For decades, NASA has been studying astronaut’s physiological responses to zero gravity, to living in outer space and to staying in space vehicles and space stations for extended periods of time. The NEEMO-9 project involved under water research since the environment provides some useful similarities to working in space. For three days of the 22-day mission two astronauts wore the FlexComp Infiniti™ system. Measurements for heart rate and electrocardiogram, respiration, skin conductance, hand temperature and finger blood volume pulse were taken to gauge the effect of isolation, workload and fatigue on the astronauts. The data collected was later studied by the research team.

As NASA’s involvement in space and underwater research winds down, private enterprise is poised to take over. As an example of the privatization of space and underwater exploration, the next space flight may be a commercial one. Interestingly, Sir Richard Branson has just embarked on what has been referred to as mankind’s greatest diving challenge where selecting the best breathing system is crucial for survival. Breathing is life sustaining under water or in space, however here on earth with an abundant supply of oxygen many of us still do not breathe correctly. Those familiar with the use of biofeedback in controlling stress know the importance of proper breathing techniques.

Thought Technology has sponsored the creation of EZ-Air Plus software distributed by the Biofeedback Foundation of Europe. Dr. Hal Myers, President of Thought Technology commented, “The EZ-Air breath pacing program helps the user master optimal breathing techniques. It’s simple enough for anyone to use on their home, office or laptop computer. Similar functionality is also included in our sophisticated Biograph Infiniti software and FlexComp hardware used by NASA to add respiration pacing to clinical standards.”

As this chapter in US history comes to a close, the skills learned in the NEEMO-9 project, using psychophysiology and biofeedback will continue to contribute to the International Space Station. Thought Technology salutes the people of NASA, their work and the mark they have made on history. NASA’s exploration has proven that Infiniti has a role to play in health and human performance at work and at home.

Material adapted from Thought Technology Ltd.

Researcher Donald Penzien

He said the costs of prescription prophylactic drugs – the kind chronic migraine sufferers take every day to prevent onset – may not seem much even at several dollars a day.

“But those costs keep adding up with additional doctor visits and more prescriptions,” Penzien said. “The cost of behavioral treatment is front-loaded. You go to a number of treatment sessions but then that’s it. And the benefits last for years.”

Published in the June issue of the journal Headache, the study compared the costs over time of several types of behavioral treatments with prescription-drug treatments. The research team included investigators from Wake Forest University, UMMC and the University of Mississippi.

The researchers found that after six months, the cost of minimal-contact behavioral treatment was competitive with pharmacologic treatments using drugs costing 50 cents or less a day. Minimal-contact treatment is when a patient sees a therapist a few times, but largely practices the behavioral techniques at home, aided by literature or audio recordings.

After one year, the minimal-contact method was nearly $500 cheaper than pharmacologic treatment.

“We have a whole armamentarium of behavioral treatments and their efficacy has been proven. But headache sufferers are only getting a tip of these options,” said Dr. Timothy Houle, associate professor of anesthesiology and neurology at Wake Forest University, and the study’s principal investigator. “One reason is people think behavioral treatment costs a lot. Now with this study, we know that the costs are actually comparable, if not cheaper, in the long run.”

At a time when health-care costs are under national scrutiny, the study offers a framework for comparing costs that researchers can update and use for years to come.

“We thought, ‘Wouldn’t it be fun to model this and see how it comes out over time?’” Penzien said. “All the figures are there so if someone disagrees with it, they can plug in their own numbers.”

The researchers did not compare the effectiveness of methods, nor did they calculate the costs over time of individual drugs, since dosages and prices vary widely. Rather, they figured the per-day costs of each method based on fees of physicians and psychologists. For the physician group, they added in the cost of prescription beta-blocker drugs at various prices.

For instance, among the psychologists surveyed, one-on-one behavioral sessions cost between $70 and $250 for the intake visit and $65 and $200 for follow-up visits. That put the median intake cost at $175 and median follow-up cost at $125 for a median 10 visits.

The researchers calculated the median cost of pharmacologic approaches at $250 for the intake session and a professional fee of $140 per session. Median time to the first follow-up was 52.2 days, rising to 60 for the second with a median five visits per year.

To get information on behavioral treatments, the researchers surveyed members of the Behavioral Issues Group of the American Headache Society. For figures on pharmacologic treatments, the researchers surveyed a group of Headache Society-member physicians they knew treated substantial numbers of headache sufferers.

The most expensive behavioral treatment method – individual sessions with a psychologist in clinic – cost more than pharmacologic treatment with $6-a-day drugs in the first months. But at about five months, individual sessions become competitive. After a year, they are cheaper than all methods except treatment with drugs costing 50 cents or less a day.

Overall, group therapy and minimal-contact behavioral treatment were cost-competitive with even the cheapest medication treatment in the initial months. At one year, they become the least-expensive headache treatment choice.

Material adapted from University of Mississippi Medical Center .

Researchers from the University of New South Wales, Australia, teamed up to investigate whether physiological responses to emotions correlate with emotional empathy in a group of adults with severe TBI and a group of healthy control participants. After determining the emotional empathy abilities of the participants by questionnaire, the researchers measured activation of their facial muscles and sweat glands, in response to happy and angry facial expressions, using facial electromyography (EMG) and skin conductance.

They found that the control group spontaneously mimicked the emotional facial expressions they saw, and also perspired more in response to angry faces. In contrast, those in the TBI group generally scored lower in emotional empathy and were less responsive, specifically to angry faces. Lack of emotional empathy was specifically found to be associated with reduced physiological responses to angry faces.

“The results of this study were the first to reveal that reduced emotional responsiveness observed after severe TBI is linked to changes in empathy in this population. The study also lends support to the conclusion that impaired emotional responsiveness – including facial mimicry and skin conductance – may be caused, at least in part, by dysfunction within the system responsible for emotional empathy”, explains author Arielle De Sousa. “This has important implications for understanding the impaired social functioning and poor quality of interpersonal relationships commonly seen as a consequence of TBI, and may be key to comprehending and treating empathy deficits post-injury.”

Material adapted from Elsevier.

Reference
Arielle de Sousa, Skye McDonald, Jacqueline Rushby, Sophie Li, Aneta Dimoska, and Charlotte James, “Understanding deficits in empathy after traumatic brain injury: The role of affective responsivity,” Cortex, Volume 47, Issue 5 (May 2011), published by Elsevier in Italy.

A case study in the Spring 2011 issue of the journalBiofeedback details the heart rate variability biofeedback training of a collegiate golfer. The study examined psychological and physiological measures as well as sport performance.

At the beginning and end of the 10-week study, the golfer completed psychological questionnaires, and researchers recorded muscle tension, respiration, and heart rate, and assessed her sport performance using virtual reality golf. The resonance frequency of the golfer’s cardiovascular system was determined. In weekly sessions, she learned to breathe slowly, but not too deeply, to meet that frequency, and was given instructions for transferring her breathing skills to competitive sport.

