Table of contents

Introduction to Biofeedback
Temperature Biofeedback
Part- 1 Skin Temperature Exercise # 1
Feedback Electromyography (EMG)
Electromyography - EMG - Exercise # 2
Electromyography - EMG - Exercise # 3 Upper Trapezium Evaluation
Heart rate variability (HRV)
Blood Volume Pulse (BVP)
Respiratory biofeedback
Heart rate variability (HRV) Exercise 1
Feedback Encephalography (EEG)
Diabetes
Peripheral neuropathy
Epilepsy
Asthma
Fibromyalgia
Post Traumatic Stress Disorder (PTSD)
Temporomandibular disorders (TMD)-(TMJ)
Anxiety
Chronic Pain
Headaches - Migraines - Tension Headaches
Menopause
Raynaud's Disease
Hypertension ( High Blood Pressure )
Sleep Disorders
CPT Codes and insurance

Overview:

What is biofeedback?

Biofeedback is a technique that trains people to improve their health by controlling certain bodily processes that normally happen involuntarily, such as heart rate, blood pressure, muscle tension, and skin temperature. Electrodes attached to your skin measure these processes and display them on a monitor. With help from a biofeedback therapist, you can learn to change your heart rate or blood pressure, for example. At first you use the monitor to see your progress, but eventually you will be able to achieve success without the monitor or electrodes. Biofeedback is an effective therapy for many conditions, but it is primarily used to treat high blood pressure, tension headache, migraine headache, chronic pain, and urinary incontinence.

Are there different types of biofeedback?

The four most commonly used forms of biofeedback therapy are:

• Electromyography (EMG), which measures muscle tension
• Thermal biofeedback, which measures skin temperature
• Neurofeedback or electroencephalography (EEG), which measures brain wave activity
• HRV--Heart rate variability

How does biofeedback work?

Researchers aren't sure exactly how or why biofeedback works. However, there does seem to be at least one common thread: most people who benefit from biofeedback have conditions that are brought on or made worse by stress. For this reason, many scientists believe that relaxation is the key to successful biofeedback therapy. When your body is under chronic stress, internal processes like blood pressure become overactive. Guided by a biofeedback therapist, you can learn to lower your blood pressure through relaxation techniques and mental exercises. When you are successful, you see the results on the monitor, which encourages your efforts.

What happens during a biofeedback session?

In a normal biofeedback session, electrodes are attached to your skin. They send information to a small monitoring box that translates the measurements into a tone that varies in pitch, a visual meter that varies in brightness, or a computer screen that shows lines moving across a grid. The biofeedback therapist then leads you in mental exercises. Through trial and error, you can soon learn to identify the mental activities that will bring about the physical changes you want.

What is biofeedback good for?

Biofeedback seems to be effective for a range of health problems. For example, it shows promise for treating depression, asthma, PTSD, anxiety, and TMJ.

Research also suggests that thermal biofeedback may ease symptoms of Raynaud's disease (a condition that causes reduced blood flow to fingers, toes, nose or ears) while EMG biofeedback has been shown to reduce pain, morning stiffness, and the number of tender points in people with fibromyalgia. A review of scientific clinical studies found that biofeedback may help people with insomnia fall asleep.

Biofeedback can also be used effectively in children. For example, EEG neurofeedback (especially when combined with cognitive therapy) has been reported to improve behavior and intelligence scores in children with attention deficit/hyperactivity disorder (ADHD). Biofeedback, combined with fiber in the diet, may help relieve abdominal pain in children. Thermal biofeedback helps relieve migraine and chronic tension headaches among children and teens as well.

Biofeedback may also be useful for the following health problems:

• Anorexia nervosa
• Anxiety
• Asthma
• Autism
• Back pain
• Bed wetting
• Chronic pain
• Constipation
• Depression
• Diabetes
• Epilepsy and related seizure disorders
• Head injuries
• High blood pressure
• Learning disabilities
• Motion sickness
• Muscle spasms
• Sexual disorders, including pain with intercourse
• Spinal cord injuries

How many sessions will I need?

Each session generally lasts less than 1 hour. The number of sessions required depends on the condition being treated. Many people start to see results within 8 - 10 sessions. Treatment of headache, incontinence, and Raynaud's disease requires at least 10 weekly sessions and some follow-up sessions as health improves. Conditions like high blood pressure, however, usually require 20 weekly biofeedback sessions before you see improvement. You will also be taught mental exercises and relaxation techniques that you can do at home for at least 5 - 10 minutes every day.

Are there any risks associated with biofeedback?

Biofeedback is considered safe. No negative side effects have been reported.

Temperature Biofeedback - Hand Warming

Hand warming is one of the many different methods used in Biofeedback training. At this point it may be useful to specify exactly what Biofeedback is and is not. The first incorrect idea about Biofeedback is that Biofeedback instruments actually change or influence bodily processes. This belief is incorrect. Biofeedback equipment merely monitors or measures bodily functions. The instrument "feeds back" information to you, so you become aware of small changes in your body, and the factors that bring about these changes. Through this, an awareness develops, that makes it possible to control your physiological functions.

Biofeedback training, and hand-warming in particular, have been shown to have a beneficial effect for those who suffer from migraine headaches, high blood pressure, insomnia, pain, stress, digestive disorders, and many, many other ailments.

Biofeedback training does not require the use of drugs or surgery to alter the body, but teaches your body to alter itself. Once a biofeedback skill has been acquired, the patient usually then has no need for further use of training equipment, and may use feedback only to occasionally tune or validate the utilization of their skill.

The basic theory behind hand-warming stems from our understanding of the fight-flight response. The fight-flight response is an automatic change of physiological markers that take place when a person suddenly perceives danger or stress. Blood flow is significantly decreased in the extremities while being increased to the vital organs of the body. This enables a person to react physically to danger. This physiological change was very favorable and served as an automatic protection device, in primitive society. Although the fight-flight response has been beneficial and necessary for survival, it can also be harmful. If we overuse this natural response by constantly interpreting things as being stressful or dangerous, that really are not, we are chronically sending this response to the body.

The main goal of hand-warming is to assist in measuring our level of stress through skin temperature, and thereby allow us to change our stress level to meet the circumstances. The more stressed a person is, the lower the temperature in the hands, feet, and other extremities. The lower the stress level, the higher the temperature should be in the extremities.

Training Recommendations

When measuring hand temperature the following items should be considered:

1. Attach the probe to the middle finger of your dominant hand.
2. The probe should be attached to the fleshy underside of your finger.
3. Always record temperature from the same place of your finger.
4. Use scotch tape with perforations, or cloth medical tape, so that the finger perspires as little as possible.
5. Do not adhere the tape too tight, or circulation will be inhibited.
6. Temperature readings should be taken when the ambient temperature is between 69 - 73° F. (Room Temperature)
7. Avoid other contact with warm or cold objects such as drinks or outdoor exposure.

Temperature biofeedback

Biofeedback is the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will. Processes that can be controlled include brainwaves, muscle tone, skin conductance, heart rate and pain perception.

Biofeedback may be used to improve health or performance, and the physiological changes often occur in conjunction with changes to thoughts, emotions, and behavior. Eventually, these changes can be maintained without the use of extra equipment. Biofeedback has been found to be effective for the treatment of headaches and migraines.

Temperature biofeedback or blood flow is a basic tool for general relaxation training. It monitors skin temperature and aids relief in certain circulatory disorders such as Raynaud's disease.

This device shows when blood flow increases by registering an increase in finger temperature. Blood flow in the hands is sensitive to stress and relaxation, so it is necessary that you learn to watch the rise and fall of your temperature. Soon, you will become so aware of your internal feelings linked with relaxation that you will begin to produce this state voluntarily.

How temperature biofeedback helps:

For relief from migraine and cluster headache, and certain types of chronic pain, temperature biofeedback works best. Temperature feedback is very good in assisting you gain control over a migraine by simply warming your hands. For best results, a sensor is attached to your foot or to the middle or small finger of your dominant hand. If you are tense or anxious, your skin temperature will automatically fall as blood is redirected inwards to the muscles and internal organs.

Measuring skin temperature, therefore, is similar to monitoring muscle tension, in terms of managing stress. If you know this, it can help you reduce the frequency of your migraine headaches, and help you relax. With temperature biofeedback device in place, you can get ample relief from your ailments and lead a healthy life.

How temperature biofeedback works:

If you are stressed or in pain, your body reacts with a "fight or flight" response that involves greater muscle tension, heart rate, respiration, hormonal changes, blood flow to the head, and lesser blood flow to the extremities. When your body is ready to fight or run away, it responds by increasing blood flow to the brain, heart and large muscles which help you move.

However, blood flow is reduced to the hands and feet to stop you losing blood in an injury. When the blood flow to the head increases, it results in the head feeling warm, and when it reduces in the extremities, it results in these areas feeling cool. Temperature biofeedback, therefore, can be useful for demonstrating deep relaxation. Conversely, when the subject stops the relaxation process, the hand temperature begins to decrease and become cooler.

Normality range:

The temperature of your hands and fingers, when measured, should range between 93.2°F and 96.8°F, and indicates that your body is very relaxed. If it reads a lower value of about 86°F-91.4°F, it shows that you are under slight stress which could increase with any drop in temperature. However, if your temperature falls below 78.8°F, it could point to problems of blood circulation in the fingers or Raynaud's Syndrome, which can be organic or psychological in origin. It is necessary to remember that temperature measuring is sensitive to room temperature, and a standard room temperature is usually 77°F.

Methods of Producing Relaxation

You now have a basic understanding of hand temperature and what it indicates about your present level of stress. How do we regulate our hand temperature and reduce stress?

There are many different ways to increase your hand temperature. We suggest that you try them all, and find the method that works best for you. The basic idea behind each of these methods is to focus yo9ur consciousness on the experience of being profoundly relaxed.

DEEP BREATHING- This is one of the most common ways used to relax. It has an ancient therapeutic history. It is accomplished by taking deep diaphragmatic breathes and then exhaling for a longer count than the inhalation.

MUSCLE TENSING- This is accomplished through sessions of tensing muscles and then completely relaxing them. It is believed that the relief you experience after tensing your muscle is an analogue of the conscious relaxation process you are trying to learn.

IMAGERY- The relaxation response is activated in this method by having the person think about a very peaceful, warm and calm place, such as lying on your beautiful imaginary beach. It is helpful if the person actually imagines the warmth along with imagining themselves there.

MUSIC- We are just beginning to understand the impact of music. Some people find it quite easy to increase their hand temperature by just sitting in a comfortable chair and listening to appropriate soft music.

AUTOGENIC PHRASES- In this method, positive, present tense statements are said to one's self. Examples would be: I feel quite relaxed. My hands are beginning to feel warm. My muscles are all loose and comfortable. I can feel the blood running into my hands. My hands feel heavy and warm. This is a very popular method and seems to work for most people.

OPEN FOCUS- On open focus training you try to imagine an interior portion of space in your body. Examples might be: Can you imagine the space between your eyes? Can you imagine that your hands and fingers are filled with space? Each statement is made and then you pause briefly concentrating for about 10 seconds on the specific area.

Once you have discovered a method that works for you, take time once a day to practice your relaxation routine. For maximum benefit, you should be able to reach and maintain a temperature of 95.5 degrees F for five minutes each training session. This simple procedure pays great dividend for your effort.

Temperature Training Procedures

1. Starting hand temperature will vary with room temperature; hand temperature will be colder in a cold room than in a warm room.
2. In a room of normal temperature, when you are neither deeply relaxed nor stressed, starting hand temperature will be in the mild or high 80's. Finger temperature of 80°F is cool, 75° F is cold, and 70° F or below is very cold; 90° F is warm, and the training goal is 95-96° F for 10 minutes. If your hands are quite cold, temperature may increase very slowly, and only after several minutes of training; If your hands are in the low-mid 80's temperature may increase rapidly; if your hands are in the low-mid 90's temperature may increase slowly, with only a few degrees of increase, but at that level, a few degrees is a significant change.
3. When you are beginning temperature training find a comfortable, quiet environment in which to train; later training you will be able to practice and use this skill in any environment.
4. You should use a blanket in a cold room.
5. Make sure that the tape is not too tight.
6. Learning to raise and lower hand temperature is the goal for self-regulation.
7. When training on the dominant hand is mastered, place the thermistor on the non-dominant hand to make sure that the training is generalized.
8. The autogenic training phrases are a guide. You may experiment with other phrases, imagery, body feelings, etc. if your hands and feet are cold, it may be best to focus on feelings of heaviness, not warmth.
9. Relaxation sessions should begin with a few minutes of deep breathing.
10. As with all types of self-regulation, PASSIVE VOLITION is essential.
11. Initial temperature training should be practiced when you are feeling relatively comfortable i.e. not during a headache. When the hand warming/relaxation skill is learned, you will use it for prevention of the symptom, at symptom onset, and during the symptom.

The following is for use with the Nexus-10

Part- 1 Skin Temperature Exercise # 1

1. Insert Temperature cable into input (F) ..... Press the ( I ) key to confirm input if unsure
2. Double click on Biotrace + icon to open program (CLICK OK )
3. Click on Add Client.. Enter clients name and then (CLICK OK) turn the encoder on
4. Click Exit on the bottom right corner of window
5. Click on Record new session.... The left side reads Category ...The right reads Screens
6. Find the line Stens Labs Biofeedback... click on that line
7. From the Screens side of the window, find Temperature Linegraph ... single click to assign to a function key (example F1, F2 ect. Or double click to load the screen
8. Sensor placement: Attach the temperature sensor to the Palmer surface of the middle finger of clients left hand
9. Explain the test to the client. E.g. Pre-baseline, training, Post-baseline (modify this to adjust to appropriate test)
10. For the first two minutes record the Base-line (move screen away from clients view) click on Start Recording.
11. Baseline ( 0 - 2.00 min. ) Training ( 2.00 - 6:00 min ) Post-Baseline ( 6:00 - 8:00 min )
12. Be sure do document readings for comparison on future sessions
13. from the category side of the screen click on Stens Labs Biofeedback
14. from the Screens side find Temperature Linegraph, click on that once
15. Press F1, then click YES
16. From within the category side click on Skin Temperature
17. From the Screens side find Temperature with Circle Zoomer, click once, press F2 then YES
18. From the bottom of the screen click on Record, see client window again, choose client, click continue
19. Turn Encoder on, then click on Start Recording, press F1 to switch to line graph
20. Test sensor by holding it between 2 fingers, if it works press STOP when asked to save click NO
21. Sensor placement: Attach the temperature sensor to the Palmer surface of the middle finger of clients left hand
22. Record Baseline... Tell client "for the next 2 minutes a baseline will be recorded, do not watch the screen"
23. Click on Record, see client window, choose client, click continue, Click on Start Recording
24. When the session timer reaches 2:00 Press F2 and then press PAUSE
25. Tell client, "for the next four minutes I want you to relax and allow your hands to warm"
26. Click on PAUSE to begin recording
27. When the timer reaches 6:00 press F1 and then press PAUSE
28. Tell client, "we will now record a final baseline, do not watch the screen"
29. click on PAUSE, when timer reaches 8:00 click on STOP
30. You are now asked to save data, click on YES, type Temperature Lab 1
31. Press the TAB key to switch to the report mode, process the results with the client

Training Techniques

1. Read script or use verbal relaxation during training session.
2. Use skin temperature in conjunction with BVP, HRV, GSV, and Respiration
3. Use alternate training screens for Skin Temperature training
4. Check for established protocols or exercises from within Biotrace or any appropriate outside source
5. Visual feedback with graphs or animations
6. Audio feedback with tones or MP3 file

Feedback Electromyography (EMG)

Feedback EMG is the process of monitoring displaying to the trainee the ongoing contraction and relaxation patterns generated by their skeletal muscles. Its objective is to heighten proprioceptive awareness of the mechanisms of muscle posture and to develop voluntary control over dysfunctional, semi-voluntary or involuntary muscle activity. The achievement of muscoskeletal control skills has direct clinical applications in both physical medicine (neuromuscular reeducation) and in the redress of psychological, psychosomatic, and stress-related disorders.

