Biofeedback An interactive and innovative treatment modality. Gretchen Noble, PsyD Children s Medical Center Dallas Pediatric Pain Management Center biofeedback: The technique of making unconscious or involuntary bodily processes perceptible to the senses in order to manipulate them by conscious mental control. A learning model focused on self-regulation. A non-pharmacological training technique in which people are taught to improve their health and performance by using signals from their own bodies. goals of intervention: Increasing perceptual awareness and accuracy. Regulating and balancing the autonomic nervous system (ANS). Developing increased awareness of processes that are outside conscious awareness and/or under less voluntary control. 1
relaxation: an afterthought... Individuals can learn to relax without feedback Deep breathing Progressive muscle relaxation Guided imagery Biofeedback always includes a patient, a therapist, and monitoring equipment. equipment: types of feedback: Breathing Hyperventilation, anxiety, asthma Brain wave Alcohol/drug use, insomnia, brain damage Electrodermal Stress-response, SNS arousal Electromyography Tension headache, muscle pain Finger pulse (blood flow) Hypertension, anxiety Skin temperature Migraines, Raynaud s Disease 2
common misconceptions: Biofeedback works like magic and only takes one session! Biofeedback will fix symptoms and take away pain. When I m hooked up to the computer, it changes how my body works. If I do something wrong, the machine may zap me! the most studied, empirically supported groups: Migraine temperature Tension headache EMG Abdominal pain / IBS Heart-rate variability Essential hypertension Temperature, HRV Cardiac arrhythmias HRV clinical efficacy guidelines: Developed by the Task Force of the Association for Applied Psychophysiology and Biofeedback and the Society for Neuronal Regulation in 2001 Reported the efficacy of psychophysiological interventions Rated efficacy on a 1-5 scale, with 5 representing those treatments with statistically significant superior results across 2 or more studies 3
level 3 efficacy: Multiple observational studies, clinical studies, wait list controlled studies, and within subject and intrasubject replication studies that demonstrate efficacy. level 3: probably efficacious Insomnia Alcohol / substance abuse Arthritis Chronic pain Recurrent abdominal pain Elimination disorders Epilepsy Pediatric migraine Traumatic brain injury level 4 efficacy: In a comparison with a no-treatment control group, alternative treatment group, or sham (placebo) control utilizing randomized assignment, the investigational treatment is shown to be statistically significantly superior to the control condition or the investigational treatment is equivalent to a treatment of established efficacy in a study with sufficient power to detect moderate differences, and The studies have been conducted with a population treated for a specific problem, for whom inclusion criteria are delineated in a reliable, operationally defined manner, and The study used valid and clearly specified outcome measures related to the problem being treated, and The data are subjected to appropriate data analysis, and The diagnostic and treatment variables and procedures are clearly defined in a manner that permits replication of the study by independent researchers, and The superiority or equivalence of the investigational treatment has been shown in at least two independent research settings. 4
level 4: efficacious Adult headache Hypertension Temporomandibular disorders (TMD) Urinary incontinence: males Anxiety ADHD level 5 efficacy: The investigational treatment has been shown to be statistically superior to credible sham therapy, pill, or alternative bona fide treatment in at least two independent research settings. Level 5: efficacious and specific Urinary incontinence: women Biofeedback is widely sited as superior to control group, better than or equal to other behavioral treatments (e.g., pelvic floor exercises), and better than medication in females across the lifespan. 5