By the end of the study, these efforts showed positive results. Prior to the study, the golfer’s score on 18 holes of virtual reality golf was 46 strokes, while after the study she reduced her score to 30 strokes. Her putting, driving distance, and birdie and par scores also improved. Psychologically, the golfer reported reductions in six of 11 areas of stress.

As with learning to compete in a sport, heart rate variability biofeedback needs extended time and practice to achieve the best results. In this study, the golfer achieved the correct rate of breathing only after four weeks of training.

Increased heart rate variability indicates a flexible autonomic nervous system that is responsive to both internal and external stimuli, and related to fast reaction times and adaptability. Previous studies with wrestlers, baseball players, and Latin and Ballroom dancers where heart rate variability biofeedback was applied have consistently showed improved performance.

Material adapted from Allen Press Publishing Services.

Download / Reference
Lagos et al. Virtual Reality–Assisted Heart Rate Variability Biofeedback as a Strategy to Improve Golf Performance: A Case Study, Biofeedback, Volume 39, Issue 1, Spring 2011.

“The initial plan is to have six weeks (of classes) for people to see how they do,” Wilkins said. “If we find there are some people who still have not gotten to the point where they feel healthy about their stress level, we’ll go into more experiential (techniques), which we will do in the second six weeks (of class).”

The class will start off with an evaluation of the participants’ stress level, which includes inherently negative stress, such as a deadline, and inherently positive stress, such as a family event.

“We’re going to be starting with looking at the person’s recent experiences – that can be over the last two or three years – and evaluating what his or her stress level is,” Wilkins said. “At the end of that session, each person there should be able to know, ‘What’s my stress level, and is that a healthy level or a level that I may want to work on?’”

Pierre Wilkins, a social worker with the Army Substance Abuse Program, demonstrates use of the biofeedback equipment at Moncrief Army Community Hospital. The screen shows images that are designed to either increase or reduce stress in the participant. Throughout the biofeedback sessions, participants learn how to control their reaction to stressors. (Photo Credit - Susanne Kappler) (click to enlarge)

After that, participants will identify if they have any stress-related symptoms, such as frequent headaches, anxiety or depression, and how severe these symptoms are. Once the symptoms are identified, the focus of the class shifts to changing behavior to reduce stress. The change in behavior will be based on the participants’ individual needs, Wilkins said.

“For example, some person might say, ‘I don’t like shopping,’ or, ‘I don’t shop often, and I’m kind of tied to my personal space.’ Maybe the goal would be to say, ‘Go out shopping today and buy something that you find frivolous or not meaningful and see how it feels,’” he said.

Wilkins said he hopes that most people will be able to deal with their stress better after the first six weeks. For those who would like to continue working on their stress reduction, the second six-week class will examine how breathing and other physical factors contribute to stress and relaxation, said Bill York, a social worker with ASAP.

York will also offer a series of individual biofeedback sessions to people who want to continue after the second six-week class. York described biofeedback as a “noninvasive treatment technology that is based upon the principle that changes in thinking and emotions can result in changes in the body.”

People who participate in biofeedback sessions are connected to electrical sensors, which measure an array of bodily functions, such as heart rate, breathing rate, skin temperature, and muscle tension. While connected, the participant is subjected to visual and auditory stimulants.

Participants in biofeedback sessions are connected to electrical sensors, which measure heart rate, breathing rate and skin temperature among other things. The measurements provide feedback about the person's stress level. (Photo Credit - Susanne Kappler) (click to enlarge)

At the beginning of a session, a baseline is established and the participant is exposed to images and sounds that are designed to relax him or her.

“Then, all of a sudden, for 30 seconds, we show you things that are going to startle you, like creatures and various things that you will have a response to,” York said. For a Soldier, those images might include combat scenes, York said.

“We’re talking about de-stressing and all of a sudden (the Soldier) sees a picture of a rooftop, and I watch his heart rate triple in half a second,” York said.

The session will also analyze how long after the exposure to the stressor the person’s stress level remains high.

“What we do then is we look for change. Does your heart rate begin to go back down? Does your blood pressure begin to go back down in that follow-up phase?” York said. “A lot of people who are stressed; they don’t recover. Their heart rate stays up. Their breathing rate stays up.”

Throughout the sessions, people practicing biofeedback will learn to control their physical reaction to stressors, which will be reflected by the images on the screen.

For example, participants are shown an image of the sun setting over the water. As the person relaxes, the sun begins to set and the ripples in the water begin to calm.

“The advantage to this is you’re instantly seeing what your body is telling you,” York said.

The six-week stress and anxiety reduction class is open to all ID card holders, but a medical referral is needed to schedule a biofeedback session.

Material adapted from the United States Army. Original article written by Susanne Kappler, Fort Jackson Leader.

Recent studies have suggested a threefold increase has occurred in the incidence of these disorders in the last ten years. Schools and parents are wondering how to cope with increasing numbers of children who present with Asperger Syndrome, a constellation of traits first described by the Viennese paediatrician Hans Asperger in 1944.

According to Dr. Lynda Thompson, Ph.D. of the ADD Center in Toronto, “Brainwave patterns in those with Asperger’s syndrome differ from those of the same age peers. We have seen many people with Asperger’s syndrome at our ADD Centre over the past decade and have found that they respond well to neurofeedback training.”

Researchers using neurofeedback are looking at how changes in brainwave patterns indicate whether someone is paying attention to the outside world or drifting off into their own world. This type of research requires the use of specialized equipment to ensure correct measurement of brainwaves. Although this computer-based training looks promising, more research is required.

Biofeedback Foundation of Europe 15th Annual Meeting
Researchers will be attending the BFE Annual Meeting in Munich, Germany from February 22-26, 2011 to learn more about this topic from Drs. Lynda and Michael Thompson. In their 2-day workshop “Neuroanatomical Underpinnings of Effective Intervention with Asperger’s Syndrome & Autistic Spectrum Disorders – From Theory to Practice (Emphasizing the Synergistic Combination of NFB with BFB),” participants will learn to understand the basic symptoms of Asperger’s syndrome and Autism and how an assessment is carried out.

Drs. Lynda & Michael Thompson
Dr. Lynda and Michael Thompson are based in Toronto, Canada where they run the ADD Centre. They have taught workshops in neurofeedback and biofeedback on five continents.
Lynda Thompson, Ph.D. is a licensed psychologist with a background in teaching. She has authored various books, like The A.D.D. Book: New Understandings, New Approaches to Parenting Your Child (1998) co-authored with paediatrician William Sears.

Michael Thompson, MD formerly practiced medicine in addition to serving as Associate Professor and head of post-graduate education in Psychiatry, University of Western Ontario, psychiatric consultant to The Hospital for Sick Children’s neurology department, examiner for the Royal College of Physicians (Canada) and chairman of their examinations committee in psychiatry.

Together they have authored two software suites Setting Up for Clinical Success and Specialized Application Scripts (both available from the Biofeedback Foundation of Europe). They have also written numerous professional publications and collaborated on The Neurofeedback Book: An Introduction to Basic Concepts in Applied Psychophysiology, which has become a basic text in the field of EEG Biofeedback.