It has long been recognized that chronic muscle tension, a state in which an individual is continually stiff, or braced, can be an indication of an ongoing stress response. Myographic feedback can play a major role in improving the trainee's awareness of both the objective physiological indications of inappropriate stress response and the mechanisms involved in their generation and maintenance.

By learning to voluntarily control affected muscles, trainees can achieve significant clinical improvement. This improvement results from a variety of factors: First, when acute or chronic muscle tension directly contributes to the trainee's distress, relaxation of the affected muscles can relieve the discomfort. Second, the feedback of observable and objective indications of the trainee's condition can facilitate the trainee's acceptance and understanding of the problem. Third, the achievement of deep muscle relaxation can contribute to the trainee's overall relaxation and have significant clinical impact on stress-related disorders. Fourth, direct control of previously involuntary muscle activity serves to improve the trainee's sense of self-control, self-responsibility, and self-image.

As a result, the trainee may become more understanding of and less defensive towards other therapeutic procedures and recommendations. Another major application of feedback electromyography is in the neuromuscular retraining of partially to seriously dysfunctional muscles. As a muscle rehabilitation tool, feedback myography can easily be integrated into current physical therapy procedures, and can make a substantial contribution toward patient recovery

Part- 2 Electromyography ( EMG ) Exercise # 2

1. Perform skin prep for forehead sensor
2. Attach EMG active sensors #1 red and #1 black + ground sensor ( for instructions see page-12 )...red sensor above the middle of the left eye, black sensor above the middle of the right eye, the ground sensor( white ) will be in the middle of the forehead.
3. Double click on Biotrace + icon to open program (CLICK OK)
4. Click on Add Client.. Enter clients name and then (CLICK OK) turn the encoder on
5. Click Exit on the bottom right corner of window
6. Click on Record new session.... The left side reads "Category" ...The right reads "Screens"
7. Find the line Stens Labs Biofeedback . In the category side.. click on that line
8. From the Screens side of the window, find 1X EMG Linegraph ... single click to assign to a function key (example F1, F2 ect. Or double click to load the screen (for this example press the F1 key and click yes)
9. From the screens side of the menu, find the 1X EMG Bar and Linegraph click on this once then press F2,
10. From the Screens side of the window, find 1X EMG Floating Ball ... single click to assign to a function key (example F1, F2 ect. Or double click to load the screen (for this example press the F3 key and click yes)
11. Double click the 1X EMG Linegraph see client window, AND THEN click on Cancel Explain the test to client
12. To determine which port to use for EMG, press the( I) key, insert sensor into that port. Exit this window by clicking "cancel"
13. From the bottom of the screen, click the record button, ... see client window again, make sure clients name is selected and then click continue.
14. Turn the encoder on. Click on Start Recording
15. See 1X EMG Linegraph on the screen.. Check the signal by doing a behavioral test, have the client raise and lower their eyebrows ( see the trace line on Linegraph move if properly connected )
16. Click on stop. Click on NO when asked to save data
17. This Training session is approximately 16 minutes long,
    Part 1. Baseline - 0:00 to 2:00 Min.
    Part 2. Relaxation Training with progressive Relaxation phrases-- 2.00 to 6:00
    Part 3. Visual Feedback
    Part 4. Audio feedback
    Part 5. Post-Training Baseline -- 2 Minutes
18. Part 1 Tell Client -- for the next two minutes a baseline will be recorded ( they should not watch the screen during this stage
19. Click on Start Recording ... When timer reaches the 2:00 mark press F2 then click pause

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20. Part 2-- Do a progressive relaxation exercise by reading script or playing music.
21. Click on the Pause button to start recording while doing progressive relaxation.
22. When the timer reaches 6.00 min press F3 and then press Pause

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23. Part 3 -( Visual feedback ) Point the mouse anywhere within the vertical bar graph on the left side of the screen,click once with the right mouse button,
24. See Menu. From within this menu click on Feedback options and Thresholds line
25. See Biofeedback and Threshold settings menu. Point the mouse 2/3 of the way down the menu, and find the line Threshold 1 Level: see box to the right of that line, double click on it.
26. Enter a number that would be a good goal for the client, or use 3.00 as a good generic goal, click OK ( a good goal would be where client is above threshold 50% of the time )
27. Tell client-- "for the next 4 minutes, you will train with your eyes open. Relax; use the bar graph as a guide. When you relax below the goal, the ball on the right will begin to float.")
28. Adjust threshold as needed by pointing the mouse on it and moving the line up or down.
29. Click on Pause to start recording, when timer reaches 10:00 min click on the Pause button

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30. Part 4 Training session with Audio feedback with threshold - 4:00 min
31. Open the screen browser by tying the L Key from your keyboard, change categories by clicking on the line called Basic Screens on the right side on the screen find Basic EMG amplitude, and double click to load the screen
32. Tell client (for the next 4 minutes you will train with your eyes closed listening to audio feedback, you will hear a tone that will turn on with muscle tension and turn off with muscle relaxation )
33. Click on the pause button to begin recording, when the timer reaches 14:00 minutes press F1 and then click on Pause
34. Tell client ( Ok, we are almost done, for the next 2 minutes a final baseline will be recorded. Do not watch the feedback) ---- turn audio off
35. Click on Pause to begin recording, when session timer reaches 16:00 minutes click on STOP
36. You are asked to save data, click on YES In the box type in EMG Lab 1 click on OK
    To Modify report: Adjust Vertical Scale.
37. Find the left vertical scale numbers of the line graph, point the mouse anywhere in the field of vertical numbers, and see black squares appear around the vertical numbers, use the right mouse button, click once, see the menu appear, point mouse on the line Y scale range see another menu appear, click on the first line Manual Range see Enter Y-Scale range menu. Enter in new start and end values of 0 to 50 respectively, click OK

Directions for Computing Statistics

38. Step 1, compute baseline, Point mouse at the end of the baseline part at (2:00 min.)
    Click and hold down mouse button, drag mouse to the left marking the area from 2:00 min back to 0:00, release left mouse button. Click on line Segment: Compute statistics Keep records of the Mean values and possible any variance to chart client progress in successive sessions
39. Process results with client and document session
40. Exit Biotrace program by clicking on the red X in the top right corner of the screen

Part- 3 Electromyography ( EMG ) Exercise # 3 Upper Trapezium Evaluation

The purpose of this evaluation is to compare upper trapezium muscle surface EMG readings of the client using wide bandpass during four phases: baseline, task, performance, recovery, and baseline during sitting and standing. The upper trapezium is a common site of musculoskeletal pain reported by chronic headache sufferers. Bringing balance back to this area has been beneficial in treating musculoskeletal pain and chronic tension headaches.

1. From the Biotrace main menu screen click on Record new session
2. Attach EMG sensor cable into port C of the encoder box.
3. Perform skin preparation for the left and right upper traps as well as the ground location.
4. Use the #1 leads on the on the left upper trap and the #2 leads on the right upper trap.
5. Attach the ground cable into the encoder box in the port labeled GND Place the ground sensor in the middle on the backbone.
6. From the category side of the menu select Stens Labs Biofeedback, from within the Screens side of the menu double click on 2X EMG Linegraph
7. Make sure the clients name is highlighted and then click Continue
8. Do a behavioral test of the EMG system/sensors a) click on record, ask client to raise and lower the upper left trap...then ask client to raise and lower right upper trap. If reading are Consistent click on STOP button. ( click on NO when asked to save Data )
9. Explain to client to following (This test will take about 10 minutes, 5 minutes sitting and 5 Minutes standing.
   Part 1 - Record Baseline ------------------------------ 0:00 to 1:00 min.
   Part 2 - Record Shoulder shrug and recovery ---- 1.00 to 2:00 min.
   Part 3 - Record Arm abduction and recovery ---- 2:00 to 3:00 min.
   Part 4 - Record Shoulder Flexion and recovery - 3:00 to 4:00 min.
   Part 5 - Record final Baseline ------------------------ 4:00 to 5:00 min.
   In between each part you will pause the recording to read instructions to client, DO NOT pause between movement and recovery steps
10. Clip the encoder box to belt or waist band.
11. Record sitting baseline, click on the Record button on the bottom of the menu bar, see client menu, make sure clients name is highlighted, click Continue
12. Click on Start recording. Tell client ( "over the next minute sit comfortably with your eyes open" )
13. Watch the session timer, when it reaches 1:00 min. click on Pause.
14. Tell client ( "Over the next 30 seconds, I want you to perform a shoulder shrug ( demonstrate ) When I say "begin" hike your shoulders up towards your ears and hold for 30 seconds until I say stop, and then put them back down" )
15. Tell client "Begin", click on the pause button, and see session timer begin. When the session timer reaches 1:30 tell client to "STOP" continue recording until timer is at 2:00 min. then click Pause
16. Tell client "over the next 30 seconds I want you to perform an arm abduction, (demonstrate) when I say "begin" I want you to lift your arms up and away from your sides until I say stop, then put them back down again"
17. Tell client "Begin", click on the pause button, and see session timer begin. When the session timer reaches 2:30 tell client to "STOP" continue recording until timer is at 3:00 min. then click Pause
18. Tell client ( "over the next 30 seconds, I want you to perform a shoulder flexion (demonstrate) when I say "begin" I want you to lift your arms straight out in front of you and hold until I say "stop" and then put them back down"
19. Tell client "Begin" click on the pause button to begin recording, when the session timer reaches 3:30 Tell the client to "stop" continue recording until the session timer reaches 4:00 min, and then click on pause
20. Tell client: "over the next minute just sit comfortably with your eyes open.
21. Click on the Pause button to resume recording, when the session timer reaches 5:00 min. click on Pause

Part 2 of upper trap evaluation, standing exercises

22. Tell client: "for the second half of this exercise please stand up"
23. Tell client: "over the next minute stand comfortably with your eyes open"
24. Resume recording by clicking on the Pause button, watch the session timer, when it reaches 6:00 min click on Pause.
25. Tell client ( "Over the next 30 seconds, I want you to perform a shoulder shrug ( demonstrate ) When I say "begin" hike your shoulders up towards your ears and hold for 30 seconds until I say stop, and then put them back down" )
26. Tell client "Begin", click on the pause button, and see session timer begin. When the session timer reaches 6:30 tell client to "STOP" continue recording until timer is at 7:00 min. then click Pause
27. Tell client "over the next 30 seconds I want you to perform an arm abduction, (demonstrate) when I say "begin" I want you to lift your arms up and away from your sides until I say stop, then put them back down again"
28. Tell client "Begin", click on the pause button, and see session timer begin. When the session timer reaches 7:30 tell client to "STOP" continue recording until timer is at 8:00 min. then click Pause
29. Tell client ( "over the next 30 seconds, I want you to perform a shoulder flexion (demonstrate) when I say "begin" I want you to lift your arms straight out in front of you and hold until I say "stop" and then put them back down"
30. Tell client "Begin" click on the pause button to begin recording, when the session timer reaches 8:30 Tell the client to "stop" continue recording until the session timer reaches 9:00 min, and then click on pause
31. Tell client: "over the next minute just stand comfortably with your eyes open.
32. Click on the Pause button to resume recording, when the session timer reaches 10:00 min. click on Stop
33. You will be asked to save data or not, click on YES, See box on screen "Upper trap Eval" click OK
34. Press the TAB key from your keyboard to switch to the Report mode
35. Calculate the EMG statistical mean for each part of the exercise. ( hint : simultaneously hold down your "SHIFT" key from the keyboard and the left mouse button, then drag mouse )
36. Transfer Data to the "Upper Trap Evaluation Profile Statistics form"
37. Click on the red X in the upper right corner to exit program

Heart Rate Variability (HRV) Biofeedback

Heart rate variability (HRV) is the beat-to-beat variations in heart rate or pulse, which occur naturally during all levels of activity, from running and jumping to sitting still or sleeping. HRV is intimately tied to a person's emotional state, and with biofeedback you can use HRV as a treatment option for a variety of mental and emotional conditions, including anxiety and depression.

HRV patterns are different from simple heart rate patterns, and much more significant for psychological treatment. When we are in a state of stress, anxiety, anger or sadness our heart rate variation tends to be lower, disordered and chaotic. In contrast, when we are in a positive emotional state, like love, laughter or gratitude, our heart rate variation tends to be increased, ordered and rhythmic.

Using a computerized analysis of heart rate and respiratory rate information, it is possible to measure the rate of variability and use the information to create a change in emotional state.

How Does HRV Biofeedback Work?

HRV Biofeedback uses the computerized data collected and displays it on a screen so you are able to watch and monitor your heart patterns as you change your thoughts, breathing, body tension and other activities. Through practice, you develop specific techniques to adjust and modify your heart rhythms to an ideal state. After a series of sessions and use of the techniques you learn, you ultimately are able to self-regulate the ideal rhythms you desire.

What Conditions is HRV Biofeedback Used to Treat?

HRV biofeedback training is a useful treatment option for a number of psychological and mental conditions, including:

• Anxiety and Panic
• Depression
• Stress
• Insomnia
• Fatigue

The body's autonomic nervous system (ANS) governs many of the body's internal functions, through its two branches: the sympathetic branch of this ANS activates or increases the heart's action, while the parasympathetic branch acts as a brake slowing the action of the heart. The vagus nerve plays a role in the parasympathetic braking action. The balance between this throttle and brake system produces an ongoing oscillation, an orderly increase and decrease in heart rate. These autonomic inputs are mediated by two "pacemakers" in the heart, the sinoatrial (SA) and atrioventricular (AV) nodes, which are responsible for heart rhythms.The SA node initiates an electrical signal which begins each cycle of the heart's pumping action. This signal passes through the AV node which spreads the electrical current through the ventricles of the heart. A variety of factors, including breathing, pressure sensors (baroreceptors) in the arteries, the body's thermal regulation, and anxious thinking, increase specific rhythms in heart activity. The overall process of heart function is the end product of these components rhythms. Higher heart rate variability seems to indicate an optimal cooperation between the sympathetic and parasympathetic nervous system.

