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The use of EEG biofeedback technology (neurofeedback) to self-regulate brainwave frequencies with the aim of recovering or optimising function and performance is becoming increasingly established. Its clinical applications include the treatment of epilepsy [1], attention hyperactivity disorders [2] and addiction [3]. Meanwhile it has also assumed a role in optimising performance in healthy individuals within fields as diverse as cognition, sport and artistry [4], including NASA research aimed at minimizing pilot error [5]. In particular, recent studies report significant improvements in attention [6,7], memory [8], mental rotation [9], mood [10], dance [11] and musical performance [12].
The set of skills required to undertake surgical and microsurgical procedures includes many of the cognitive and sensorimotor skills which neurofeedback has been shown to enhance. The demands on those undergoing surgical training are considerable and often stressful [13,14]. There may also exist time pressures on those seeking to acquire surgical skills and the availability of expert trainers is often at a premium. To this end there is investment in developing and evaluating procedures to enhance surgical training and performance such as simulation, video, virtual reality, motion tracking and mental training [15-17] In this study, we examine the effect of two neurofeedback protocols on the acquisition of microsurgical skills by a group of trainee ophthalmic surgeons. Specifically, fast wave training has been shown to facilitate sustained attention providing a relaxed attentional focus and increasing working memory [6-8], of particular importance for surgery which requires agility, concentration and stamina for long periods of time [18,19]. The sensory motor rhythm neurofeedback protocol helps relax the motor system which is vital in complex sensory-motor performance [4,11]. On the other hand slow wave training may benefit both stamina and morale, for aside from relaxation, this protocol enhances mood and well-being, through putative action on the limbic emotion system [10,31] Ophthalmic surgery, by virtue of the scale at which surgery is undertaken and the extreme adverse consequence of error, provides an ideal model with which to evaluate the potential benefits of neurofeedback. In brief, surgical performance in a skills laboratory [14] was assessed by means of two principal measures, surgical time and technique, representing the main critical dimensions in surgical proficiency: pace and accuracy [20,21]. Our initial hypothesis was that neurofeedback training would be able to successfully modify these measures with the aim of enhancing individual surgical skills-scheduled within the context of standardized and ongoing medical training – by modulating general cerebral function (via mechanisms of neuroplasticity) towards more 'efficacious' neural information processing appropriate to both the execution, as well as the retention, of fine sensorimotor maneuvers. In this regard surgeons were neither expected nor instructed to emulate or recollect 'neurofeedback conditions' on their own immediately prior to or during their performances, rather it was envisaged that the neuromodulatory effects of sustained control of the EEG would cumulate and be simultaneously active during the course of the multiple surgical training sessions as well as during the final performance.
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In conclusion, and to the best of our knowledge, this is the first study to show extensive evidence for performance enhancement in microsurgical procedure by means of EEG self-regulation. More specifically, our data have shown that SMR/theta training provides statistically reliable improvements in surgical technique, together with a 26% reduction in time on task. This may lead to reductions in surgical stress, contact time with the eye, and lessen the risk and extent of surgical complications [43], thereby improving surgical outcomes. Our results are further supported by good agreements between qualitative and quantitative performance assessment measures.
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