Material adapted from Biofeedback Foundation of Europe.

Health care is regulated by state licensing boards; however, biofeedback is not a regulated modality. The goal is to have a recognizable credential that consumers, the health care industry, and professionals can use as a mark of excellence in the delivery of clinical services.

Additionally, the logos which refer to BCIA and to each specific program are trademarked and all certificants are encouraged to use the logo and the new terminology to refer to their certification.

BCB is Board Certified in Biofeedback.

BCN is Board Certified in Neurofeedback.

BCB-PMD is Board Certified in Biofeedback for Pelvic Muscle Dysfunction.

“We realize that recognition of the credential is not an overnight process,” remarked BCIA Board Chair, Fred Shaffer, PhD, BCB. “Our intent is to continue to set the standards of education and training and to provide a credential that will be recognized worldwide as criteria for selecting a provider.”

BCIA was formed as a non-profit organization in 1981 to establish and maintain professional standards for the provision of biofeedback services and to certify those who meet these standards. BCIA certification is the international gold standard for the selection of qualified biofeedback and neurofeedback professionals.

Visit www.bcia.org for more information.

Material adapted from Association for Applied Psychophysiology and Biofeedback (AAPB).

Additional Resources
Shaffer, F., & Crawford, J. (Winter 2009). Biofeedback Certification Institute of America goes global. Biofeedback, 37(4), 123-125.

Shaffer, F., & Crawford, J. (Fall 2009). What has Biofeedback Certification Institute of America been up to? Biofeedback, 37(3), 85-87.

Disclosure: This contributor, Christopher Fisher, PhD, is also BCN.

SEMG is a biofeedback instrument that measures muscle tension. The use of SEMG allows muscle function to be assessed in a manner that is objective and reproducible.

The Winter 2010 of the journal Biofeedback describes the case study of pressmen working at print facilities of a major U.S. news publishing company. Ergonomic analysis identified excessive workplace injuries to the neck and shoulder, most commonly the rotator cuff on the right side.

Three activities were then targeted for intervention: blanket washing, newsprint roll handling, and pre-drive belt positioning wheel adjustments. With the use of SEMG, researchers determined whether improvements to the workstation, worker technique, or both were more likely to lower the risk of injury while performing these tasks.

Data were collected by using two active electrodes placed parallel to the targeted muscles. Muscles studied included the left and right upper trapezius and the left and right lumbar paraspinals.

The researchers found that some of the workers’ movements might save time, but not injury. While washing the blanket cylinder, for example, a worker would typically put one hand on the control panel to manipulate the inch-safe buttons and simultaneously reach for the cylinder with the other hand. These actions require awkward movements that make the muscles work harder.

One solution was to re-train the worker not to perform these tasks simultaneously. By keeping the non-cleaning arm at rest, the cleaning task could be performed less strenuously. Alternatively, the researchers introduced a metal pole about 4 feet long with two ergonomic handles and a cleaning head. Through SEMG assessment, this supplement to the workstation combined with a modification of worker behavior brought about an even greater reduction in strenuous muscle activity while the worker performed the same task.

Material adapted from Allen Press Publishing Services.

Download / Reference
Thomas R. Caffrey and Robert Clasby. Surface Electromyography-Assisted Ergonomic Analysis in a Newspaper Printing Plant: A Case Study. Biofeedback, Volume 38, Issue 4, Winter 2010.

The Head of PR, Andy Shaw wrote in his opening release on Medica: “Finally, Canada’s most veteran exhibitor at MEDICA, Thought Technology Limited of Montreal, which many consider (and whose clients include a number of major professional soccer and other sport teams) the world’s foremost maker of biofeedback devices, is here with six new products.”

When Dr. Boehm asked how biofeedback and neurofeedback are used, Thought Technology Vice President and co-founder Lawrence Klein could not resist the opportunity to discuss the many uses of his company’s instrumentation. He replied, “The Schulich School of Music at McGill University in Montreal attached our instruments to several of the musicians of the Boston Philharmonic Orchestra, and 50 audience members. They measured heart rate, skin conductance, respiration, muscle tone, etc. and recorded all in Real Time, in order to discover how emotion is conveyed through music.“

“NASA used these same systems to prepare astronauts in Florida, in a capsule 65 feet under water, for three days, to discover how they adapted to the physical demands of the space capsule.“

Thought Technology Ltd. sales are 95% medical. Its psychophysiology is used in most VA Hospitals in the United States and it has 150 distributors in 55 countries. It has over 80 percent market share in China, where the distributor focuses on applications for school performance problems and rehabilitation. It recently entered into an OEM agreement to integrate their technology onto the Mediwatch pelvic floor platform.

Mr. Klein stated that, “In addition to the medical market, we have a strong presence in professional and elite sports.” Thought Technology’s equipment has been used by a number of leading Olympic Sport Coaches as well as by several professional sports teams who have set up a mental training center where trainers monitor the brainwaves, and six other physical functions of the players after their workouts, so they can regenerate and prepare their skills, mentally!

If after their visit to Medica, the Ambassador to Germany, Peter Boehm, and the Canadian High Commissioner to Dusseldorf, Leslie Reissner would like to learn more about how people around the world are using biofeedback, they can attend the Biofeedback Foundation of Europe’s 15th Annual Conference in Munich in February 22-26, 2011.

Material adapted from Thought Technology.

Contact: Helen Mavros
mail(at)thoughttechnology(dot)com
http://www.thoughttechnology.com

Editorial Note:
Financial Disclosure: Thought Technology is a valued paid advertiser at BMED Report.

The biological-behavioral treatment program is called Capnometry-Assisted Respiratory Training, or CART, said psychologist and panic disorder expert Alicia E. Meuret at Southern Methodist University in Dallas.

CART helps patients learn to breathe in such a way as to reverse hyperventilation, a highly uncomfortable state where the blood stream operates with abnormally low levels of carbon dioxide, said Meuret, one of the researchers conducting the study.

Hyperventilation, a state of excessive breathing, results from deep or rapid breathing and is common in patients with panic disorders. “We found that with CART it’s the therapeutic change in carbon dioxide that changes the panic symptoms – and not vice versa,” Meuret said.

CART: Breathing exercises twice a day
During the treatment, patients undergo simple breathing exercises twice a day. A portable capnometer device supplies feedback during the exercises on a patient’s CO2 levels. The goal of these exercises is to reduce chronic and acute hyperventilation and associated physical symptoms. This is achieved by breathing slower but most importantly more shallowly. Contrary to lay belief, taking deep breaths actually worsens hyperventilation and symptoms.

“Most panic-disorder patients report they are terrified of physical symptoms such as shortness of breath or dizziness,” Meuret said. “In our study, cognitive therapy didn’t change respiratory physiology, but CART did effectively reduce hyperventilation. CART was proved an effective and powerful treatment that reduces the panic by means of normalizing respiratory physiology.”