What is Heart Rate Variability?

By variability we mean changes in the interval or distance between one beat of the heart and the next. the interbeat interval (IBI) is the time between one R-wave (or heart beat) and the next, in milliseconds. The IBI is highly variable within any given time period. Multiple biological rhythms overlay one another to produce the resultant pattern of variability. Interbeat interval variations, or heart rate variability, have relevance for physical, emotional, and mental function. Many people confuse Heart Rate with Heart Rate Variability. The human heart is a bio-electrical pump beating at an ever changing rate: it is not like a clock that beats at a steady, unchanging rate. This variability in heart rate is an adaptive quality in a healthy body.

How is Heart Rate Variability measured?

One measure of heart rate variability is the difference between the highest heart rate and the lowest heart rate within each cardiac cycle, measured in beats per minute. This index is called "HR Max - HR Min." A second index of Heart Rate Variability, widely used in medical research is the Standard Deviation of the N-to-N interval. The N-to-N interval is the "normalized" beat to-beat interval. The SDNN is the standard deviation of those intervals, a measure of their variability. The SDNN is expressed in milliseconds (ms).Finally, a third index of variability,more reliable in the short term, is called pNN50. This index measures what percent of the Interbeat Intervals differ from neighboring intervals by 50 milliseconds or more. The pNN50 is expressed in percentages.

Can we train individuals to increase the variability of their Heart Rate and is there an ideal value for HRV?

Scientific study of the variability in heart rate is fairly recent, and only in the past ten years did it become possible to train human beings to change the variability in heart rhythms. Biofeedback practitioners have found that biofeedback training can increase HRV, through several parallel training pathways. The practitioner initially guides the subject to acquire three basic skills: 1) relax physically and emotionally, 2) reduce anxious thoughts and negative emotions, and 3) engage in smooth full diaphragmatic breathing. Next, the trainee learns to recognize and produce the smooth sinusoidal wave forms (RSA waveforms)in which respiration and heart rate co-vary in a near-phase or complete phase relationship. HRV biofeedback can reinforce breathing in the 5-7 breaths per minute range, and reinforce the production of a dominant spike in HRV at around 0.1Hz Current research suggests that each individual has a "resonant frequency" at which heart rate variability is the greatest, and this resonant frequency can be measured by biofeedback instruments. While there is no uniform "ideal value" for all persons, this resonant frequency is most frequently produced by persons in a relaxed mental state, with a positive emotional tone, breathing diaphragmatically at a rate of about 5-7 breaths per minute. Relaxed breathing at around six breaths per minute produces a spike of heart rate variability at around 0.1 Hz. Remember that one tenth of a hertz equals one tenth of a cycle per second, so that 0.1 Hz equals six cycles per minute. The other measures of HRV also tend to maximize when heart rate change is dominated by rhythms in this Low Frequency range. In this way, a trainee in HRV biofeedback can be directly reinforced for increasing one of the variability indices (HR Max - HR Min, SDNN, or pNN50)

Is there any current or ongoing research to support HRV biofeedback?

Psychophysiological research suggests that these frequency ranges reflect different biological influences. The high frequency range is associated with parasympathetic pathways, the influences of respiration in normal frequencies on vagal tone. The low frequency range is associated with the influence of blood pressure (baroreceptors) on heart rhythms, and meditative/slow breathing augments this range. The very low frequency range is associated with sympathetic activation, or more probably the withdrawal of parasympathetic braking, and also the influences of visceral and thermal regulation. Rumination and worry augment this range. Finally, the ultra low frequency range is associated with the slower-acting biological influences. Several clinical findings show the importance of the heart's variability. Changes in the rhythms of the heart occur before a fetus goes into distress, and may predict sudden infant death. Lower variability in heart rate predicts a greater risk for death after a heart attack and death from all causes in adults, especially sudden death. Studies have also shown that clinical depression lowers heart rate variability.

What is the relationship between Heart Rate Variability and Biofeedback?

Heart Rate Variability Biofeedback,or HRV biofeedback, is a new technique for training human beings to change the variability and dominant rhythms in their heart activity. The use of HRV biofeedback began in Russia, where it was applied to the treatment of asthma and many other conditions. Research is now going on in many sites within the United States, applying HRV biofeedback to a variety of medical and psychiatric conditions, including: anger, anxiety disorders, asthma, cardiovascular conditions, chronic obstructive pulmonary disorder, irritable bowel syndrome, chronic fatigue, and chronic pain. Biofeedback training can teach patients to increase the percentage of total HRV in specific frequency ranges. To date, it appears optimal to increase the amount of heart rate change in the Low Frequency Range. Evgeny Vaschillo, a Russian physiologist, hypothesizes that there is a "resonant frequency," native to each organism, which is optimal for overall health. For most persons that resonant frequency involves a dominance of heart rate change in the Low Frequency (LF) range, around 0.1 Hz. HRV biofeedback can therefore guide and reinforce trainees for shifting their overall heart rate variability into the LF range.

Does Heart Rate Variability change with age?

As human beings age or suffer illness, the total variability in heart rate is reduced, and the risk of illness and death increases. Twenty year olds often show a swing of twenty or more points between the high and low points in their heart rates. Persons over 50 often show changes of ten beats or less. Persons who are more physically active show a wider range between their maximal and minimal heart rate. HRV biofeedback can enable the individual to increase this variability in heart rate, sometimes producing a range of fifty beats a minute during training. HRV biofeedback training can focus on increasing the HR Max -HR Min index

Short-term HRV analysis and assessment of the autonomic regulation

It is believed that Heart Rate Variability (HRV) will become as common as pulse, blood pressure or temperature in patient charts in the near future. In the last ten years more than 2000 published articles have been written about HRV. HRV has been used as a screening tool in many disease processes. Various medical disciplines are looking at HRV. In diabetes and heart disease it has been proven to be predictive of the likelihood of future events. In 1996, a special task force was formed between the US and European Physiological associations to outline current finds on HRV and set specific standards on using HRV in medical science and future practice. Since then a steady stream of new information and value continues to come out of HRV research.

It all started in 1966 when a variation in the beat-to-beat intervals between heartbeats was noticed. Initially all recording devices were averaging heart rate data stream trying to get rid of any rapid HR fluctuations. Then there were very specific patterns in such fluctuations were noticed that had links to certain conditions way before any clinical symptoms appeared.

Physiological Basics of HRV

The origin of heartbeat is located in a sino-atrial (SA) node of the heart, where a group of specialized cells continuously generates an electrical impulse spreading all over the heart muscle through specialized pathways and creating process of heart muscle contraction well synchronized between both atriums and ventricles. The SA node generates such impulses about 100-120 times per minute at rest. However in healthy individual resting heart rate (HR) would never be that high. This is due to continuous control of the autonomic nervous system (ANS) over the output of SA node activity, which net regulatory effect gives real HR. In healthy subject at rest it is ranging between 50 and 70 beats per minute.

Schematic explanation of RA, LA, RV, LV parameters and their visualization on Heart Rate

Autonomic nervous system. The autonomic nervous system is a part of the nervous system that non-voluntarily controls all organs and systems of the body. As the other part of nervous system ANS has its central (nuclei located in brain stem) and peripheral components (afferent and efferent fibers and peripheral ganglia) accessing all internal organs. There are two branches of the autonomic nervous system - sympathetic and parasympathetic (vagal) nervous systems that always work as antagonists in their effect on target organs.

Sympathetic nervous system. For most organs including heart the sympathetic nervous system stimulates organ's functioning. An increase in sympathetic stimulation causes increase in HR, stroke volume, systemic vasoconstriction, etc. The heart response time to sympathetic stimulation is relatively slow. It takes about 5 seconds to increase HR after actual onset of sympathetic stimulation and almost 30 seconds to reach its peak steady level.

Schema explaining how parasympathetic and sympathetic nervous systems inhibit functioning organs

Parasympathetic nervous system. In contrast, the parasympathetic nervous system inhibits functioning of those organs. An increase in parasympathetic stimulation causes decrease in HR, stroke volume, systemic vasodilatation, etc. The heart response time to parasympathetic stimulation is almost instantaneous. Depending on actual phase of heart cycle it takes just 1 or 2 heartbeats before heart slows down to its minimum proportional to the level of stimulation.

At rest both sympathetic and parasympathetic systems are active with parasympathetic dominance. The actual balance between them is constantly changing in attempt to achieve optimum considering all internal and external stimuli.

There are various factors affecting autonomic regulation of the heart, including but not limited to respiration, thermoregulation, humoral regulation (rennin-angiotensin system), blood pressure, cardiac output, etc. One of the most important factors is blood pressure. There are special baroreceptive cells in the hear and large blood vessels that sense blood pressure level and send afferent stimulation to central structures of the ANS that control HR and blood vessel tonus primarily through sympathetic and somewhat parasympathetic systems forming continuous feedback dedicated to maintain systemic blood pressure. This mechanism is also called baroreflex, which increases HR when blood pressure decreases and vice versa. This mechanism is also targeted to maintain optimal cardiac output.

Schema showing the baroreflex functionality

Blood Volume Pulse (BVP)

BVP, Blood Volume Pulse sensor or photoplethysmograph bounces infra-red light against a skin surface and measures the amount of reflected light. This amount will vary with the amount of blood present in the skin. At each heart beat (pulse), there is more blood in the skin - blood reflects red light and absorbs other colors - and more light is reflected. Between pulses, the amount of blood decreases and more red light is absorbed. The BVP signal is a relative measure so it does not have a standard unit. From the BVP signal, the software can usually calculate heart rate and inter-beat interval. The amplitude of the BVP deviation can also be a useful measure. Heart Rate Variability can also be calculated with the BVP A photoplethysmograph (PPG) is an optically obtained plethysmograph, a volumetric measurement of an organ. A PPG is often obtained by using a pulse oximeter which illuminates the skin and measures changes in light absorption (Shelley and Shelley, 2001). A conventional pulse oximeter monitors the perfusion of blood to the dermis and subcutaneous tissue of the skin.

With each cardiac cycle the heart pumps blood to the periphery. Even though this pressure pulse is somewhat damped by the time it reaches the skin, it is enough to distend the arteries and arterioles in the subcutaneous tissue. If the pulse oximeter is attached without compressing the skin, a pressure pulse can also be seen from the venous plexus, as a small secondary peak. The change in volume caused by the pressure pulse is detected by illuminating the skin with the light from a light-emitting diode (LED) and then measuring the amount of light either transmitted or reflected to a photodiode. Each cardiac cycle appears as a peak, as seen in the figure. Because blood flow to the skin can be modulated by multiple other physiological systems, the PPG can also be used to monitor breathing, hypovolemia, and other circulatory conditions (Reisner, et al., 2008). Additionally, the shape of the PPG waveform differs from subject to subject, and varies with the location and manner in which the pulse oximeter is attached.

Photoplethysmography (PPG) is the process of applying a light source and light sensor to an appendage, such as a finger or a tow, and measuring the light that is reflected by the skin. At each contraction of the heart, blood is forced through the peripheral vessels producing engorgement of the vessels under the light source, there by modifying the amount of light reflected to the photo sensor.

Since vasomotor activity is controlled by the sympathetic Nervous System (SNS), the Blood Volume Pulse (BVP) measurements can display changes in sympathetic arousal. An increase in BVP amplitude indicates decreased sympathetic arousal and greater blood flow to the peripheral vessels.

Respiratory biofeedback

Respiration Sensor

A stretch sensitive device is strapped to the torso to measure the relative amount of expansion that occurs during respiration (breathing). As breathing in takes place the rib cage expands which stretches the device. When exhaling, the stretch relaxes and the sensor returns to its neutral position. The resulting waveform is displayed on the screen.

To monitor thoracic respiration (chest breathing), the strap is positioned to the upper aspect of the trunk. Position it on the lower aspect of the trunk to measure diaphragmatic respiration (stomach breathing).

Respiratory biofeedback: The breathing patterns of patients who are anxious or stressed are often shallow and rapid. Upper chest and neck muscles tend to be used for breathing, instead of the abdominal muscles. With respiratory biofeedback, belts with sensors are placed around the chest and the abdomen of the patient, whose breathing pattern is visualized on the computer screen. The therapist teaches patients how to relax, breathe using the abdominal muscles, and to breathe slowly and deeply to alleviate the anxiety.

1. It can increase oxygen to the brain, potentially improving a variety of neurological imbalances. This is accomplished through more efficient breathing that brings more air into the lungs.
2. It can increase the brain's production of alpha waves. These brain waves can help reduce harmful stress hormones, especially cortisol, balance the autonomic nervous system and promote muscle relaxation - all very important features for a healthier brain and body.
3. Respiratory feedback can help restore and improve normal breathing. Improper breathing is often associated with brain and spinal cord injuries and is sometimes a hidden problem even in relatively healthy people.
4. It can help improve the function of the diaphragm and abdominal muscles. In addition to breathing, these muscles play a significant role in physical activity, improving posture and supporting the spine and pelvis.
5. Because of its effect on the brain and nervous system, respiratory biofeedback can help improve the function of other muscles in the body as well, and help reduce pain - two reasons to perform this procedure before other manual biofeedback

Normal Breathing

Before performing respiratory biofeedback, we must first be sure the basic breathing mechanism is working properly. Without normal breathing, many muscles don't work as well, body movement is impaired, oxygen can be reduced and many therapies, including respiratory biofeedback, may not be effective. Normal breathing is associated with proper muscle movement - the most important being the abdominal muscles and the diaphragm muscle. These muscles coordinate movements that allow us to efficiently breathe in and out. Let's look at the two components of normal breathing - inhalation and exhalation:

1. During inhalation the abdominal muscles relax and extend outward, while the diaphragm muscle contracts and moves downward. This movement allows air to enter the lungs more easily and is accompanied by a slight whole-body backward extension, especially the spine.
2. During exhalation the abdominal muscles contract and tighten, and are gently pulled inward; the diaphragm muscle relaxes with an upward movement. This helps push air out of the lungs, with a slight whole-body flexion. We can observe another person's breathing and often tell if it's correct, especially watching the belly move out on inhalation and in on exhalation. We can also evaluate our own breathing by feeling our muscles move:

- Place the palm of one or two of your hands on the abdomen.

