEG has been recorded and the neurofeedback is being performed.
Why Some Brains Learn Faster Than Others
Not everyone learns EEG self-regulation at the same rate. This is not particularly surprising when we consider other forms of learning. Some people develop motor skills rapidly. Others require considerably more repetition. Attention, fatigue, sleep, motivation, medication, neurological injury and baseline brain function may all influence the learning environment. Attention itself is relevant to neuroplasticity.
During neurofeedback, we want the patient appropriately engaged with the feedback process. Excessive fatigue, poor sleep or reduced alertness may alter both the EEG and the patient’s capacity to participate effectively in training. There may also be periods where progress appears to plateau. The brain is a homeostatic system. It constantly attempts to maintain stability and regulate excessive excitation or inhibition. Neuroplasticity is therefore not simply a linear process where every session produces exactly the same increment of improvement.
This is why neurofeedback protocols may need to be reviewed and adjusted. We observe the patient. We review symptoms. We consider the EEG. We look at how the individual is responding to training.
Neurofeedback should be dynamic because the nervous system itself is dynamic.
What Might Change During a Neurofeedback Program?
Patients naturally want to know what they should feel. The answer varies. Some patients first notice changes in sleep. Others describe greater mental clarity or an improved ability to sustain attention. Some report feeling less overwhelmed by sensory or cognitive demands. Others notice changes in emotional regulation, headache frequency or their ability to recover following periods of intense concentration. In complex patients, the first improvement may be surprisingly subtle. A patient may say, “I still have symptoms, but I recover more quickly.”
Another may notice that a demanding day no longer causes a two-day cognitive crash. A parent may observe that their teenager is initiating tasks more readily. Someone with chronic cognitive fatigue may realise that they have read several pages of a book without repeatedly losing their place.
These changes matter! We are not simply looking for the disappearance of a symptom.
We are interested in whether the nervous system is becoming more adaptable, efficient and capable of self-regulation. Where clinically appropriate, repeat QEEG may also help us examine whether measurable EEG features have changed over the course of training. Clinical improvement and EEG change should be interpreted together.
Figure 1: The above infographic explains neurofeedback as a form of implicit brain learning, where the brain gradually learns to reproduce healthier patterns of activity through repeated feedback and reward. It shows how EEG-based signals are measured in real time, linked to visual or auditory rewards and reinforced through mechanisms such as operant conditioning, reinforcement learning, attention training and neuroplasticity. In simple terms, neurofeedback helps the brain “practice” more efficient functioning over time, even when the patient may not be consciously aware of exactly what is being learned.
Neurofeedback Is Not a Magic Reset Button
We are enthusiastic about neurofeedback because the concept is neurologically compelling and because we see patients who are seeking more sophisticated approaches to brain rehabilitation. We are equally cautious about exaggerated claims. Neurofeedback is not a universal cure. Not every person responds at the same rate. Not every neurofeedback protocol has the same level of scientific support. Some approaches have decades of research behind them, while newer techniques involving live Z-score and source-based training remain areas of developing evidence. Commercial enthusiasm can sometimes move faster than clinical research.
We believe patients deserve to understand that. Our approach is therefore NOT to promise that an advanced brain map will automatically reveal a single “abnormality” that can be trained away. The brain is considerably more complex than that.
Instead, QEEG provides another layer of physiological information. Neurofeedback provides a method of repeatedly presenting the nervous system with information about its own activity. The clinical task is to determine whether that information is relevant to the patient’s presentation and if it is, how best to use it.
Our Approach at Sydney Neuro & Integrative Health
At Sydney Neuro & Integrative Health, we see many patients whose symptoms do not fit neatly into one system. A patient may present with POTS and cognitive fatigue, but also experience migraine, visual sensitivity and poor sleep. Another may have ADHD alongside autonomic symptoms and difficulty regulating arousal. A patient following concussion may experience dizziness, headaches, poor concentration and a marked reduction in tolerance to busy environments. For these patients, we are rarely interested in one isolated number. We are trying to understand how the brain and nervous system are functioning as a whole. QEEG and neurofeedback can form part of that investigation and rehabilitation process.