The findings, “Respiratory and cognitive mediators of treatment change in panic disorder: Evidence for intervention specificity,” appeared in the Journal of Consulting and Clinical Psychology. Meuret, who developed CART, is an assistant professor in the Department of Psychology at SMU and co-directs the department’s Stress, Anxiety and Chronic Disease Research Program. The Beth & Russell Siegelman Foundation funded the research.

CART breathing a proven biological therapy
The study pitted CART against a conventional cognitive therapy treatment, or CT. Traditional CT teaches patients techniques aimed at helping them change and reverse catastrophic thoughts in order to reduce fear and panic.

In the CART-CT study, 41 patients were assigned to complete either a CART or CT treatment program for panic disorder and agoraphobia, a fear of being trapped with no means of escape or help.

Both treatment programs were equally effective in reducing symptoms, said Meuret. But CART was the only treatment to physiologically alter panic symptoms by actively reversing hyperventilation in the patients. Cognitive therapy did not change the respiratory physiology, said Meuret.

Treatment helps patients address terror associated with panic
The study is the second randomized control trial to measure CART’s effectiveness. By reversing hyperventilation, patients reported a new ability to reduce panic symptoms by means of changing their respiration.

With CT, Meuret said, if a patient reports shortness of breath, the therapist challenges the assumption by asking how often the person actually has suffocated during a panic attack, then hopes that will reverse the patient’s thinking.

“I found that process very challenging for some of my patients because it acknowledges the symptom but says it’s not a problem,” Meuret said.

“CART, however, tells us a patient’s CO2 is very low and is causing many of the symptoms feared, but it can also show how to change these symptoms through correct breathing. There has been an assumption that if people worry less about symptoms it will also normalize their physiology, but this study shows that this is not the case,” she said. “Hyperventilation remains unchanged, which could be a risk factor for relapse down the road. Apart from hyperventilation being a symptom generator, it is an unhealthy biological state associated with negative health outcomes.”

Broader study planned to measure CART
The researchers plan to branch out with their studies on CART by taking the program into the community, particularly to ethnic minorities. They believe CART is a more universally understood treatment due to its physical exercises – as opposed to cognitive therapy’s more intellectual methods – and therefore more accessible to a broader range of people with varying levels of education and different cultural backgrounds. Ongoing studies will test the efficacy of CART in patients with asthma and fear of blood.

Material adapted from Southern Methodist University.

Hypertension falls into two broad categories, “primary” or “essential” hypertension, and “secondary” hypertension. Primary hypertension, which accounts for 95% of all cases, is “hypertension with no identifiable cause”. Secondary hypertension is that for which there is an identifiable cause, for example loss of circulatory, pulmonary, kidney function, etc. There’s an elephant in the room and its called “essential hypertension” – how can 95% of instances accounting for 100s of millions of cases in the US alone be without known etiology?

This article suggests that a large percentage of cases of essential hypertension are in fact attributable to suboptimal respiration and proposes that the broad category of “essential” hypertension be reconsidered as, a) those cases that respond promptly and favorably to respiration intervention, and b) those that do not. Those cases that do can be reclassified as “respiration responsive.” Where hypertensive symptoms are not responsive to respiration intervention, other pathologies might be considered as the root cause, for example, dysautonomia, or even early stage “secondary hypertension”.

Breathing is thought to affect blood pressure via the motive force that it applies to the movement of blood, in effect aiding the heart and vascular system in circulating blood throughout the body. This force is effected via the “thoracic pump” (see Figure 1) which generates negative pressure in the lungs during inhalation causing blood to rush through the vena cava and right heart filling the dense pulmonary capillary bed. The right heart facilitates this process via increasing heart rate yet with relatively low stoke volume and pressure (hence the need for increased rate). During the period of inhalation, blood flow out of the lungs into the left heart and arterial tree is slowed, reduced volume resulting in reduced arterial pressure. To limit this fall in volume and pressure, the arterial tree constricts to maintain pressure within viable range, however, blood volume and pressure in the arterial tree still fall.

Figure 1 - The thoracic pump alternating between venous/right heart and arterial/left heart.

During exhalation, the large volume of blood that was stored in the lungs during inhalation is ejected into the pulmonary veins and the left heart under positive pressure, making its way into the arterial tree as a wave. This wave, referred to in medical texts as “the respiratory arterial pressure wave,” can be on the order of hundreds of milliliters of blood. As this occurs, the heart slows down and stroke volume increases in order to move this large quantity of blood through the left heart into the aorta. During the period of exhalation, blood pressure in the arterial tree rises, however, the arterial tree relaxes, increasing its volume in order to accommodate the wave of blood and to prevent arterial pressure from rising too much. However, blood volume and pressure in the arterial tree still rise.

The net effect is that when one breathes slowly, deeply, and rhythmically, the diaphragm does much of the “work” of drawing blood through the venous circulation to the lungs, a job that otherwise falls to the right heart. During exhalation, because of the large volume of blood being ejected by the lungs, the heart slows down. In other words, the heart gets to rest during inhalation because the diaphragm is facilitating venous flow and the heart gets to rest during exhalation because the diaphragm is facilitating arterial flow. When the diaphragm is not “contributing,” the job of maintaining blood flow and pressure falls to the heart and vascular system. Then the result of slow deep rhythmic respiration is an overall decrease in work performed by the heart and vascular system and with this decrease a reduction in systemic pressure. It is believed that while the heart gets more rest, the overall rate of blood flow actually increases, i.e. circulatory efficiency is maximal when we breathe slowly, deeply, and rhythmically.

When one is not breathing “adequately” the process described above makes little contribution to circulatory efficacy. To put it in perspective, the adult diaphragm has a maximum range of 10 centimeters of movement. Most adults breathing normally employ only 1 centimeter of this range. To effect desired changes in blood pressure, the range of diaphragm movement must be increased, ideally in to the 4-6 centimeter range, i.e. where 50% (vs.10%) of diaphragm range is normally employed. If one is to undertake to modify their breathing pattern in order to maintain healthy blood pressure, this re-training of diaphragm range may occur gradually.

Figures 2 and 3 demonstrate the blood volume in the capillary circulation as measured at the earlobe. Figure 2 is the respiratory arterial pressure wave of “non-breathing” and Figure 3 is that of resonant breathing. Figure 2 demonstrates little change in either volume, pulse amplitude, or heart rate. Figure 3 demonstrates dramatic variation in all three, this outcome being a function of slow, deep, rhythmic operation of the diaphragm and thoracic pump.

Figure 2 - Respiratory arterial pressure wave of typical shallow breathing (Instrument: Valsalva Wave Pro)

Figure 3 - Respiratory arterial pressure wave of resonant breathing (Instrument: Valsalva Wave Pro)

The association between respiration and hypertension can demonstrated in the moment with many primary hypertensives by assessing their blood pressure before and after a period of deep rhythmic respiration where it is typical that average blood pressure [(systolic + diastolic)/2]drops substantially, for example 10 -20 mmHg even within a 10 minute period. Where it may be 130/80 before breathing intervention, it may be 110/70 after, a delta in average blood pressure of 15mmHg.