- Slowly breathe in and feel the abdominal muscles expand outward. The belly should get bigger during inhalation.- Slowly exhale and feel the abdominal muscles tighten and be pulled inward. The belly is more flat on exhalation. During normal breathing, most movement occurs in the abdominal areas with only slight movement of the chest. The chest expands more during much deeper breathing such as during exercise. We can assess a patient by watching the abdominal movement, and also by placing our hands on his or her abdomen during breathing - we should feel the muscles expand on inhalation, and flatten and tighten on exhalation. Those who breathe improperly often move their muscles opposite that of normal. This happens for various reasons. Brain and spinal cord injuries can disturb the breathing muscles. In other individuals, poor breathing can come from stress, the stigma of not showing a big belly, and even overexercising the abdominal muscles, making them too tight to relax. If breathing is not normal, it's important to re-train the breathing mechanism before using respiratory biofeedback. The procedure is simple - follow those steps just outlined for normal inhalation and exhalation, and continue for about two minutes, three times a day. It may only take a few days to restore the natural habit of normal breathing. Then, performing respiratory biofeedback can help maintain normal movement.

Dysfunctional Breathing Patters

Thoracic breathing (chest breathing )

Reverse breathing ( diaphragm motion is reversed )

Clavicular breathing ( color bones rise )

Hyperventilation

Heart Rate Variability (HRV) biofeedback training.

HRV & Breathing exercise # 1

1. Attach Respiration Sensor to client
2. Attach BVP sensor to client (left hand, index finger)
3. From within the main menu of the Biotrace software click on Record New Session
4. From within the Category side find Basic Screens ..from the screens side find Basic BVP, click once
5. Press F1, click YES
6. From the screens side find Basic Respiration, click once, press F2, click YES
7. From the Category side find Respiration and HRV, from the screens side find Res & HR Dual Linegraph + FB Click once, press F3, click YES
8. Double click on Res & HR Dual Linegraph + FB to load screen
9. see client window, then click CANCEL bottom right corner
10. to determine proper port press (I) Insert both sensors. Exit this window by clicking CANCEL
11. Confirm that screens are assigned correctly by typing (K)
12. Turn encoder on, see Res & HR Dual Linegraph + FB turn off audio
13. Press F1, See Basic BVP screen study the HR pulses, make sure they have a net amplitude of 10 units
14. Press F2, see Basic Respiration screen, click on the STOP button click NO when asked to save data.
15. Tell client "This exercise will consist of 6 parts
    1. Baseline
    2. Respiration: Even
    3. Respiration: Extended
    4. Respiration: Clients choice
    5. Respiration and Heart Rate line graph
    6. Post-basline
16. Tell client "Sit comfortably with your eyes open, but do not watch the screen"
17. Click on the RECORD button, Point mouse in Respiration Linegraph and press the S key 5 times to smooth the respiration trace line.
18. When the session timer reaches 1:00 min press PAUSE ( BASELINE finished )
19. Tell client "for the next 2:00 min watch the feedback screen, try to breath diaphragmatically and create symmetrical looking waves on the screen" .."when you inhale, breathe IN to a count of 4, then exhale to a count of 4"
20. Click on the PAUSE button to restart data collection, you should see the Respiration screen with no HR. press F2 if you forgot
21. Once the timer reaches 3:00 min press PAUSE
22. PART 3, Respiration extended
23. Tell client "for the next 2:00 minutes watch the screen, this time when you exhale, make it longer than the inhalation, for example, if you breathe in to a count of 4, try to breathe out to a count of 8" it's ok if you can't exhale that long, just try to make the exhalation longer than the inhalation"
24. Click on the PAUSE button to restart the data
25. When the timer reaches 5:00 press PAUSE
26. Part 4 Respiration clients choice
27. Tell client "for the next 2:00 minutes watch the feedback screen, This time, perform the Breathing pattern that you liked best: even, extended or something in-between"
28. Click on PAUSE to restart data collection, when the timer reaches 7:00 click F3 then PAUSE
29. Part 5, Breathe with your heart,
30. Tell client, "this time I want you to sit and relax and practice breathing assisted by the Respiration & HR Graphs watch the red trace line of the heart rate display, when it goes up-breath in.-when it goes down breathe out"
31. Click PAUSE to restart date collection, see Respiration & HR Graphs once the timer reaches 9:00 min. click on PAUSE
32. Part 6, collect a Post-baseline
33. Tell client "for the next minute a final baseline will be recorded, do not watch the screen"
34. Click PAUSE to restart data collection, when the timer reached 10.00 min click STOP
35. Click on YES when asked to save data, type in HRV and Breathing Lab 1 then click OK

View Report ( LineGraph ) mode

36. Press the TAB key to view report, Point mouse inside review screen, do a right click mouse, see window open, Highlight ONLY the heart rate and respiration line in blue. Click OK
37. Change Horizontal time access to 60 second
38. Point the mouse anywhere within the white review graph, and do a right mouse button cick
39. Point at line "Size of TIME axis". See window click on the line Time axis 60 seconds You should now see the first 60-seconds of the baseline.
40. From the keyboard see arrow pointing to the right ( ? ) ,,,
    Remember : This exercise consisted of 6 parts
    1. Baseline
    2. Respiration: Even
    3. Respiration: Extended
    4. Respiration: Clients choice
    5. Respiration and Heart Rate line graph
    6. Post-basline
41. Use client HR & Resp form to fill in Data ( note to self make the form!
42. Patterns and Analysis of Respiration

Feedback Encephalography (EEG)

Feedback encephalography is the process of monitoring and displaying to an individual the ongoing EEG activity generated in by their brain. Its most common clinical application is to redress a chronic mental posture constituting a component of a psychosomatic or psychological disorder. Many individuals suffering from stress-related disorders exhibit excessive mental arousal and rumination associated with high-frequency (beta) EEG activity. Characteristically, these individuals do not experience periodic mental relaxation associated with synchronized alpha EEG activity. By learning to enhance the generation of EEG alpha activity, such individuals may cultivate a more normal mental posture and thus modify a portion of maladaptive psychosiological mechanisms, which tend to perpetuate or exacerbate their condition.

The electroencephalographic potentials emitted by the human brain provide one of the few objective measurements of activity of the human central nervous system. While the sources and mechanics are not fully understood, EEG potentials originate in the firing mechanisms of neurons and travel along the surface of the cerebral cortex as well as through deeper layers of the brain. There are four basic types of EEG patterns, classified according to their frequency (number of Hertz or cycles-per-second). They are beta, 12-20Hz, alpha, 8-12Hz, theta, 4-8Hz, and delta, 0-4Hz. In adults, each of these frequency bands represents a specific mental arousal level, and is associated with a set of generalized behavioral correlates. It should be emphasized, however, that individuals might differ somewhat in terms of their subjunctive experiences of these EEG states.

In feedback electroencephalography, EEG activity is detected by surface electrode sensors attached to the scalp - then amplified, analyzed, and translated into visual and auditory feedback displays. By receiving immediate and continuous information reflecting EEG frequency and amplitude fluctuations, the trainee can learn to recognize and associate specific patterns of EEG activity with discernible mental and physiological states. With time, this can generate desired EEG activity and its mental and physiological connection.

Brain wave activity provides us with information on brain function. Understanding some basic information about brain waves is an important component of respiratory biofeedback. The brain produces different frequencies and amplitudes of electrical waves depending upon levels of consciousness. Sensation, attention (self awareness), intellectual activityand the planning of physical movement have distinct electrical correlates in the brain that can be measured. Measuring brain waves during various activities, such as reading, performing a math problem, listening to music, with eyes open and closed, provides further information about brain function. Once analyzed through brain mapping such as the quantitative EEG (QEEG), areas of the brain can be trained to function better through biofeedback, often referred to as neurofeedback.

Four commonly measured brain waves, and at least two others that have been observed:

Beta waves (12 . 32 Hz) are associated with full awareness and high cortical activity . a busy brain, such as during a business meeting, planning a trip or mentally doing several things at one time.

Alpha waves (8 . 12 Hz) are associated with a sense of relaxed alertness and high creativity; Typical during meditation, listening to music, and when eyes are closed. The ability to generate alpha waves is associated with the self regulation of stress and may contribute to an expanded state of consciousness.

theta waves (4 - 8 Hz) are an awake but dreamy state common just before the onset of sleep; Most prevalent in youth but occurs during deep creativity and meditation in adults at any time.

Delta waves (0.5 - 4 Hz) are very slow wave occurring during most stages of sleep. Abnormal if occurring while awake and may indicate a lack of nutrients such as glucose or oxygen, medication effects, or poorly functioning neurons.

Theta waves (4 - 8 Hz) are an awake but dreamy state common just before the onset of sleep; Most prevalent in youth but occurs during deep creativity and meditation in adults at any time

The ability to produce alpha waves is associated with an overall healthy brain and body, especially in relation to controlling stress. It is one reason people have, for thousands of years, pursued meditation, the use of psychedelics and other drugs, prayer and other activities that seek to promote the alpha state. Specifically, alpha waves can reduce high levels of the stress hormone cortisol, and help balance the autonomic nervous system.

These alpha waves can have dramatic effects on our whole body, such as improved memory, learning and comprehension, better blood sugar regulation, improved gut function, and balanced hormones. When we're relaxed, creative, meditating and happy, our brain produces large amounts of alpha waves. For these and other reasons, one main focus of respiratory biofeedback is the creation of alpha waves.

The inability to produce alpha waves is abnormal. Blood sugar problems, inadequate sleep, nutritional imbalance and very high levels of stress hormones can impair the ability to produce alpha waves. Even certain structural problems, such as those in the jaw joint or neck muscles innervated by the cranial nerves (neck flexors and SCM) can significantly reduce our ability to generate healthy alpha waves

Biofeedback-Assisted Relaxation in Type 2 Diabetes

1. Ronald A. McGinnis, MD,
2. Angele McGrady, PHD, MED, LPCC,
3. Stephen A. Cox, MD and
4. Kimber A. Grower-Dowling, BA

+ Author Affiliations

1. From the Department of Psychiatry, Medical University of Ohio, Toledo, Ohio

Abstract

OBJECTIVE-The objective of this randomized controlled study was to determine the effects of biofeedback and relaxation on blood glucose and HbA1c (A1C) in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS-Patients with type 2 diabetes were randomized to either 10 sessions of biofeedback (electromyograph and thermal) and relaxation or 3 sessions of education. All sessions were individual. A total of 39 participants were entered, and 30 completed the 3-month protocol. Average blood glucose, A1C, forehead muscle tension, and peripheral skin temperature were assessed, and inventories measuring depression and anxiety were administered prerandomization and after completion of treatment/control.

RESULTS-Biofeedback and relaxation were associated with significant decreases in average blood glucose, A1C, and muscle tension compared with the control group. At 3-month follow-up, the treatment group continued to demonstrate lower blood glucose and A1C. Both groups decreased scores on the depression and anxiety inventories. Patients with depression had higher blood glucose levels and tended to drop out of the study.

CONCLUSIONS-This study supports the use of biofeedback and relaxation in patients with type 2 diabetes for up to 3 months after treatment. Further research is necessary to determine the long-term effects of biofeedback and the effects of mood on patients' responses to treatment.

BIOFEEDBACK IN TYPE 2 DIABETES

Diabetes is characterized by elevated blood glucose and resistance of cell membranes to insulin, such that glucose is impeded from crossing from the blood into the cells. Standard treatment consists of oral antihyperglycemic agents, exogenous insulin, diet, and exercise.20 Type 2 diabetes may be the most behaviorally demanding of all chronic illnesses because patients must take an active role in daily management. Typical requirements are to measure blood glucose and take oral medicine, perhaps along with insulin, as well as to exercise, monitor diet, and adjust calories depending on activity level.

The goal of psychophysiologic therapy is not to replace standard treatment with relaxation training or biofeedback but rather to use biofeedback-assisted relaxation therapy to improve control of blood glucose. For example, McGinnis and colleagues compared the effects of 10 sessions of biofeedback (both surface electromyography and thermal feedback) and relaxation therapy versus three sessions of education in a sample of 30 patients with type 2 diabetes.21 No medicines were changed unless medically necessary. Patients kept daily logs of blood glucose, and had their hemoglobin A1c measured before and after treatment. Significant between-group differences in hemoglobin A1c and average blood glucose emerged in favor of the biofeedback group.21 However, patients with high scores on the Beck Depression Inventory22 (indicating more severe depressive symptoms) tended to drop out of the study or did not do as well as patients who were not symptomatic.

Another application of biofeedback in type 2 diabetes has been demonstrated by Rice and Schindler23 and Fiero et al.24 These investigators showed that patients with peripheral neuropathy, a common long-term complication of diabetes, were able to warm their hands and feet with the use of thermal biofeedback. Increased peripheral blood flow mediated the decrease in neuropathic pain.

Possible mechanisms of biofeedback in diabetes

Several explanations can be suggested to account for the results of biofeedback on blood glucose levels. Forehead muscle tension feedback (surface electromyography) helps patients to reduce facial tension and relax skeletal muscles, while increased finger temperature is an indicator of general relaxation. In the patients who completed the above study by McGinnis et al,21 both depression and anxiety scores decreased, which suggests a psychological mechanism for blood glucose reduction. Patients also reported improved sleep duration and quality with the use of relaxation therapy at bedtime.