When we recommend a neurofeedback program, we want patients to understand why consistency matters. A minimum schedule of twice-weekly training over approximately ten weeks is not designed to create an arbitrary package of appointments. It reflects the fact that neurofeedback is a learning process. The brain must repeatedly encounter the feedback. Neural systems must repeatedly practise the target state and have the opportunity to consolidate what it is learning.
The future of neurological rehabilitation will almost certainly involve increasingly sophisticated ways of measuring brain activity. But technology alone is not the treatment.The real work is performed by the brain itself.
Neurofeedback simply gives the brain something it rarely receives:
Accurate, immediate information about its own activity and repeated opportunities to learn from it.
Interested in QEEG Brain Mapping or Neurofeedback?
If you are experiencing persistent problems with attention, cognitive fatigue, brain fog, headaches, sleep, anxiety, post-concussion symptoms or complex neurological and autonomic symptoms, a QEEG may provide another layer of information about how your brain is functioning.
At Sydney Neuro & Integrative Health, we use QEEG findings alongside your clinical history, neurological presentation and other relevant investigations to determine whether neurofeedback may be appropriate for you. If neurofeedback is recommended, we will explain the findings from your brain map, the type of training we believe is most relevant to your presentation and what a structured treatment program may involve.
Book an appointment for a QEEG Brain Mapping evaluation or contact our clinic to discuss whether QEEG-guided neurofeedback may be appropriate for you.
References
Arns, M., Clark, C. R., Trullinger, M., deBeus, R., Mack, M., & Aniftos, M. (2020). Neurofeedback and attention-deficit/hyperactivity-disorder (ADHD) in children: Rating the evidence and proposed guidelines. Applied Psychophysiology and Biofeedback, 45, 39–48.
Coben, R., Hammond, D. C., & Arns, M. (2019). 19 channel Z-score and LORETA neurofeedback: Does the evidence support the hype? Applied Psychophysiology and Biofeedback, 44(1), 1–8.
Collura, T. F. (2014). Technical foundations of neurofeedback. Routledge.
Congedo, M., Lubar, J. F., & Joffe, D. (2004). Low-resolution electromagnetic tomography neurofeedback. IEEE Transactions on Neural Systems and Rehabilitation Engineering, 12(4), 387–397.
Enriquez-Geppert, S., Huster, R. J., & Herrmann, C. S. (2017). EEG-neurofeedback as a tool to modulate cognition and behavior: A review tutorial. Frontiers in Human Neuroscience, 11, 51.
Hammond, D. C. (2011). What is neurofeedback: An update. Journal of Neurotherapy, 15(4), 305–336.
Kropotov, J. D. (2009). Quantitative EEG, event-related potentials and neurotherapy. Academic Press.
Marzbani, H., Marateb, H. R., & Mansourian, M. (2016). Neurofeedback: A comprehensive review on system design, methodology and clinical applications. Basic and Clinical Neuroscience, 7(2), 143–158.
Mirifar, A., Beckmann, J., & Ehrlenspiel, F. (2022). Neurofeedback and neural self-regulation: A new perspective based on allostasis. Reviews in the Neurosciences, 33(6), 607–625.
Ros, T., Baars, B. J., Lanius, R. A., & Vuilleumier, P. (2014). Tuning pathological brain oscillations with neurofeedback: A systems neuroscience framework. Frontiers in Human Neuroscience, 8, 1008.
Sherlin, L., Arns, M., Lubar, J., Heinrich, H., Kerson, C., & Strehl, U. (2011). Neurofeedback and basic learning theory: Implications for research and practice. Journal of Neurotherapy, 15(4), 292–304.
Strehl, U. (2014). What learning theories can teach us in designing neurofeedback treatments. Frontiers in Human Neuroscience, 8, 894.
Thatcher, R. W. (1998). Normative EEG databases and EEG biofeedback. Journal of Neurotherapy, 2(4), 8–39.
Thatcher, R. W., & Lubar, J. F. (2009). History of the scientific standards of QEEG normative databases. International Journal of Psychophysiology, 73(2), 95–104.