Figure 4 - Blood volume variability increasing during resonant breathing (Instrument: Valsalva Wave Pro)

There are additional quantitative diagnostic indicators that can also be employed easily to determine if respiration is facilitating increased circulatory effectiveness and the internal changes that result in reduced systemic pressure. These include variation in blood volume during respiration as measured in the capillary circulation, and variation in the heart rate, which is thought to be an outcome of autonomic regulation due to variation in blood volume and pressure.

Figures 4 and 5 demonstrate blood volume variability and heart rate variability increasing over the course of 10′s of seconds while employing resonant breathing.

Figure 5 - Heart rate variability increasing during resonant respiration (Instrument: Valsalva Wave Pro)

If breathing relatively slowly, deeply, and rhythmically does not facilitate variation in either blood volume or heart rate, the data seems to indicate that there will be little change in blood pressure after vs. before the initial “diagnostic” breathing intervention. This being said, if blood pressure is relatively high, and if significant positive changes in blood volume variability, and its correlate heart rate variability can be facilitated, blood pressure will almost certainly be reduced over the course of 8-12 minutes of resonant “coherent” breathing.

Stephen Elliott is President and life scientist for COHERENCE – The New Science Of Breath. He is the principal author of The New Science Of Breath (2004) and Coherent Breathing – The Definitive Method (2007). Stephen is the creator of the instrument Valsalva Wave Pro which allows monitoring and training of the “Valsalva Wave”, the heart rate, and the pulse wave.

Stephen’s research colleague is Dee Edmonson, R.N., BCIAC-EEG (www.neurologics.us).

Women who reported feeling stressed two weeks before the beginning of menstruation were two to four times more likely to report moderate to severe symptoms than were women who did not feel stressed.

Premenstrual syndrome (http://www.nichd.nih.gov/health/topics/menstruation_and_the_menstrual_cycle.cfm.) is a group of physical and psychological symptoms occurring around the time of ovulation, which may extend into the early days of menstruation. Symptoms include feelings of anger, anxiety, mood swings, depression, fatigue, decreased concentration, breast swelling and tenderness, general aches, and abdominal bloating.

The study was conducted by researchers in the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the University of Massachusetts-Amherst, and the State University of New York, Buffalo. The study was published online in the Journal of Women’s Health.

“We were interested in identifying factors that might predict who might be most at risk for having more severe symptoms,” said Audra Gollenberg, Ph.D., a postdoctoral fellow in NICHD’s Division of Epidemiology, Statistics and Prevention Research. “It may be possible to lessen or prevent the severity of these symptoms with techniques that help women to cope more effectively with stress, such as biofeedback, exercise, or relaxation techniques.”

The current analysis was part of the NICHD’s BioCycle Study, directed by Enrique Schisterman, Ph.D., also an author of the current article. The BioCycle Study seeks to examine ovarian functioning during the course of the menstrual cycle in healthy women. The researchers administered questionnaires to 259 women ages 18-44 who did not have any long-term health conditions, and who were not using oral contraceptives or taking any other hormonal formulations.

Each woman was provided with an at-home fertility monitor to follow the phases of her monthly cycle. The women completed questionnaires about their stress levels for each of the four weeks of their cycle. Items on the survey included:

• How often have you felt unable to control the important things in your life?
• How often have you felt nervous or stressed recently?
• How often have you been able to control interruptions in your life?

Women ranked their responses according to a scale, ranging from never to fairly often. In addition to the weekly questionnaires about stress, the women also responded to questionnaires about their symptoms, in the week coinciding with ovulation, and the following week, during menstruation. Most of the women (250) took part in the study for two menstrual cycles. The remaining nine women participated for only one cycle.

Women whose responses indicated they felt stressed were more likely to report moderate or severe levels of psychological symptoms, such as depression or sadness, crying spells, anger, irritability, and anxiety associated with menstruation. Similarly, women who felt stressed were also more likely to report moderate or severe levels of physical symptoms such as body aches, abdominal bloating, lower back pain, fatigue, abdominal cramping, headache, and cravings for sweet or salty foods. Overall, women reporting high stress levels were two to four times more likely to report moderate to severe psychological and physical symptoms during menstruation than were women who did not report high stress levels.

For the women who took part in the study for more than one cycle, symptoms corresponded with changes in their stress level. For example, women who felt stressed in the weeks preceding one cycle but didn’t feel stressed during the other cycle, tended to have more pronounced premenstrual symptoms after the cycle in which they reported stress. Women with high stress preceding both cycles were 25 times more likely to report moderate to severe symptoms than were women with low stress preceding both cycles.

The researchers couldn’t rule out that anticipation of pain and other symptoms might add to a woman’s stress level and result in more severe symptoms. However, they sought to compensate for this possibility by administering the questionnaires on stress early, during the symptom-free parts of the women’s cycles, when they were less likely to be anticipating severe symptoms.

A number of medications are used to treat the symptoms of premenstrual syndrome, said study author Mary Hediger, Ph.D, also of the Division of Epidemiology, Statistics and Prevention research. These include diuretics, pain killers, oral contraceptive pills, drugs that suppress ovarian function, and antidepressants.

“Each woman is an individual, and some women may experience severe symptoms that require medications,” Dr. Hediger said. “However, future studies may show that stress reduction techniques can prevent or reduce the severity of premenstrual syndrome, which might provide a cost effective alternative to medications for some women.”

Material adapted from National Institutes of Health.

Schoomaker explained that with the increasing numbers of Soldiers returning from combat with severe wounds, reports of medication abuse and suicides with pain as a possible factor are troubling.

“While these issues might not be directly related to pain management, I felt a thorough evaluation and assessment of current pain-management practice was indicated,” Schoomaker said.

He said part of the problem is that severely injured Soldiers, like those in Warrior Transition Units, are often prescribed multiple medications and sometimes seen by several different doctors, which can cause inconsistencies in care. But he maintained that this is not just an Army problem – it is a problem throughout the U.S. healthcare system.

“This is a nation-wide problem … we’ve got a culture of ‘a pill for every ill,’” agreed Brig. Gen. Richard W. Thomas, assistant Army surgeon general.

“As a physician, the hardest thing to deal with is patients with chronic pain,” said Col. Jonathan H. Jaffin, director of heath policy and services, Army office of the surgeon general. “So many of us went into medicine to relieve suffering, and chronic pain is frustrating because we want to relieve that pain.”

The task force visited 28 military, Veterans Affairs and civilian medical centers between October and January to observe treatment capabilities and best practices. Schoomaker’s said his goal is to form a pain-management strategy that is holistic, multidisciplinary, and puts Soldiers’ quality of life first.

“This is an opportunity to change medical care and the way we take care of patients,” noted Thomas.

Schoomaker stressed that Army practices have always been in compliance with America’s medical regulations, but he thinks the Army can do better.