BIOFEEDBACK IN ESSENTIAL HYPERTENSION

Biofeedback-assisted relaxation therapy has also been applied to control essential hypertension. The definition of hypertension, according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7),25 is systolic blood pressure greater than 139 mm Hg and diastolic blood pressure greater than 90 mm Hg. Prehypertension refers to systolic blood pressures between 130 and 139 mm Hg and diastolic pressures between 80 and 89 mm Hg. Standard treatment for established hypertension is antihypertensive medications, diet, and exercise. For patients in the prehypertensive blood pressure range, lifestyle changes are the primary intervention, unless the patient has multiple risk factors.25

Representative clinical evidence

Linden et al reported on the effects of 10 weeks of individualized psychophysiologic treatment on ambulatory blood pressure in patients with essential hypertension.26 Patients were initially screened for anxiety, depression, and anger, after which a program was designed for each patient based on his or her psychological risk factors. All patients received some form of relaxation therapy, and some received biofeedback. Over time significant reductions in ambulatory systolic and diastolic blood pressure were observed.26 In a separate study, Yucha et al provided a multimodal training program to hypertensive individuals and also reported significant decreases in blood pressure. 27

Elliott et al trained hypertensive patients to use the RESPeRATE™ device to achieve the slow, deep breathing associated with the "relaxation response" sought in relaxation training.28 After initial training, patients were instructed to practice this device-guided breathing technique at home. Significant reductions in systolic blood pressure were observed over 8 weeks in the patients who used the device compared with controls who simply monitored their blood pressure at home. A maximum mean systolic blood pressure reduction of 15 mm Hg was achieved in the group of patients who practiced device-guided breathing for the greatest number of minutes during the 8-week study. Similar results with device-guided breathing using this device have been reported in two separate studies.29,30

More general stress reduction programs have also achieved success when offered to patients with essential hypertension in the clinic or the workplace. Studies of programs focusing on meditation and repeated practicing of centered breathing and relaxation responses, without use of biofeedback, have reported reductions of approximately 10.7 mm Hg in systolic pressure and 6.4 mm Hg in diastolic pressure.31,32 McCraty and colleagues provided a stress management program to hypertensive individuals at their place of work,33 based on the premise that individuals' work demands are a source of chronic stress and thus create an ideal setting for the application of new coping skills. In this study, stress reduction training was associated with significant reductions both in blood pressure and in global measures of distress.33

Prehypertensive patients: An ideal target population

Although meta-analyses demonstrate that there is support for the efficacy of biofeedback in patients with essential hypertension,34,35 the field has been handicapped by the reality that most patients with hypertension are already being treated pharmacologically, which means that their blood pressure levels when starting biofeedback treatment are often low,36 limiting the potential effects of the intervention. The new category of patients with prehypertension may thus be the ideal population for stress management therapies, since their blood pressure is elevated, but not elevated enough to have prompted medication prescriptions in most cases. Lifestyle modifications, which could certainly include stress management, are the recommended first-line therapies for these prehypertensive patients.25

Possible mechanisms of biofeedback in hypertension

One can hypothesize on the mechanisms of action of relaxation-based therapies in hypertension. Relaxing the muscles of the face via electromyography biofeedback and increasing finger temperature facilitates whole-body relaxation and decreased sympathetic adrenergic activity. Parasympathetic dominance is facilitated by the use of breathing techniques to increase heart rate variability. 37,38 The improved deep sleep that results from relaxation may also reduce blood pressure by restoration of nighttime blood pressure dipping.16

IDENTIFYING THE BEST CANDIDATES IS NOT EASY

Some individuals are excellent candidates for biofeedback, while others do not benefit despite their best efforts.39,40 The likelihood of response is generally associated with adherence to medical recommendations and willingness and ability to follow instructions for home practice of relaxation. Nevertheless, some patients who attend sessions and practice still do not succeed, perhaps because they have few signs of overarousal in the system, such as a high degree of sympathetic activation, muscle tension, or low heart rate variability. Further, patients must be able to demonstrate that they learned the skill that was trained, such as consistent warming of the hands. If the training was for heart rate variability, the patient should be in the optimal range of heart rate variability and be able to demonstrate high-frequency waves.34 Patients with specific characteristics, such as stress sensitivity, may benefit more than those whose blood pressure and blood glucose are chronically elevated with few fluctuations.

CONCLUSIONS

The etiology of the metabolic syndrome is complex and multifactorial. Psychophysiologic interventions such as biofeedback and relaxation training are sometimes warranted for multiple aspects of metabolic syndrome, and they target several specific associated disruptions, particularly chronic stress, negative mood, and behavior. Initial patient evaluation should aim to assess the patient's readiness for change, which must be present to a sufficient degree before continuing with biofeedback or relaxation techniques. Use of motivational interviewing techniques is recommended to increase patients' preparedness for change.41 Understanding patients' characteristic responses to stress will guide decisions on the type of biofeedback and relaxation therapies to use and whether or not psychotherapy will be necessary. Specific modalities of biofeedback or particular types of relaxation do not appear to be as critical as the total package of individualized psychophysiologic therapy.

Peripheral neuropathy

Another application of biofeedback in type 2 diabetes has been demonstrated by Rice and Schindler23 and Fiero et al.24 These investigators showed that patients with peripheral neuropathy, a common long-term complication of diabetes, were able to warm their hands and feet with the use of thermal biofeedback. Increased peripheral blood flow mediated the decrease in neuropathic pain.

Alternative medicine

By Mayo Clinic staff

Some people with peripheral neuropathy try alternative treatments for relief of their symptoms. Although these techniques haven't been as rigorously studied as most medications, the following therapies have shown some promise in the treatment of peripheral neuropathy:

• Biofeedback. During a biofeedback session, the therapist applies electrical sensors to different parts of your body to monitor your body's physiological response to your peripheral neuropathy symptoms. The biofeedback device then teaches you how your body responds using cues such as a beeping sound or flashing lights. This feedback can help you associate your body's response with certain physical functions. Once you begin to recognize your body's responses, you can learn ways to lessen the reaction through techniques such as relaxation or guided imagery.
• Alpha-lipoic acid. Used as a treatment for peripheral neuropathy in Europe for years, this antioxidant may help reduce the symptoms of peripheral neuropathy. Discuss the use of alpha-lipoic acid with your doctor before using it, because alpha-lipoic acid may affect your blood sugar levels. Side effects may include stomach upset and skin rash.
• Neuropathy pain. Diabetic peripheral neuropathy affects the sensory nerves in the feet with pain and, later, with loss of feeling. The additional oxygenation and available nutrients to the tissues following the effects of relaxation provide improved sensory function in the nerve fibers that correspond to touch.20 This was shown by measuring the Current Perception Threshold (CPT) levels by electrical stimulation of the great toe. The change in CPT levels pre- to post- intervention indicated a significant difference between the experimental and control groups. A significant improvement (increased sensation in the feet) was noted in the large myelinated nerve fiber functioning in the experimental groups, which used biofeedback-assisted relaxation, compared to the control groups who did not (P < 0.02).
• In another study by Fiero et al.,21 it was suggested that diabetic neuropathy might interfere with the ability to self-regulate peripheral temperature and that assessing neuropathic status may be important before prescribing thermal biofeedback. On the other hand, in mind-body therapies, "thinking of warmth" may surpass or be more accurate than "feeling warmth."
• The beneficial effects of thermal biofeedback-assisted relaxation have been demonstrated for several additional vascular disorders, including hypertension,22 migraine,23 and Raynaud's syndrome.24

GSR FOR EPILEPSY

Clinical efficacy of galvanic skin response biofeedback training in reducing seizures in adult epilepsy: a preliminary randomized controlled study.

Nagai Y, Goldstein LH, Fenwick PB, Trimble MR.

Source

Department of Clinical and Experimental Epilepsy, Institute of Neurology, University College London, Queen Square, London WC1N 3BG, UK. y.nagai@ion.ucl.ac.uk

Abstract

We investigated the effect of galvanic skin response (GSR) biofeedback training on seizure frequency in patients with treatment-resistant epilepsy. Eighteen patients with drug-refractory epilepsy were randomly assigned either to an active GSR biofeedback group (n = 10) or to a sham control biofeedback group (n = 8). Biofeedback training significantly reduced seizure frequency in the active biofeedback group (P = 0.017), but not the control group (P > 0.10). This was manifest as a significant between-group difference in seizure reduction (P 0.01). Furthermore, there was a correlation between degree of improvement in biofeedback performance and reduction of seizure frequency (rho = 0.736, P = 0.001), confirming that the effect of biofeedback treatment was related to physiological change. Our findings highlight the potential therapeutic value of GSR biofeedback in reducing seizure frequency in patients with drug-resistant epilepsy.

Asthma

It is reasonable to assume that restoration of autonomic homeostatic reflexes would be salutary for the specific condition. For asthma, for example, we know that allergic and inflammatory processes play key roles in symptom production, but the role of autonomic regulation has often been overlooked. It has been shown that 6- 8 sessions of training, in which subjects concentrate on producing breath patterns consistent with their own internal resonance (usually about 6 breaths per minute), can dramatically reduce asthma symptoms even with reduced medication use. The report of his full National Institutes of Health (NIH) sponsored trial was presented at the Spring 2003 American Thoracic Society meeting in Seattle.

Why biofeedback would help this problem: Many people with asthma have an unusual breathing pattern in which they take a deep breath and then breathe in and out with very shallow, rapid breaths rather than exhaling all the way. This prevents their being able to take reasonably deep breaths and leaves them chronically short of breath. Many workers consider it essential to train asthmatics not to barrel breathe. Pneumographic biofeedback is perfect for detecting and retraining this pattern. Asthmatics can be taught to recognize and correct abnormal interactions between heart rate variability and breathing. Correcting this abnormal relationship has been shown to reduce the symptoms of asthma

Fibromyalgia

From a pilot study of the efficacy of heart rate variability (HRV) biofeedback in patients with fibromyalgia

Hassett AL, Radvanski DC, Vaschillo EG, Vaschillo B, Sigal LH, Karavidas MK, Buyske S, Lehrer PM.

Source

Department of Medicine, Division of Rheumatology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School (UMDNJ-RWJMS), P.O. Box 19, MEB-484, New Brunswick, NJ, USA. a.hassett@umdnj.edu

Abstract

Fibromyalgia (FM) is a non-inflammatory rheumatologic disorder characterized by musculoskeletal pain, fatigue, depression, cognitive dysfunction and sleep disturbance. Research suggests that autonomic dysfunction may account for some of the symptomatology of FM. An open label trial of biofeedback training was conducted to manipulate suboptimal heart rate variability (HRV), a key marker of autonomic dysfunction.

METHODS:

Twelve women ages 18-60 with FM completed 10 weekly sessions of HRV biofeedback. They were taught to breathe at their resonant frequency (RF) and asked to practice twice daily. At sessions 1, 10 and 3-month follow-up, physiological and questionnaire data were collected.

RESULTS:

There were clinically significant decreases in depression and pain and improvement in functioning from Session 1 to a 3-month follow-up. For depression, the improvement occurred by Session 10. HRV and blood pressure variability (BPV) increased during biofeedback tasks. HRV increased from Sessions 1-10, while BPV decreased from Session 1 to the 3 month follow-up.

CONCLUSIONS:

These data suggest that HRV biofeedback may be a useful treatment for FM, perhaps mediated by autonomic changes. While HRV effects were immediate, blood pressure, baroreflex, and therapeutic effects were delayed. This is consistent with data on the relationship among stress, HPA axis activity, and brain function.

Biofeedback for Post Traumatic Stress Disorder (PTSD)

Heart rate variability (HRV) and posttraumatic stress disorder (PTSD): a pilot study.

Tan G, Dao TK, Farmer L, Sutherland RJ, Gevirtz R.

Source

Michael E. DeBakey Veterans Affair Medical Center, Houston, TX, USA.

Abstract

Exposure to combat experiences is associated with increased risk of developing Post Traumatic Stress Disorder. Prolonged exposure therapy and cognitive processing therapy have garnered a significant amount of empirical support for PTSD treatment; however, they are not universally effective with some patients continuing to struggle with residual PTSD symptoms. Heart rate variability (HRV) is a measure of the autonomic nervous system functioning and reflects an individual's ability to adaptively cope with stress. A pilot study was undertaken to determine if veterans with PTSD (as measured by the Clinician-Administered PTSD Scale and the PTSD Checklist) would show significantly different HRV prior to an intervention at baseline compared to controls; specifically, to determine whether the HRV among veterans with PTSD is more depressed than that among veterans without PTSD. The study also aimed at assessing the feasibility, acceptability, and potential efficacy of providing HRV biofeedback as a treatment for PTSD. The findings suggest that implementing an HRV biofeedback as a treatment for PTSD is effective, feasible, and acceptable for veterans. Veterans with combat-related PTSD displayed significantly depressed HRV as compared to subjects without PTSD. When the veterans with PTSD were randomly assigned to receive either HRV biofeedback plus treatment as usual (TAU) or just TAU, the results indicated that HRV biofeedback significantly increased the HRV while reducing symptoms of PTSD.

Temporomandibular disorders (TMD)-(TMJ)

A meta-analysis of EMG biofeedback treatment of temporomandibular disorders.

Crider AB, Glaros AG.

Source

Department of Psychology, Williams College, Williamstown, Massachusetts, USA.

Abstract

AIMS:

Outcome evaluations of treatments incorporating electromyographic (EMG) biofeedback for temporomandibular disorders (TMD) have been conducted for more than 2 decades. The purpose of this study was to review the available literature to determine the efficacy of biofeedback-based treatments and to estimate treatment effect sizes.

METHODS:

A literature search located 13 studies of EMG biofeedback treatment for TMD, including 6 controlled, 4 comparative treatment, and 3 uncontrolled trials. Three types of outcome were examined: patient pain reports, clinical exam findings, and ratings of global improvement.

RESULTS:

Five of the 6 controlled trials found EMG biofeedback treatments to be superior to no treatment or psychologic placebo controls for at least 1 of the 3 types of outcome. Data from 12 studies contributed to a meta-analysis that compared pre- to post treatment effect sizes for EMG biofeedback treatments to effect sizes for control conditions. Mean effect sizes for both reported pain and clinical exam outcomes were substantially larger for biofeedback treatments than for control conditions. In addition, 69% of patients who received EMG biofeedback treatments were rated as symptom-free or significantly improved, compared with 35% of patients treated with a variety of placebo interventions. Follow-up outcomes for EMG biofeedback treatments showed no deterioration from post treatment levels.

CONCLUSION:

Although limited in extent, the available data support the efficacy of EMG biofeedback treatments for TMD.

Myofacial Pain and TMJ

The Use of Electromyographic Biofeedback for the Treatment of Facial Pain

Introduction

It is estimated that approximately 70 to 90% of patients with facial pain have either a primary or secondary muscle disorder and that pain in these patients can be alleviated with biofeedback(1). Facial pain usually results from acute overstretching of muscles, whiplash, muscle fatigue, oral surgery or immobilization of muscle or as a consequence of a muscle-bracing oral habit, such as clenching and/or grinding and malocclusion.

The pain experienced most often is described as a dull deep ache that is usually constant and active for months, sometimes for years. The pain is usually more intense on awakening, and is frequently unilateral or one-sided. Often, clicking or popping sounds originating from the temporomandibular joint (TMJ) area are reported. Mandibular movements are limited because patients have difficulty opening their mouth. The jaw often deviates to the affected and painful side of the face. The pain may radiate into the temple muscles and down into the sternocleidomastoid muscle and splenius capitis muscles as well as to the

Biofeedback for Anxiety

Everybody gets anxious. Treatment is called for if the amount of anxiety is out of proportion to the problem or lasts too long. Many methods for helping people reduce and control their anxiety have been shown to be effective. Behavioral techniques include relaxation training, cognitive restructuring, and biofeedback. Any form of biofeedback that helps people become aware of their physiological responses as they become anxious and that helps people learn to relax is apparently at least as effective as any other behavioral technique.

Why biofeedback would help this problem: There are several different underlying problems which cause abnormal levels of anxiety. Biofeedback helps each for different reasons.

a.) Breathing problems which cause anxiety: Half or more of people who habitually breathe too rapidly with shallow breaths are anxious because of the effects of their breathing on their brains' chemistry. Most of these people are not aware they have incorrect breathing patterns. These incorrect patterns are easily detected using psychophysiological assessments and are corrected using several types of biofeedback related to helping people normalize their breathing patterns. When the breathing is normalized, the anxiety goes away.

b.) When a person experiences greater levels of anxiety or the anxiety lingers far longer than it should, the body's normal responses to an emergency situation don't shut down. This can cause the body to wear out while thinking and memory patterns change. The physiological reactions to anxiety are accurately assessed using psychophysiological recording techniques so both the patient and therapist always know when any therapy is helping and how much. Biofeedback treatments show the patient the abnormal physiological response levels. Patients use this knowledge to recognize when they are becoming abnormally anxious (so they learn to identify when is actually causing the anxiety) and to control their anxiety.