a learning model: heighten awareness of physiological differences / changes learn to control the perceptible changes skill generalization Learning is interactive... guided by instruction and information to develop a skill. creating learned behaviors: heighten awareness of physiological differences and changes What does it feel like to breathe 10x per minute versus 20x per minute? What words would you use to describe the sensation you feel? learn to control the perceptible changes first by using the external signal (visual or auditory feedback) next by using internal cues / sensations skill generalization No longer need to receive feedback / no machines an overview of the basics: Breathing is the foundation of all types of biofeedback training All patients begin by completing a stress protocol to obtain pre-intervention, baseline data Patients first achieve mastery of respiration regulation, then move on to heart rate variability regulation EMG training follows, if indicated based on skilllevel and/or diagnostic group Effective skill generalization is the primary indicator for treatment termination 6
intervention one: Joe - 10-year old male with chronic abdominal pain - significant psychological and medical factors influencing pain - 26 breaths per minute pre-intervention stress test: RESP HR / BVP intervention seven: - resolution of pain complaints - 9 breaths per minute 7
post-intervention LST: Resp / HRV coherence intervention one: Aaron - 14-year old male with migraine headache - 13 breaths per minute pre-intervention stress test: 0-50% coherence 8
Intervention 4: - 6 breaths per minute Smoothness / rhythmicity via pauses coherence training: Resp/HR simulation of pain/distress poor coherence in-sync strong coherence post-intervention LST: 75%-100% coherence 9
progress at termination: 10-year old male 14-year old male Each with notably improved management of symptoms associated with pain and stress. anecdotal observations: the clinic s first 5 months... Patients report heightened sense of control over their symptoms and decreased impairment, regardless of perceived changes in pain Patients report notably increased relaxation and awareness of physiological changes By their final session, none of the patients have been able to comfortably recreate their week 1 pace of breathing All would recommend biofeedback to another child/adolescent who shared their symptoms All teenagers independently reported that it was cool or interesting to learn something that few people know about You can achieve positive results with migraine patients even when you can t rely on temperature-based biofeedback. All would recommend biofeedback to someone else with pain. appropriate referrals: Appropriateness for treatment is based upon: Diagnostic group / comorbidities Capacity for self-regulation Processing information Learning Adjusting Practicing Motivation / commitment to treatment protocol 10
inappropriate referrals: Cognitive limitations Impaired learning Slowed processing speed Inability to regulate or self-correct History of abuse Lowering of defenses History or current experience of psychosis Difficulty differentiating realities incorporating biofeedback into your multidisciplinary treatment approach: BARRIERS Cost of training and equipment Billing / Financial reimbursement Availability of resources Quiet office space Non-medical environment Referrals (internal vs. external) incorporating biofeedback into a multidisciplinary treatment approach: PERKS Provides an additional non-pharmacological modality Targets management of stress and/or anxious responding (even when they don t believe they are stressed or anxious!) Promotes active coping and self-management May increase internal locus of control Provides a life-long skill set 11
references: Association for Applied Psychophysiology and Biofeedback, Inc. (2008). Retrieved from http://www.aapb.org/tl_files/aapb/files/yucha- Gilbert_EvidenceBased2004.pdf Burgio, K.L., Locher, J.L., Goode, P.S., Hardin, J.M., McDowell, B.J., Dombrowski, M., et al. (1998). Behavioral vs drug treatment for urge urinary incontinence in older women: A randomized controlled trial. Journal of the American Medical Association, 280(23), 1995-2000. Gilbert, C., & Moss, D. (2003). Basic tools: Biofeedback and biological monitoring. In D. Moss, A. McGrady, T. Davies, & I Wickramaskera (Eds.), Handbook of mindbody medicine in primary care: Behavioral and physiological tools (pp. 109-122). Thousand Oaks, CA: Sage. Hermann, C., & Blanchard, E.B. (2002). Biofeedback in the treatment of headache and other childhood pain. Applied Psychophysiology & Biofeedback, 27(2), 143-162. Hughes, T. (2010). Biofeedback Certification Training. Moss, D., & Gunkelman, J. (2002). Task force report on methodology and empirically supported treatments: Introduction and summary. Biofeedback, 30 (2), 19-20. Schwartz, M., & Andrasik, F. (3rd edition, 2003). Biofeedback: A practitioner's guide. NY: Guilford. Yucha, C. & Gilbert, C. (2004). Evidence-based practice in biofeedback and neurofeedback. Association of applied psychophysiological and biofeedback. Gretchen.Noble@childrens.com 12