“Everything we do in the Army, even managing a toothache, is all in compliance with national standards … what we want to do is set the bar higher,” Schoomaker explained.

Schoomaker’s higher standards include offering treatment alternatives that might not yet be prescribed in average doctor’s offices, but which patients are already seeking out on their own, such as acupuncture. He said the Army has looked at research on the effectiveness of complementary techniques, and he would like to see them integrated into traditional medical treatment.

“Programs such as biofeedback and yoga have been subjected to scientific randomized trials and have been proven to be effective,” Schoomaker said.

Biofeedback involves measuring body signals — such as temperature, heart rate, muscle tension and brain waves — to help patients with relaxation techniques and pain reduction.

Schoomaker said he is hopeful that Soldiers will be receptive to alternative methods of care once they see that the treatments work.

“Seeing success is the best way to convince people of the usefulness and the need for other approaches,” agreed Jaffin.

The 109 recommendations are divided into four areas: to provide tools and infrastructure that support pain management, build a full spectrum of best practices, focus on Soldiers and families, and synchronize a culture of pain awareness, education and intervention.

Schoomaker said the recommendations that can be put into policy under his authority will be implemented in the coming months, and the 2010 National Defense Authorization Act asks the secretary of defense to integrate a pain-management policy into the military health-care system no later than March 2011.

Material adapted from the United States Army.

Introduction (Continued)
Hypertension is a condition where the pressure of the blood in the vascular system, specifically the arterial system, is excessive. The body manages the flow and pressure of blood via a number of mechanisms. These include varying the capacity (the internal dimensions) of the arterial tree, varying the output of the heart, and managing the volume of fluid in the circulation, primarily a function of the kidneys.  All of these are managed by the body in “real time,” i.e., on an ongoing basis – while we work, while we play, while we sleep.

“High blood pressure” or hypertension exists when blood pressure is in excess of 120/80 (or the recently revised 115/75), the first number being systolic pressure and the second, diastolic pressure. For either systolic or diastolic pressure to be high, one or more of the mechanisms that maintain blood pressure in a healthful range fail to perform their regulatory function.

All three mechanisms, arterial capacity, heart output, and kidney throughput, are automatically managed by the autonomic nervous system. Therefore, we can say that hypertension is an instance where the autonomic nervous system is either performing its task of managing blood pressure correctly – based on correct assessment of physiological status, it is performing its job in error. If it is the former, then it is the physiological status that is at issue. If it is the latter, then it could be considered a form of dysautonomia.

There is strong evidence that blood pressure is highly related to the “state” of the autonomic nervous system, where the state of excitation or “sympathetic” emphasis correlates highly with higher blood pressure and the state of relaxation or “parasympathetic” emphasis correlates highly with lower blood pressure. This makes sense because arterial capacity,  heart rate, and heart output are directly under autonomic control. “Heart rate variability” (HRV), or the degree to which the heart rate varies, also correlates highly with autonomic status: lower variability correlates highly with sustained sympathetic bias and higher variability correlates with increased parasympathetic (vagal) action.

Heart rate variability is also known to correlate with respiration, where slower, deeper, more rhythmic respiration correlates highly with increased HRV and faster, shallower, more arrhythmic respiration correlates highly with diminished HRV.  This raises two questions, a) Does blood pressure correlate with heart rate variability? b) Does blood pressure correlate with the frequency, depth, and rhythmicity of respiration?

Research Hypothesis
In this article, researchers Elliott and Edmonson present preliminary findings regarding the first question, does blood pressure correlate with heart rate variability?

Fig 1. (click to enlarge) Respiratory Arterial Pressure Wave, Pulse Wave, and Heart Rate (from Valsalva Wave Pro)

Their hypothesis is this… Slow, deep, rhythmic breathing results in the phenomenon of the respiratory arterial pressure wave (or more completely the arterio-venous wave) which is known to rise and fall by 20mmHg. (Medical Physiology, Guyton & Hall, 2002). The respiratory wave is depicted in the first and second red graphs at the top of Figure 1.

This respiratory arterio-venous wave is believed to be the physiological impetus for “breathing induced heart rate variability,” the bottom blue graph. Changes in blood flow and pressure resulting principally from respiration are detected by baroreceptors, specialized neurons distributed throughout major arteries. The autonomic nervous system uses baroreceptor input to coordinate heart rate, heart output, and vascular capacity to facilitate the respiratory wave. It is noted that other factors, e.g. stretch receptors in the chest, heart, etc. are also involved in this autonomic sensing and regulation.

When the arterio-venous wave is low, heart rate variability is low; when the arterio-venous wave is high, HRV is high. Neither the respiratory wave or its result, HRV, can be high if arteries are not relaxed during the exhalation phase of breathing. If arteries are relaxed during the exhalation phase of breathing, blood pressure cannot be high. Therefore, if correct, there should be an inverse correlation between HRV and blood pressure, i.e., high blood pressure and high HRV should be mutually exclusive, this being our hypothesis for Part I of the study.

Fig 2. (click to enlarge) One Hundred Three (103) Measurements of Blood Pressure and HRV

Research Results
The study consists of 103 instances of data collected from 42 clients after each engaged in 8-12 minutes of Coherent Breathing with HRV biofeedback. Because the Part I goal is simply to understand the real time relationship between blood pressure and HRV, both of which are considered variables, each assessment can be considered unique. It should be noted that 15/23 or 65% of hypertensives no longer demonstrated hypertensive pressures after the 8-12 minute period where the boundary is 100mmHg average blood pressure [(systolic+diastolic)/2]. As the impact of breathing with HRV biofeedback  is a Part II consideration, those results will be presented in a future article.

Figure 2 presents the data, where it is seen that all of the data instances fall into the upper left, lower left, or lower right quadrants. There is one instance in the upper right but it is extremely close to the normo-tensive boundary of 100 mmHg. From this we can conclude that there are virtually no instances where average blood pressure is above normotensive and heart rate variability is above 13 beats. (HRV is measured in beats difference between the peak heart rate and the valley heart rate . The bottom graph of Figure 1 is an example of the heart rate varying.) The data is summarized by Figure 3.

Fig 3. Four Quadrant Summary of Data

The power trend line of Figure 2 curves gently upward as we move to the left, demonstrating stronger effect and nonlinearity in the relationship. In fact, if segmented there is a very dramatic difference in the correlation between blood pressure and HRV to the left and right of 13 beats, the correlation coefficient ≤13 beats being -0.62 and the correlation coefficient >13 beats being -0.05.

The linear trendline of Figure 4 demonstrates the strength of the effect ≤13 where we see that 1mmHg in average blood pressure relates to .3 beats of HRV; conversely, 1 beat of HRV relates to 3.3 mmHg average blood pressure. Again, please zoom in to see the graphic more clearly.