Children who are successfully trained to increase SMR show decreased activity levels. Successful neurofeedback training to decrease Theta while increasing Beta results in increased attention span and increased ability to learn math.

The training almost always takes place in a therapist's office. Sensors are pasted onto the scalp over the parts of the child's brain, which are to be trained. The sensors are connected to a computer, which runs a special training program. The program usually appears in the guise of a videogame. The videogame's progress or simply continuation is dependent upon the child producing the desired proportion of brain waves. The treatment may take 30 to 50 or more sessions for effects to be apparent and lasting

Brief summary of evidence supporting the efficacy of biofeedback for abnormal levels of anxiety:

Yucha and Gilbert (2004) report that "very few well- controlled, randomized studies have shown biofeedback to be superior to other relaxation and self-control methods for reducing anxiety. Most show biofeedback (EMG, GSR, thermal, or neurofeedback) to be roughly equivalent to progressive relaxation or meditation. Two studies showed biofeedback's efficacy in reducing anxiety without making comparisons with other relaxation techniques. Hurley and Meminger (1992) used frontal EMG biofeedback with 40 subjects trained to criterion and assessed anxiety over time using the State-Trait Anxiety Inventory (STAI). State anxiety improved more than trait anxiety. Wenck, Leu, and D'Amato (1996) trained 150 7th and 8th-graders with thermal and EMG feedback, and found significant reduction in state and trait anxiety. Roome and Romney (1985) compared progressive muscle relaxation to EMG biofeedback training with 30 children and found an advantage for biofeedback; Scandrett, Bean, Breeden, & Powell (1986) found some advantage of progressive muscle relaxation over EMG biofeedback in reducing anxiety in adult psychiatric inpatients and outpatients. Vanathy, Sharma, and Kumar (1998), applying EEG biofeedback to generalized anxiety disorder, compared increased alpha with increased theta. The two procedures were both effective in decreasing symptoms.

Rice, Blanchard, and Purcell (1994) studied reduction in generalized anxiety by comparing groups given EMG frontal feedback, EEG alpha-increase feedback, EEG alpha- decrease feedback, a pseudo-meditation condition, and a wait-list control. All treatment groups had comparable and significant decreases in the STAI as well as drops in Psychosomatic Symptom Checklist. Similar results were obtained by Sarkar, Rathee, and Neera (1999) by comparing the generalized anxiety disorder response to pharmacotherapy and to biofeedback; the two treatments had similar effects on symptom reduction. Hawkins, Doell, Lindseth, Jeffers, and Skaggs (1980), concluded from a study with 40 hospitalized schizophrenics that thermal biofeedback and relaxation instructions had equivalent effect on anxiety reduction. Fehring (1983) found that adding GSR biofeedback to a Benson-type relaxation technique reduced anxiety symptoms more than relaxation alone."

* Much of the information provided here is from Carolyn Yucha and Christopher Gilbert's 2004 book "Evidence Based Practice in Biofeedback & Neurofeedback" AAPB, Wheat Ridge, CO.

Biofeedback and chronic pain

Overview & Efficacy: Hundreds of controlled and clinical studies of various sizes, some with multiyear follow-ups, show that biofeedback can help and / or eliminate chronic pain either by rectifying the underlying problem causing the pain or by reducing stress magnifying it.

Why biofeedback would help this problem: There are many different causes of chronic pain. In many instances there is a specific problem which can be identified. In others, the body has become oversensitive to stimulation. Anxiety can also magnify pain tremendously. Psychophysiological assessments can frequently identify causes of chronic pain not diagnosable through other techniques. For example, in low back pain, they can detect abnormal patterns with which low back muscles interact with each other as well as abnormal amounts of muscle tension - the combination of which frequently causes low back pain. Biofeedback treatments aimed at rectifying specific problems such as abnormal patterns of muscle tension in jaw muscles causing tension headaches, lack of blood-flow in the stump causing burning phantom limb pain, etc. can be very successful. Biofeedback to help people control their anxiety and, thus, reduce the overall amount of pain felt, can also be very helpful.

Scientists cannot yet explain how biofeedback works. Most patients who benefit from biofeedback are trained to relax and modify their behavior. Most scientists believe that relaxation is a key component in biofeedback treatment of many disorders, particularly those brought on or made worse by stress.

Their reasoning is based on what is known about the effects of stress on the body. In brief, the argument goes like this: Stressful events produce strong emotions, which arouse certain physical responses. Many of these responses are controlled by the sympathetic nervous system, the network of nerve tissues that helps prepare the body to meet emergencies by "flight or fight."

The typical pattern of response to emergencies probably emerged during the time when all humans faced mostly physical threats. Although the "threats" we now live with are seldom physical, the body reacts as if they were:

The pupils dilate to let in more light. Sweat pours out, reducing the chance of skin cuts Blood vessels near the skin contract to reduce bleeding while those in the brain and muscles dilate to increase the oxygen supply. The gastrointestinal tract, including the stomach and intestines, slows down to reduce the energy expensed in digestion. The heart beats faster, and blood pressure rises.

Normally, people calm down when a stressful event is over especially if they have done something to cope with it. For instance, imagine your own reactions if you're walking down a dark street and hear someone running toward you. You get scared. Your body prepared you to ward off an attacker or run fast enough to get away. When you do escape, you gradually relax.

If you get angry at your boss, it's a different matter. Your body may prepare to fight. But since you want to keep your job, you try to ignore the angry feelings. Similarly, if on the way home you get stalled in traffic, there's nothing you can do to get away. These situations can literally may you sick. Your body has prepared for action, but you cannot act.

Individuals differ in the way they respond to stress. In some, one function, such as blood pressure, becomes more active while others remain normal. Many experts believe that these individual physical responses to stress can become habitual. When the body is repeatedly aroused, one or more functions may become permanently overactive. Actual damage to bodily tissues may eventually result.

Biofeedback is often aimed at changing habitual reactions to stress that can cause pain or disease. Many clinicians believe that some of their patients and clients have forgotten how to relax. Feedback of physical responses such as skin temperature and muscle tension provides information to help patients recognize a relaxed state.

The feedback signal may also act as a kind of reward for reducing tension. It's like a piano teacher whose frown turns to a smile when a young musician finally plays a tune properly.

The value of a feedback signal as information and reward may be even greater in the treatment of patients with paralyzed or spastic muscles. With these patients, biofeedback seems to be primarily a form of skill training like learning to pitch a ball. Instead of watching the ball, the patient watches the machine, which monitors activity in the affected muscle. Stroke victims with paralyzed arms and legs, for example, see that some part of their affected limbs remains active.

The signal from the biofeedback machine proves it. This signal can guide the exercises that help patients regain use of their limbs. Perhaps just as important, the feedback convinces patients that the limbs are still alive. This reassurance often encourages them to continue their efforts.

The above material was provided by The US Department of Health and Human Services.

Biofeedback for treatment of Headaches ( Migraine-tension )

Overview & Efficacy:

Numerous controlled, clinical, comparative, and long term follow-up studies have proven beyond any doubt that biofeedback can reduce and cure tension and migraine headaches among adults and children. Several medical groups strongly recommend using biofeedback before or instead of medications.

Why biofeedback would help this problem:

Tension headaches are usually caused by muscles in the neck, shoulders, jaws and other facial structures being kept too tense for too long. These muscles may become too tense because some people can not recognize the actual level of tension in painful muscles, because of postural problems while working, over-reactions by the muscles to stress, poor habits, etc. Psychophysiological assessments can identify which muscles are not functioning correctly and what circumstances lead to the incorrect patterns of tension. Biofeedback of muscle tension is used to train people to recognize actual levels of tension and to correct these levels in conjunction with relaxation training. Temperature biofeedback for migraine headaches work through a similar chain of logic.

Biofeedback and Relaxation Training for Headaches

By Gay Lipchik, PhD

Biofeedback, progressive muscle relaxation and abdominal breathing are just several of the behavioral medicine techniques proven to reduce headaches and improve quality of functioning. When employed regularly and combined with preventative medication and optimized acute therapy, quality of life is significantly better than with medication alone.

Headache sufferers are justifiably offended when a doctor or a friend dismisses their pain with an offhand remark such as, "You're just under too much stress. Try to relax."

Physical and mental tension can certainly make headaches worse. But simply telling someone to relax doesn't help deal with deadlines, demanding bosses, crying babies, honking horns, unpaid bills, and missed sleep, to name just a few of life's daily hassles. Relaxation is a skill. Like other skills, it can be mastered with time, practice and a good instructor. There are a variety of mind-body approaches to easing tension and improving pain tolerance. Some have proven track records in preventing headaches or reducing their severity.

Biofeedback and progressive muscles relaxation are the most widely accepted non-drug techniques for headache control and prevention. Their effectiveness has been demonstrated during 25 years of research with well over 100 investigations.

Biofeedback and relaxation training typically yield a 45% to 60% reduction in headache frequency and severity. This is equivalent to the reduction in headache achieved by many headache medications, such as propranolol (Inderal©) and amitriptyline (Elavil©), but without any of the negative side effects. The most common limitation of biofeedback and relaxation training is that it requires time commitment and implementation effort on behalf of the patient. Biofeedback sessions may take one hour and training sessions may include several weekly visits over the course of several months.

For many headache sufferers, the combination of drug and non-drug treatments yields the most significant improvement in headache activity. For example, the average improvement with either biofeedback alone or propranolol alone is a 55% reduction in migraine. However, when biofeedback is combined with propranolol, the average improvement is a 70% reduction in migraine.

Bringing the Body into Awareness using Biofeedback

Biofeedback (or biological feedback) uses an instrument that monitors a bodily response, such as muscle tension or skin temperature, as the person tries to modify that response. For example, the monitor might give feedback with a tone that goes higher if the muscles in the forehead tighten and lower if the muscles relax. Another type of monitor uses a visual display such as a light that changes color as you increase or decrease temperature in your hands (or feet).

Increased muscle tension and changed body temperature are two of the body's responses to stress and strain. By providing you with instant and continuous information on these involuntary and unconscious processes in the body, you can observe and modify your body's reaction to stress. After you have used biofeedback to develop your ability to recognize and reduce tension in your body, you will be able to do so anywhere and any time without the help of the equipment. These skills aid in preventing, reducing, or stopping a headache. Biofeedback, like progressive muscle relaxation, works best when you learn the skills from a qualified professional, typically a psychologist or psychiatrist who is trained in this procedure.

Typically, electromyogram (EMG) biofeedback is used as a prevention approach for tension-type headaches. With EMG biofeedback, an EMG machine monitors skeletal muscle tension. Just about any muscle can be monitored, but three muscles most commonly used are:

1. Frontalis: the muscle in your forehead that is involved with frowning and tightens up when you are worried or under pressure.
2. Masseter: this muscle tightens your jaw and often stays clenched when you are tense, frustrated, or angry.
3. Trapezius: this muscle hunches your shoulders and tightens when you are alarmed or anxious or in response to environmental stressors, such as sitting too long at a computer.

These muscles are used in EMG biofeedback because they typically respond to stress and can be easily measured. EMG training is done by placing two sensors (electrodes) at a specified distance from each other on the skin over the identified muscle. A third sensor is placed on a neutral spot to serve as an electrical reference point. These sensors do not cause any discomfort whatsoever; they simply record your body's responses.

Thermal or hand-warming biofeedback was first used at the famous Menninger Clinic in Kansas. Researchers there discovered that headache patients who learned to raise the temperature of their hands using biofeedback had fewer and less severe headaches when they practiced this skill regularly.

Hand-warming works in the following way: When a person is anxious or under stress, the blood vessels in the fingers narrow and the hands become cooler. That's why we tend to get "cold and clammy hands" when we're frightened or nervous. On the other hand, when you are relaxed, the blood vessels in your hands expand and your hands get warmer. You can get an idea of how stressed you are by taking your hand or finger temperature with a thermometer or biofeedback instrument. You can learn to reduce your level of arousal through the process of temperature biofeedback training. Then, whenever your hands are cool or you are experiencing stress, you use your hand-warming skills to produce a more relaxed state.

Although it's often assumed that "tension-type" headache responds better to techniques to control muscle tension, it has been found that migraine patients improve as much with EMG biofeedback as they do with thermal biofeedback. Thus, the mechanism of action for biofeedback and relaxation training may be more complex than meets the eye. We know that headache sufferers who regularly practice these techniques report a decreased sense of helplessness and an increased sense of self-control. These changes in mental outlook and behavior may increase your ability to prevent headaches as well as your ability to reduce pain, especially if used as soon as you notice a headache coming on.

Relaxation Training

Relation training involves learning how to achieve a physical and mental state of calm and relaxation within a few minutes. It is a systematic set of procedures, rather than simply trying to relax on your own with activities like gardening, reading, or watching TV. Relation training is recommended for headache management because headaches are often related to the body's reaction to everyday stresses like deadlines, demanding bosses, crying babies, honking horns, unpaid bills, and missed sleep, to name a few of life's daily hassles. For headache-prone people, stress does not need to be excessive Unpredictability or change in life is all that is needed. Even normal everyday levels of stress can trigger a headache.

Relaxation training slows down the sympathetic nervous system, which is responsible for the stress response. The sympathetic nervous system is involved in regulating heart rate, blood vessel expansion and contraction, blood pressure, sweat production, sleep, and alertness. During stress, heart rate and blood pressure increase, sweat production increases, breathing becomes shallow, and adrenaline and other hormones are released, causing blood vessels to constrict and muscles to contract. You may have noticed that your shoulders are hunched up and your jaws are clenched during stress. You can see then how slowing the stress response might be beneficial.

Deep relaxation reverses many of the physical responses that can trigger headaches. Additionally, during deep relaxation, the relaxed person takes fewer breaths per minute, yet breathes more deeply, "bathing" the blood cells in oxygen, which means more oxygen gets to the muscles and to the brain. Increasing oxygen supply to the brain seems to help prevent headaches. With practice, deep relaxation changes your body's response to adrenaline and other stress hormones so that it takes a greater disruption from life stresses (and the stress response) to trigger a headache. Becoming deeply relaxed not only helps reduce headache frequency, but it can give a greater sense of self-control as well as decrease irritability, anxiety, depression, insomnia, and blood pressure.

Learning to Relax

Relaxation training is typically provided "live" in a clinic office by an experience therapist (usually a psychologist). Learning to become deeply relaxed may take several sessions, so you may be scheduled for 4 to 10 visits. Visits may be scheduled a couple of weeks apart or once weekly. During your clinic visits, you will be given instructions and in-office practice sessions for a variety of relaxation techniques. Most likely you will be provided audiotapes and written materials to help you practice at home between your office visits. Then you will learn how to use these skills in your daily life. Relaxation training typically begins with two primary techniques: abdominal or deep breathing and progressive muscle relaxation.

Deep Breathing: To teach you deep breathing, your therapist will ask you to place one hand on your chest and one hand on your abdomen, just under your ribs, so that you are more aware of your breathing. Next, you will be asked to breathe in slowly through your nose, pulling your breath down towards your stomach, pushing your abdomen outwards, allowing yourself to fill your lungs completely. Your hand on your abdomen should rise slightly more than your hand on your chest when you are breathing deeply. Breathe out slowly, pulling your stomach in towards your spine, and think the word "relax." With each slow, deep breath you likely will feel yourself becoming more relaxed. After you have learned to breathe deeply, you will be asked to focus on slowing your breathing. For the first 1 to 2 weeks, you will probably be asked to practice this breathing exercise for 5 to 10 minutes, 2 to 3 times daily as well as during progressive muscle relaxation (PMR) training. After you have mastered the technique, you should check in with yourself throughout the day to remember to breathe deeply.

Progressive Muscle Relaxation: Next you will be instructed in PMR, the most commonly used muscle relaxation technique for the management of headaches. With PMR, you physically tense and then relax your muscles. It might sound like a contradiction, but for a muscle to become relaxed it is helpful for it to be tightened first. Tightening muscles also makes you more aware of what tense muscles feel like. This will help you to identify tension in those muscles early on, so you can apply relaxation skills to prevent the muscle from becoming tenser and to reserve the stress response. Your therapist will demonstrate how to gently tense and relax each muscle. You will learn to tense and then relax muscles in your hands, forearms, upper arms, feet, calves, thighs, stomach, chest, shoulders, neck, face, and head. Next, your therapist will take you through an in-office practice of slowly tensing and relaxing these muscles, while asking you to focus on each muscle, comparing sensations of relaxation with sensations of tension. Between muscle groups, you will be asked to focus also on your breathing. After tensing and relaxing all of the muscle groups, your therapist may ask you to focus on a relaxing scene that you have discussed before beginning the PMR practice. For example, many patients describe a beach scene, waterfalls, or walking through the woods. For many patients this helps to further deepen their relaxation, and the imagery can be used alone as a quick relaxation skill. The entire practice session takes about 25 to 30 minutes.

During your in-office practice of PMR, the room may be dimly lit and you may be offered the comfort of a recliner. You also will be asked to remove your eyeglasses, and you might be asked to remove your shoes, loosen your tie, belt, or any other restrictive closing (suit jacket, for example) in order to be as comfortable as possible. Your therapist will probably ask you to rate your tension levels before and after your in-office practice. And you will probably be asked to keep track of your practice in relaxation logs so that you can discuss with your therapist any problems you might have with practicing the techniques.

The Relaxation Routine

Some people become very relaxed after their first practice session, but the vast majority of people do not notice substantial reductions in muscle tension, stress levels, or headache activity until they have practiced for some time. So, do not become discouraged if you do not get immediate results. Also, not everyone can imagine the pleasant relaxing scene as vividly as they'd like. This will likely come with practice, although some people find it difficult to learn this skill. If it doesn't get easier with practice, don't use it as a relaxation strategy. It is important that you use what works best for you rather than to get discouraged. You don't have to master all of the techniques your therapist teaches you to improve.

For relaxation training to be effective at reducing your headaches, initially you need to practice daily for about 25 minutes at a time. Ideally, you will practice twice daily. You need to practice enough that deep relaxation becomes a habit, so that when you say "relax" to yourself, your body knows how to respond. The amount of time it takes to get deeply relaxed gets shorter with practice and as you learn briefer methods of relaxation in your follow-up office visits.

The goal is for relaxation training to be a portable skill that you can use any time, any place, at any moment's notice. Initially, however, you might want to consider that your body is in training. You have to train your body to know what it is to be completely relaxed.

Summary

Deep relaxation is a skill that teaches you how to recognize signs of stress in your body and how to reduce them before they reach the level of painful muscles and headache. These techniques work best to prevent headaches. However, they can be helpful if you use them as soon as you notice a headache starting, rather than during a full-blown attack.

Biofeedback and relaxation techniques are most effective in preventing headaches, rather than treating a headache in progress. Nonetheless, many headache sufferers do report that these techniques often lessen the severity and duration of headache if used during a headache attack. Many patients find these techniques to be effective alternatives to medication, while research also shows that typically headaches are best controlled over time by combining these techniques with some use of preventive and acute medication.

Gay L. Lipchik, PhD Ohio University Headache Treatment & Research Project. Westerville, OH

Updated May 2008 from Headache, volume 9, issue 2. Summer 1998.

Biofeedback for treatment of Menopause

Many women have success with this treatment, others have found success with another drug-free therapy known as biofeedback.

What is biofeedback? Biofeedback is a technique that teaches an individual to consciously control their body's involuntary responses including blood pressure, temperature, muscle contractions, heart rate and brain waves. A person receiving biofeedback is hooked up electronically to machines so their physiological process can be monitored and relayed back to the person as a tactical, auditory, or visual signal.

How can biofeedback help women during menopause? During menopause, women suffer from a variety of physical and emotional symptoms which are typically cased by a deficiency of estrogen and progesterone. The following are the symptoms that biofeedback has been known to effectively help menopausal women find relief from: Migraines and/or headaches Hot flashes. A low libido related to anxiety . A loss of appetite related to anxiety. High blood pressure caused by stress. Specific types of pain and depression

How is biofeedback performed? Patients are treated individually, so a menopausal woman will first be asked about her health and the symptoms she is experiencing. She will then be treated based on the decision of the practitioner.

Most biofeedback sessions begin with the patient sitting in a chair. A band that has three wired metal sensors attached to it is placed on the head and the patient is given headphones. The headphones produce audio that sounds like static. Each static click means that alpha waves are being emitted by the brain. These waves are a sign of relaxation. The quicker the static clicks, the more a patient is relaxing. The practitioner will then analyze the patient's level of relaxation and measure the temperature, heart rate, and muscle tension for a few minutes. The patient will then be asked to perform a mental task that presents a challenge which will lower the temperature in the hands and raise blood pressure. The patient will then be taken back to the original relaxation stage where they will rest for a moment before they are then asked about their emotional issues.

How long are sessions? Most people begin with ten sessions under the supervision of a trained practitioner. Each session lasts one hour in length. However, the purpose of biofeedback is to teach an individual how to control their vital functions on their own so they can effectively treat themselves to control and prevent symptoms. Of course, knowing how to perform biofeedback takes plenty of know-how and practice. Therefore, it is mandatory that you are taught by a professional.

Raynaud's Disease

Cold Hands, Warm Heart?! Actually, the warmth of our heart plays a significant role in keeping our hands warm. For the person with Raynaud's however, the warmth of the heart does little to keep blood moving into the hands. What's happening?

The Radiator System of the Body

Just like water flowing through the steam radiators in my old but charming home, our blood flows throughout our bodies bringing warmth. Like the boiler in the basement, the heart pumps warm blood to every living cell. That blood has been warmed by virtue of hanging around the inner core of our bodies. How warm is this blood? Well, it's 98.6° F, our "normal" body temperature. This warm blood will circulate throughout your body if nothing obstructs the pipes (your blood vessels). When it reaches your hands, it should be able to keep them at about 90°F or warmer when you're sitting inside (at normal room temperature; 70°F or so).

The Aeration System of the Body

When we inhale, our lungs take in oxygen-rich air. Then the oxygen slides through the lining of the lungs and gets picked up by the blood and stored in its storage bins (hemoglobin molecules). The oxygen-rich blood runs through our arteries and delivers the oxygen to the all the cells in our body. The cells use the oxygen to do work (cellular repair, synthesis of materials and energy, even cellular reproduction!!!). The waste material is the carbon dioxide, which is taken by the blood through our veins back to the lungs. It's the same carbon dioxide that we exhale. When the blood is carrying oxygen, its color is red; when it's carrying carbon dioxide, it's more bluish (thus our arteries are red and our veins are blue).

Raynaud's Colors: White, Blue and Red

When a person experiences Raynaud's, their small blood vessels that feed the skin constrict through a process called "vasospasm". These constricted blood vessels don't let the blood flow freely into the hands and they turn white (just as your face might turn white when you are frightened...the blood "drains" from your face). As the cells in the hands begin to cry out for oxygen (which the blood was supposed to carry to them), the skin turns blue. After a time, the blood returns to the hands and they turn red.

Biofeedback in the Treatment of Raynaud's

The goal of biofeedback therapy is to put an end to this red, white and blue thing! Thermal biofeedback has a great track record. For people with Raynaud's Disease, thermal biofeedback training is successful 80 to 90% of the time. Effects continue to be shown at one year and three year follow-ups.*

Here's how it works. You'd sit in a comfortable chair and train the body to vasodilate.

Did you expect more? Well, that's the beauty of thermal biofeedback training. It's elegantly simple. So why isn't everyone with Raynaud's Disease running to their nearest biofeedback therapist? It's because biofeedback is more about training than treatment. There's no "take two aspirin and call me in the morning." The training takes time, motivation, and practice. It takes about 20 sessions as well as home training to accomplish this feat.

Raynaud's Problems/Biofeedback's Solutions

Raynaud's sufferers have two challenges to overcome. The first is to reduce the stress that causes the initial vasoconstriction and the second is to reverse the constriction once it occurs. Biofeedback therapy offers a two-pronged solution: downshifting the nervous system overall and training people to vasodilate their peripheral blood vessels.

Biofeedback trains you to induce voluntary control of physiological processes that have been altered by pathological disorders. I recall memorizing the function of the Autonomic Nervous System by saying "the Autonomic Nervous System is the automatic nervous system". It was spontaneous and beyond conscious control. Then East met West and everything changed. Our western scientists began studying the yogic masters in the East and discovered that they were in fact consciously controlling the automatic system. After years of collaboration, the West was able to mechanize and computerize the process of training that allows you to take conscious control over "automatic" bodily processes.

Stress is More Than a Feeling

You've often heard the phrase "I feel stressed", and most of us know exactly what is meant. We feel overwhelmed and out of control. Often we experience physical symptoms like an upset stomach, headache, fatigue and ...cold hands. It's the Sympathetic branch of the Autonomic Nervous System that helps prepare the body to meet emergencies by "fight or flight." In an effort to meet the energy and strength requirements of an emergency, our digestion slows down, our muscles tighten, and we expend energy and the blood vessels near the skin contract.

Some of my patients swear they are not feeling stressed when they experience stress related symptoms. Then I ask, "How much sleep are you getting? What have you been eating? Have you been sick in the last few months?" Ah, here's the culprit--biological stress.

Biofeedback training accomplishes two very important tasks for Raynaud's sufferers. First, it helps them train to vasodilate their peripheral blood vessels so their hands can stay nice and warm. Second, it teaches them to reduce the impact of stress so their blood vessels will be less likely to constrict in the first place! Warm heart; warm hands...what a perfect match!

*These results were obtained in the treatment of primary Raynaud's (Raynaud's Disease). For secondary Raynaud's (Raynaud's Phenomenon), biofeedback has been shown to be helpful in reducing some of the symptoms.

Biofeedback for treatment of Hypertension ( High Blood Pressure )

Overview & Efficacy: Numerous high quality studies have demonstrated that people having high blood pressure - especially if it is stress related - can benefit extensively from biofeedback as long as they learn and practice the skills needed to control their blood pressures. Many hypertensives no longer need any medications after successful biofeedback training.

Why biofeedback would help this problem: There are many reasons why a person may have high blood pressure. One of the most common is abnormal increases in blood pressure due to stress. Increased blood pressure is one of many normal responses to stress. Sometimes blood pressure goes up so much that a highly reactive person's ears turn redder, and may even tingle and / or ring. This is a normal response to stress. For some people, these increases don't return to normal levels for a long time. The time to return to normal may take longer and longer until blood pressure never returns to normal. The person has now developed high blood pressure. Biofeedback based treatments help people recognize and control their response to stress and also help them recognize when they are successfully controlling their blood pressures. Thus, biofeedback can directly and indirectly help people learn to control blood pressure.

Lower High Blood Pressure with Biofeedback

Biofeedback is a clinically-validated therapy that measures and displays your body's performance to help you increase awareness and control of your physiology. Patients who want to reduce their reliance on medication and increase their control of their own health are excellent candidates for biofeedback. Biofeedback clinical trials have shown that personal biofeedback training is an effective treatment for hypertension.

What is hypertension?

The National Heart, Lung, and Blood Institute has defined blood pressures of 140/90 or higher as hypertension and values between 120-139/80-89 as pre-hypertension

The upper number is systolic blood pressure, which measures blood pressure when the left ventricle of the heart contracts. The lower number is diastolic blood pressure, which measures blood pressure when the left ventricle relaxes.

High blood pressure is a major risk factor for coronary heart disease and heart attack, kidney failure, and stroke.

Who is mainly affected?

About 60% of American adults suffer from prehypertension or hypertension.

High risk groups include:

• African Americans
• the elderly
• individuals with low socioeconomic status
• individuals who are overweight

While the prevalence of hypertension has increased 10% in the past decade, hypertension is still poorly controlled:

• 31% of patients are unaware that they have high blood pressure
• 66% have been told by health professionals to modify lifestyle and take drugs to control their blood pressure
• 31% achieve satisfactory control

How do biofeedback practitioners assess patients with essential hypertension?

After a medical evaluation to rule out diseases and medications that can produce elevated blood pressure, a clinician may conduct a psychophysiological profile that monitors your breathing, finger temperature, heart rhythm, skeletal muscle activity, and skin conductance using biofeedback electrodes during resting, mild stressor, and recovery conditions.

The psychophysiological profile will enable your clinician to develop an individualized training program to correct abnormal physiological changes associated with hypertension.

Frequent findings during biofeedback stress tests of hypertensive patients include:

• shallow, rapid breathing with frequent breath-holding
• constriction of the small arteries of the fingers and toes
• reduced heart rate variability
• contraction of muscles in the upper shoulders, neck, and forehead
• increased sweat gland activity

What is biofeedback therapy?

Biofeedback techniques use biofeedback instruments to increase your awareness and control of minute-to-minute physiological changes. A clinician's biofeedback instructions are guided by the information provided by the biofeedback devices suggested by the psychophysiological profile.

How does biofeedback treat this disorder?

Biofeedback training methods may combine stress management training with one or more forms of biofeedback, including:

• EEG biofeedback (brain electrical activity)
• EMG biofeedback (skeletal muscle activity)
• heart rate variability biofeedback (timing between heartbeats)
• respiratory biofeedback (breathing patterns)
• skin conductance biofeedback (sweat gland activity)
• temperature biofeedback (blood flow through small arteries)

How effective is biofeedback for hypertension?