Fig 4. Correlation Below 13 Beats

Discussion
The large difference in correlation below vs. above 13 beats suggests that the physiological mechanisms of blood pressure and HRV are closely linked in lower HRV ranges and less so in higher HRV ranges. Additional research to confirm these results and further characterize this “range” is warranted. The data is reasonably supportive of the Part I hypothesis that high blood pressure and high HRV are mutually exclusive as there are no instances where blood pressure is above normo-tensive and HRV is above 20 beats (our “Hi” HRV boundary). The full report also presents systolic and diastolic pressures and their correlation with HRV. Please visit www.coherence.com for more details.

Stephen is life scientist and President, COHERENCE L.L.C. in Allen, Texas (www.coherence.com)

Dee Edmonson, R.N., BCIAC-EEG practices neurotherapy at the Neurotherapy Center of Plano. (www.neurologics.us)

Act fast because there are limited quantities on-hand for this special offer. Check BMED Press’ website for emWave Desktop video demonstration, screen-shots, and more.

Visit BMED Press store to check out this special offer.

Enjoy.

CFisher

The Behavioral Medicine Report (BMED Report) receives a referral fee when you purchase products through links on this website. Your support of these vendors provides for the continued operation of BMED Report. Please read our Financial Disclosure for full details. BMED Report thanks you for your support!

Visit the HeartMath store to purchase your copy.

Thanks!
CFisher

It is well established that variation in heart rate during respiration (respiratory sinus arrhythmia) correlates highly with health risk, and is especially indicative of health outcomes associated with acute heart conditions, where less variability is indicative of increased risk of poor outcome. Decreased HRV is generally an outcome of autonomic nervous system imbalance, specifically excessive sympathetic (activating) emphasis and deficient parasympathetic (deactivating) emphasis. Heart failure correlates highly with sympathetic overdrive and diminished HRV. The authors cite previous work that suggests that this progression toward autonomic imbalance is indicative of the progression in heart failure.

HRV is generally considered to be a measure of autonomic tone and cardiovascular adaptability to varying demand, where “adaptability” is a sign of robustness and lack of adaptability its opposite. Exercise tolerance is similarly a measure of the human organism’s ability to adapt to increased work load, cardio-pulmonary performance underlying both measures.

Heart failure patients receiving a six week course of HRV biofeedback and breath training increased exercise tolerance as compared to a control group which received training in a six week placebo program of quasi-false alpha theta EEG biofeedback that had previously been established not to produce cardiovascular effects. Both the treatment group and the placebo group received equal training once per week for 6 weeks and were requested to practice what they learned at home for 20 minutes each day. The HRV/breath training involved breathing more fully and deeply in such a way as to maximize variation in heart rate which was monitored with an instrument. Participants also used an instrument to monitor their HRV during home training.

Improvement in the treatment group was limited to those participants that demonstrated relatively higher (31% or greater) left ventricle ejection fraction (LVEF), where LVEF is an accepted indicator of heart disease severity, the higher LVEF being indicative of less severity. 50% of treatment group participants with higher LVEF demonstrated statistically significant increases in exercise tolerance. Additionally, participants with higher LVEF demonstrated an upward trending improvement in heart rate variability during the study period. Improvement in both exercise tolerance and HRV were effectively limited to those with less severe heart failure.
While not the first of its type, this is an important study because it focuses on the phenomenon of heart rate variability in its proper physiological context, i.e. as a biological indicator of cardio-vascular-pulmonary-respiratory integrity.

Stephen Elliott

Stephen is the principle author of The New Science of Breath
and Coherent Breathing: The Definitive Method. He is an avid heart rate variability researcher and the inventor of the “Coherent Breathing” method as well as “Valsalva Wave Pro” – an instrument that monitors the blood wave in the circulatory system produced during resonant breathing (See www.coherence.com and www.valsalvawave.com, respectively).

Specifically, the effects on marital satisfaction and psychophysiologic reactivity will be measured. Pre and post baseline measures of physiological parameters such as breathing, heart rate and heart rate variability, sweat gland activity, and hand temperature will be monitored with specialized equipment, as well as audio and video monitoring of the couple during the study sessions. In this study, we will be monitoring and giving feedback to each partner about their physiology and teaching them how to control reactivity in order to remain more calm when discussing emotionally charged subjects with their partner. The therapist will have the ability to stop and replay recordings in order to demonstrate changes in physiology to the couples. The study hypothesizes that participants will be able to learn to modify their physiologic reactions and thereby improve communication and marital satisfaction with their intimate partner.

The aim of this study is one of directed therapy, to focus on the process of how couples talk to one another, and how to better resolve conflicts, rather than to simply talk about burning issues in the relationship. If further therapy is required to expand on specific relational issues, subjects will be referred back to their original therapist. There will be no financial compensation for participating in this study, as this is a non-funded research project, and no charge will be made for these sessions. Involvement for the full 10 sessions is a commitment that will be much appreciated and, we anticipate will be of benefit to the couples involved. In short, we are currently looking for participant couples to join a 10 session original study of Interpersonal Biofeedback.

For more information or to refer patients for participation, please contact Steven C. Kassel, MFT, BCIA-c, BCIA-EEG via email or by phone at (661) 259-3704. Thank You.

Steven Kassel

Editorial Note: While The Behavioral Medicine Report believes that Steven Kassel will conduct safe and quality research, we cannot guarantee your safety or satisfaction with the results. We encourage all participants to discuss the research with the primary investigator and to review the informed consent documents before deciding to participate.

Here are the Wild Divine Videos:

Journey To the Wild Divine – The Passage:

More information on Journey To the Wild Divine: The Passage.

Journey to the Wild Divine – Wisdom Quest:

More information on Journey to the Wild Divine: Wisdom Quest

Healing Rhythms:

More information on Healing Rhythms.

Enjoy.

CFisher

Visit our Financial Disclosure Statement regarding vendor links on this site. You can support the continued operation of The Behavioral Medicine Report by visiting vendors advertised on this website using the provided links.

Basics of SEMG covers a range of topics that include the anatomy and physiology of relevant body muscles, the characteristics of the SEMG signal, various types of SEMG sensors and electrodes, suggested electrode placements, identification of artifacts, and more. The document is very well written with beautiful drawings of the human body complete with muscle identification and suggested sensor placement, as well as great text summary charts. Of course, Thought Technology emphasizes their own software and equipment (and rightfully so) in all demonstrations, but most of the concepts apply equally well to other biofeedback equipment.

Download
Download Basic Of Surface Electromyography Applied To Physical Rehabilitation and Biomechanics.

Enjoy.

CFisher

EmWave PC is an extremely popular HRV biofeedback system that I use on daily basis in a neurofeedback clinical setting. I have personally found it to be a very effective tool that teaches patients how to self-regulate their autonomic nervous system, to induce coherent breathing, and reduce anxiety.

You can get the discount here.