Biofeedback instructions can help patients achieve impressive reductions in blood pressure using biofeedback equipment. One review found that the most effective treatments were stress management training, EMG biofeedback, and temperature biofeedback, respectively. Stress management biofeedback that guides stress management training with biofeedback is a promising treatment strategy.

In a landmark Menninger Foundation study that combined EMG and temperature biofeedback with breathing training and relaxation, 65% of patients completely discontinued medication while reducing their blood pressure 15/10 mmHg to an average value of 128/80. Another 24% of their patients reduced their medication by one-half while reducing pressure 17/12 mmHg.

The Association for Applied Psychophysiology and Biofeedback's (AAPB) Evidence-Based Practice in Biofeedback and Neurofeedback by Carolyn Yucha, PhD, and Christopher Gilbert, PhD, awarded this treatment the second-highest rating of efficacious.

Is there insurance coverage for biofeedback?

Payment for biofeedback therapy varies across insurers and geographical locations. Psychologists may bill biofeedback services as psychotherapy to increase the likelihood of reimbursement.

How safe is biofeedback training?

Biofeedback is safer and has a better side-effect profile than many conventional medical treatments, including aspirin.

Patients may briefly experience mild side-effects during deep relaxation, including intrusive thoughts, fear of losing control, anxiety, tingling, increased heart rate, muscle spasms, tics, and muscle twitches, which disappear with training.

Who are poor candidates for biofeedback training?

Biofeedback may be inappropriate if you suffer from:

• acute medical crisis
• agitation
• delirium
• severe depression
• dissociation (depersonalization, dissociative reaction, and fugue)
• mania
• severe obsessive-compulsive disorder (OCD)
• paranoid disorders
• schizophrenia

Why is an experienced therapist important?

In rare cases, inexperienced therapists may depart from evidence-based practice and apply a procedure to a disorder for which it was never intended or they may ineffectively apply an appropriate procedure, resulting in treatment failure. Insufficiently trained clinicians can potentially harm their patients if they do not understand the effect of training on existing medical conditions (epilepsy) or medication (high blood pressure).

Biofeedback training may reduce your need for medication for asthma, diabetes mellitus, epilepsy, glaucoma, hypertension, and hypothyroidism. You should regularly evaluate the dosage of these medications

Use your mind

We have a lot more control over our bodies than we think. Many autonomic body functions -- such as pulse rate, temperature and blood pressure -- can be controlled with a little concentration. This yogi-like feat is called "biofeedback" in scientific circles and it's been proven to work wonders.

A recent study led by professor and registered nurse Carolyn B. Yucha at the University of Nevada, Las Vegas found that patients could drop their blood pressure by as much as 10 points by simply thinking about it. Patients with high and normal blood pressure were taught basic relaxation techniques and biofeedback. In a biofeedback session, patients monitor their pulse, blood pressure and temperature as they practice deep breathing. Through this monitoring, they learn how to affect their autonomic functions.

Yucha was able to determine which patients would benefit from biofeedback. She found that people with high blood pressure, low fingertip temperature and a tendency to react quickly or negatively to stressful situations reaped the most benefit from biofeedback. Unfortunately, she says, many doctors don't prescribe biofeedback and health insurance companies don't cover the technique. Additionally, many people simply don't want to take the time to learn the techniques. "In my experience, MDs write prescriptions for antihypertensive drugs and most patients prefer to pop a pill than to invest the time to learn relaxation," she says.

High Blood Pressure Range

Systolic pressure (mm Hg)	Diastolic pressure (mm Hg)	Stages of High Blood Pressure
210	120	Stage 4
180	110	Stage 3
160	100	Stage 2
140	90	Stage 1

Normal Blood Pressure Range

Systolic pressure (mm Hg)	Diastolic pressure (mm Hg)	Pressure Range
130	85	High Normal Blood Pressure
120	80	Normal Blood Pressure
110	75	Low Normal Blood Pressure

Low Blood Pressure Range

Systolic pressure (mm Hg)	Diastolic pressure (mm Hg)	Pressure Range
90	60	Borderline Low blood Pressure
60	40	Too Low Blood Pressure
50	33	Dangerously Low Blood Pressure

Biofeedback to Reduce Stress and Insomnia

Over the past few years, new research brought forth new approaches and strategies that can help us make improvements in self-development. Some of the main approaches include Biofeedback, which can provide you with some stress relief. Studies show that those suffering with insomnia. Whether it is medically or psychologically based, endure excessive levels of stress as well. By lowering your stress levels, you can find relief and achieve a recuperative night of rest.

Biofeedback helps by improving brain and physical performance. A monitoring device is used to display feedback. The monitor works by reading your body functions. It then examines the data to see how your body performs. Thus, by using this solution, you can connect with your bodily functions, and gain more control.

Biofeedback is one way of finding stress relief. Most of us, however, cannot afford to go out and spend money on monitoring devices. Thus, we must look into other solutions, and one that comes to mind is a guide to manage daily pressure by using positive thriving solutions. What this means is that you learn how to use your stress in a way that helps you to thrive on positive thinking.

What CPT codes should I use for biofeedback?

CPT Codes The CPT codes concerning biofeedback and their codes in the CPT Manual are:

Biofeedback 90901 This code applies to biofeedback training using any modality.

90911 This code applies to biofeedback training of the perineal muscles and/or the anorectal or urethral sphincter. It includes EMG biofeedback, and/or manometry.

Other Psychiatric Services or Procedures 90875 This code applies to individual psychophysiological therapy that incorporates biofeedback training by any modality with psychotherapy (e.g., insight oriented, behavior modifying or supportive psychotherapy). It must be face-to-face with the patient and session length is approximately 20-30 minutes.

90876 The definition for this code is the same as for 90875, but the session length is approximately 45-50 minutes in duration.

The only difference between the 90875 and 90876 is the length of the treatment session, i.e., 20-30 minutes versus 45-50 minutes. Anyone who can legally provide psychological/mental health services within their state can use the 90875 or 90876 codes. Of course not every insurance company pays for this service or they may pay for it within one client coverage policy contract and not within another, adding to the coding, billing, and reimbursement confusion. The code for psychotherapy without biofeedback is discussed later under the section on Other Codes.

Health and Behavior Assessment/Intervention Codes The new CPT Health and Behavior Assessment/Intervention codes were basically developed to recognize the work of professionals, like psychologists, with physical health problems. Their use does not require that there be a psychological diagnosis. Prior to their creation, psychological interventions could not be provided to those with medical or physical problems unless there was a psychological diagnosis to help verify "medical necessity."

These new codes, 96150-96155, are used for health and behavior assessments and interventions where it is not necessary to make a psychological diagnosis (e.g., DSM IV). Of course one must engage in the activities that fit the definition for these specific codes. The health and behavior codes follow.

96150 This code applies to health and behavior assessment (e.g., healthfocused clinical interviews, behavioral observations, psychophysiological monitoring, health-oriented questionnaires). A practitioner can bill for each 15 minutes of face-to-face assessment with the patient. This code is used for the initial assessment.

96151 This code is used for re-assessment(s).

96152 This code applies to health and behavior interventions. Each 15 minutes of face-to-face intervention with an individual client is billable.

96153 This code applies to group treatment/intervention (2 or more patients).

96154 This code applies to family treatment/intervention (with the patient present).

96155 This code applies to family treatment/intervention (without the patient present).

Other Codes That Are Potentially Useable Some other codes that might be used if approved by the third-party payer follow:

94010 This code applies to spirometry and includes a graphic record, total timed vital capacity, and expiratory flow rate measurement(s), with or without maximal voluntary ventilation.

94400 This code applies to the breathing response to CO2 (includes the CO2 response curve).

96002 This code applies to dynamic surface electromyography during walking or other functional activities for 1-12 muscles.

95957 This code applies to digital analysis of the electroencephalogram (EEG) (e.g., for epileptic spike analysis). (Some practitioners are using this code for QEEGs because it consists of a digital analysis of the EEG).

90806 This is the code for individual psychotherapy, insight oriented, behavior modifying and/or supportive psychotherapy in an office or outpatient facility for sessions lasting approximately 45-50 minutes, face-to-face with the patient. (Note: some insurance companies will allow biofeedback to be used as a psychological modality if part of a psychotherapy treatment and provided by a licensed mental health provider, but not if provided by an unlicensed provider. Do not try to deceive the insurance company about what you are doing by using this code when only biofeedback services are provided. Doing so would be fraud).

Guidelines for Third Party Reimbursement for Biofeedback

Ronald Rosenthal, PhD

In an ideal world, we would be able to generate a long list of insurance companies and managed care organizations that have consistently paid for biofeedback services. However, the world we live in is far from ideal and insurance reimbursement for biofeedback continues to be inconsistent and unpredictable.

In order to try to bring some order to this topic, it is important to remember how third party reimbursement works. When billing to third party payers, we need to complete (accurately) a claim form that provides specific information about what we did. In addition to the basic demographic information identifying your client, the claim form will include a diagnosis code and a procedure code. All of the decisions regarding payment will be based upon the combination of codes you provide.

The first step in the process is to contact the insurance company and verify coverage. The basic details of coverage may be available on-line, but it you want to determine if you will be paid for biofeedback services, you will need to call the insurance company. Payment may be restricted to participating providers or there may be higher deductibles and increased copays if you are not a network provider. Some services may also require preauthorization

Many insurance companies have (long) lists of excluded services, and the biofeedback codes are often on these lists. In other cases, the procedure codes will only be paid if the diagnosis code is from a list of covered conditions. As an example, the basic mental health procedural codes, like 90806, used by psychologists and counselors are only covered when the diagnosis is for a psychiatric or developmental disorder.

There is a relatively small set of procedural codes for biofeedback. There are two pure biofeedback codes, 90901 and 90911. The 90901 code is for any modality of biofeedback and the 90911 code is pelvic floor training for the treatment of incontinence. There are also two codes for mental health providers, 90875 and 90876. These refer to sessions that combine biofeedback with some kind of talk therapy or counseling-90875 for a 25 minute session and 90876 for a 50 minute session In addition to the codes listed above, some practitioners have been billing using codes from the physical medicine section of the code book or with the new health and behavior intervention/assessment codes. The use of these other codes reflects the complex and diverse ways that biofeedback training can be used. Most biofeedback practitioners believe in an integrated treatment approach in which biofeedback training is just one part of a package. Other modalities could include counseling, breathing training, relaxation and meditation techniques, Feldenkrais exercises, Tai-Chi, yoga, and so on. The basic biofeedback codes may not reflect accurately all of what is done within a session.

The set of alternative codes that have been used with biofeedback include 96150 and 96152, 97532, 97112. 96002 and 90806. The 90806 code is for psychotherapy, not biofeedback, and providers combining biofeedback and psychotherapy are advised to use 90876 or 90875,. Some providers may be tempted to use 90806 when 90876 is not covered, but this can be considered to be a misrepresentation and leaves one open to charges of insurance fraud. Many clinicians have reported that insurance company representative have told them to use the 90806 when 90876 is not covered, but unless these instructions are obtained in writing, a significant risk remains. The health and behavior codes, 9615x, were released in 2002. They are used for the assessment or treatment by a psychologist of patients with primarily a physical complaint diagnosed by a physician. These codes recognize the mind/body connection and the interplay of biopsychosocial factors in the expression of health and disease. In many cases, a legitimate case for the use of these codes can be made for treatment that includes biofeedback for patients with chronic medical conditions such as headache, hypertension or fibromyalgia.

The health and behavior codes are time based codes. They are billed in 15 minute units and permit billing for extended sessions, e.g., 6 units for a 90 minute evaluation. They must be linked to a medical diagnosis given by a physician. It was intended that payment for these codes would come from the general medical pool of funds, not from mental health funds. In practice, the use of the medical diagnosis has caused problems at times because some insurance companies require the use of only mental health codes by psychologists.

The 97532 code refers to cognitive retraining; it has typically been used by speech and language pathologists working to improve cognitive function of patients with cognitive deficits. Many neurofeedback providers have started to use this code when working with clients with ADHD or TBI. The 97112 code refers to neuromuscular retraining of movement, balance or coordination. Surface EMG training (as well as some less common techniques) in rehabilitation settings can be coded with 97112. I have also come across a relatively new code, 96002, that is used for dynamic surface EMG recording for gait training and other functional activities. We may be able to use this code when providing EMG biofeedback to improve motor control

Medicare

Medicare will pay for CPT codes 90901 and 90911 when specific criteria are met. Medicare does not reimburse for 90876. Under Medicare guidelines, biofeedback training for muscular pain or weakness may be eligible for payment. Each carrier will have a list of eligible diagnoses and you would have to check to see what conditions are eligible for your local carrier and whether you can be reimbursed as a provider.

The main concern when billing Medicare with 90901 is that reimbursement is quite low. The allowance is between $40-50 per session, regardless of the length of the session. The reimbursement for 90911 is typically higher. Billing Medicare for 90901 also requires the use of a modifier (GP or GN) to indicate whether the services are coordinated with physical therapy or occupational therapy.

All of the Medicare carriers are now paying for the health and behavior intervention codes. In Florida, the allowance is $97 for the evaluation (96150-1 hour or 4 units) and $89 for individual treatment (96152-1 hour or 4 units).

I don't have information on Medicare coverage of 97532. Since the vast majority of clients getting neurofeedback for attention deficit disorder are children, it is highly unlikely that they will have Medicare for insurance.

The federal workers' compensation program (http://owcp.dol.acs-inc.com/portal/main.do) will pay for biofeedback training. The enrollment process can be tedious, but once you are enrolled as a participating provider, you can bill for biofeedback services provided to federal employees who are injured on the job.

We have reports of biofeedback reimbursement from Aetna, United and Delta on the West coast. The best advice is to be persistent and prepared. Have your office verify coverage for all possible biofeedback codes for all of your patients. Coverage often varies widely based upon the specifics of a given contract and may include restriction based upon type of licensure. If you get a rejection initially, contact a supervisor, case manager or provider relations. If you have success

Biofeedback to Reduce Stress and Insomnia

Over the past few years, new research brought forth new approaches and strategies that can help us make improvements in self-development. Some of the main approaches include Biofeedback, which can provide you with some stress relief. Studies show that those suffering with insomnia. Whether it is medically or psychologically based, endure excessive levels of stress as well. By lowering your stress levels, you can find relief and achieve a recuperative night of rest.

Biofeedback helps by improving brain and physical performance. A monitoring device is used to display feedback. The monitor works by reading your body functions. It then examines the data to see how your body performs. Thus, by using this solution, you can connect with your bodily functions, and gain more control.

Biofeedback is one way of finding stress relief. Most of us, however, cannot afford to go out and spend money on monitoring devices. Thus, we must look into other solutions, and one that comes to mind is a guide to manage daily pressure by using positive thriving solutions. What this means is that you learn how to use your stress in a way that helps you to thrive on positive thinking.