CFisher

Overall, biofeedback (all combined) produced a robust moderate effect size of .58 (95% CI=.52-.64) in pre vs. post headache conditions. In treatment specific comparisons, biofeedback (all combined) achieved a moderate effect size (.45) compared to a no-treatment (wait-list) control condition, but did not exhibit superiority (nor was biofeedback inferior) over known beneficial treatments (relaxation and pharmacotherapy). The authors noted a “trend” toward significance for biofeedback over pharmacotherapy, as well as few, if any, reported side effects in the biofeedback treatments. Importantly, biofeedback therapies failed to achieve statistical significance when compared to placebo control groups, despite a .25 effect size. This is because the confidence interval (0.00-.49) included zero.

The researchers also compared each biofeedback treatment to another (e.g. EMG vs TEMP, etc.). All biofeedback treatment were equally effective (statistically speaking), though HRV obtained the highest numerical effect size at .68 (medium to large effect size). Another important finding is that biofeedback treatment effects endured at 1 year or more follow-up. Concurrent patient home training sessions improved treatment effect sizes at study completion and at extended follow-up. Additionally, biofeedback significantly reduced anxiety and depression, and significantly improved beliefs of self-efficacy. In fact, gains in self-efficacy were higher than pain improvements.

The authors mentioned how impressed they were with these results given that the participants reported chronic migraines (average of 16 years). They further stated that, “Thus, based on the present results BFB can be recommended to therapists, physicians and healthcare providers as an efficacious non-medical treatment alternative for highly chronified migraine patients; suitable also for the long-term prevention of migraine attacks” (pg. 122).

In my opinion, a well designed randomized, double-blind, placebo controlled study with a large number of participants is warranted and could help clarify the benefits of biofeedback for migraine headache.

Summary of Important Highlights From The Current Study:

• Study Design: meta-analysis
• Primary Inclusion Criteria: migraine headache (average years suffering: 16.9 years)
• Number of Participants: 2,229 (experimental = 1,718; control = 511)
• Participants’ Average Age: 37.1 (SD=10.0)
• Participants’ Gender: 88.6% female
• Primary Outcome: overall moderate effect size of .58 (95% CI=.52-.64) in pre vs post headache and .45 (95% CI=.26-.63) wait-list control comparisons
• Limitations: biofeedback did not produce statistically meaningful gains over placebo conditions.

CFisher

Reference:

*Nestoriuc, Y., & Martin, A. (2007). Efficacy of biofeedback for migraine: A meta-analysis. Pain, 128, 111-127.

One important distinction must first be made. EEG biofeedback, better known as neurofeedback, has been frequently discussed at BMED Report.  The current TTH study mostly involves peripheral biofeedback.  The basic principles of peripheral biofeedback are very similar to neurofeedback except that instead of the patient monitoring his or her EEG (in neurofeedback), the patient receives feedback and reinforcement of their body signals.  Biofeedback can include a number of different measures, such as heart rate variability (HRV), skin temperature, electromyography (EMG; muscle electricity), and electrodermal response (sweat).  These signals are indirect measures of autonomic nervous system activity and/or muscular activity.  Similar to neurofeedback, the biofeedback therapist encourages certain desired states with visual and auditory reinforcements. 

53 studies involving 1532 patients, ages 10.3 to 66.7, with TTH were identified for inclusion in this meta-analysis.  EMG biofeedback was the most frequently used modality across all studies; however, studies using temperature (2), electrodermal (1), and EEG (1) biofeedback, as well as combined relaxation (9) were also included. Please review the original article for a more comprehensive overview of inclusion criteria and descriptions of each study.

An overall medium-to-large effect size of .73 was found across all 53 studies for pre/post comparisons of symptom improvement (or lack thereof) following biofeedback treatment.  Statistically significant medium-to-large effect sizes were reported for headache reduction (frequency, intensity, duration, and headache index).  Interestingly, patient anxiety, depression, and self-efficacy also significantly improved across 19 studies. Biofeedback treatment compared no-treatment or placebo control groups again produced statistically significant improvements with medium-to-large effect sizes (.81, .50 respectively).  Biofeedback also improved patient outcome over and above relaxation modalities as evidenced a by small, but statistically significant, effect size (.20).  Combined EMG biofeedback and relaxation therapy were the most effective treatment for TTH.   Children and adolescents had the best results, though adults did very well too.  Adults with chronic (long term) TTH actually fared better than those with acute (short-term) TTH. Geriatric patients did not realize significant treatment effects, but only 2 groups comprising a total of 12 participants were included in the analysis. Importantly, treatment gains were found to persist for years at follow up, with an average follow up period of 15 months.

Unfortunately, only a handful of studies were located to allow for adequate comparison of biofeedback to pharmacotherapy and traditional behavioral/talk therapies; however, researchers noted that in 2 of the 3 studies biofeedback treatment was favored over pharmacotherapy with large effect sizes.

Remember that a meta-analysis is not a “cause and effect” experiment. Nonetheless, it does provide a statistically valid and reliable way to make standardized comparisons across studies (subject to statistician error and bias of course), and provides reasonable estimates of a treatment effectiveness in a number of different settings with different populations.

In summary, the results of this meta-analysis suggest that peripheral biofeedback may represent an efficacious treatment of TTH for many people.

Reference:
*Nestoriuc, Y., Rief, W., Martin, A. (2008).  Meta-analysis of biofeedback for tension-type headache: Efficacy, specificity, and treatment moderators. Journal of Consulting and Clinical Psychology, 76(3), 379-396.

02/14/09 Update

Original Post: The Behavioral Medicine Report readers hopefully are becoming more familiar with biofeedback. Upcoming articles will cover other types of biofeedback treatments, not just neurofeedback, such as heart rate variability (HRV), temperature, and electrodermal (EDR) biofeedback. Today, please direct your attention to an important free and valuable resource that is available to the general public and professionals.  AAPB recently released the 2008 edition of  “Evidence-Based Practice in Biofeedback and Neurofeedback,” written by Carolyn Yucha, Ph.D. and Christopher Gilbert, Ph.D.

This mini-book is available for download as a PDF. The authors review existing biofeedback research for a multitude of mental and physical disorders that include anxiety, depression, autism, substance abuse, ADHD, chronic pain, migraine, and more. The authors make clear efficacy recommendations for each disorder based on research they located. The efficacy ratings range from 1-5 as follows:

1. Level 1: Not empirically supported
2. Level 2: Possibly Efficacious
3. Level 3: Probably Efficacious
4. Level 4: Efficacious
5. Level 5: Efficacious and specific

To obtain a specific efficacy rating, strict criteria are established. Level 1 is the lowest rating, while Level 5 is the highest rating that can be achieved. You can review the article for a more detail discussion.

Siegfried Othmer, Ph.D., a well known and noted neurofeedback clinician and researcher, recently provided a critical overview Yucha & Gilbert’s work.  Most of his complaints were that the authors failed to include important research articles and were too conservative in their efficacy ratings. Dr. Othermer’s comments are here. Nevertheless, “Evidence-Based Practice in Biofeedback and Neurofeedback” represents a great starting point for those that want to better understand the effectiveness of biofeedback with specific disorders.

Download Evidence-Based Practice in Biofeedback and Neurofeedback” (2004 edition only)

CFisher