Alternative Medicine (CAM). Many biofeedback practitioners react Traditional Chinese Medicine is not even perceived as alternative. …
Volume 31, Number 3
Fall, 2003
Patients want to be seen and treated as a whole person, not as diseases A whole person is someone whose being has physical, emotional, and spiritual dimensions Ignoring any of these aspects of humanity leaves the person incomplete and may even interfere with healing Koenig, 2000, p 1708
Special Issue on Complementary and Alternative Medicine and Integrative Medicine
FROM THE EDITOR
Fall 2003 Issue of Biofeedback Magazine
Special Issue on Complementary and Alternative Medicine and Integrative Medicine
Donald Moss, PhD
Patients want to be seen and treated as a whole person, not as diseases A whole person is someone whose being has physical, emotional, and spiritual dimensions Ignoring any of these aspects of humanity leaves the person incomplete and may even interfere with healing Koenig, 2000, p 1708
Donald Moss, PhD
This fall issue of Biofeedback is dedicated to the place of biofeedback in the emerging movement of Complementary and Alternative
Medicine CAM Many biofeedback practitioners react defensively to discussions of CAM, pointing out that biofeedback has a three decades long history, is supported by countless research studies documenting efficacy, and therefore should be recognized as mainstream and not complementary Nevertheless there are shared values linking biofeedback and CAM A review of the CAM literature Moss, 2002, p 283 shows that CAM consumers are interested in pursuing therapies with the following characteristics, among others: 1 A holistic view of mind, body and spirit 2 Viewing and treating the patient as a unique human being 3 A personal supportive relationship between healer and patient 4 An active role for the patient in the healing process 5 The inherent healing power of the living organism 6 Lifestyle and habit changes as tools to optimize health 7 Interventions to elicit the bodys healing powers 8 An aversion to invasive treatments that crush disease but harm the patient 9 A belief in eclecticism and
empiricism 10 An acceptance for unconventional interventions and models that appear to work Most biofeedback practitioners would probably accept at least the majority of these characteristics as desirable features of biofeedback and self-regulation oriented therapies as well This common ground in values suggests that biofeedback may discover in CAM a window of opportunity for wider acceptance We are probably appealing to many of the same patient groups, and presenting similar treatment approaches to our patients What Do We Mean by CAM? Complementary and alternative therapies, most broadly, have been defined as therapies which are not taught in medical schools Because CAM therapies are making inroads in mainstream medicine, James Gordon recently revised
this definition to say that CAM therapies are therapies which physicians over 30 did not learn in medical school Gordon Moss, 2003 Lake 2003 further clarified that complementary therapies include therapies which are compatible with the
natural scientific paradigms of mainstream medicine, but which have not gained widespread acceptance Herbal medicines are an example, since herbs have clear physiological mechanisms, just as do pharmaceutical medications Biofeedback is another example, since biofeedback therapies rest on a paradigm of physiological and cognitive mechanisms that is compatible with mainstream medical thinking On the other hand, alternative therapies are based on paradigms and mechanisms beyond the realm of mainstream medicine An example would be the reference to life energies or Qi as mechanisms of action in Traditional Chinese Medicine Who Uses CAM? First, research by Eisenberg and others shows that increasing numbers of individuals are using CAM Adam Burke 2003 shows that these numbers include a number of special groups: First, individuals with cultural backgrounds that include traditional medicine are high users of CAM therapies For members of traditional Chinese communities in the United States,
Traditional Chinese Medicine is not even perceived as alternative Rather, this is their mainstream medicine Second, individuals with chronic, complex and serious health problems use CAM in high numbers They often feel threatened by their illness, are disappointed in the results of mainstream medicine, and sample eagerly the offerings of CAM Finally, the cultural creatives use CAM in large numbers Cultural creatives are persons who share alternative values and lifestyles, and who often are dissatisfied with the mainstream conventional culture Burke argues that the latter two groups are especially ripe for biofeedback, since there is substantial evidence that biofeedback can help persons with complex and chronic conditions, and biofeedback itself continues to carry some flavor of the counter-culture What Do We Mean by Integrative Medicine? The full title of this special issue refers to both CAM and Integrative Medicine Integrative Medicine refers to a vision for the new health care,
integrating mainstream therapies and CAM therapies under one roof Ideally, future patients will encounter one seamless health care, inte-
Continued on page 12
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Biofeedback
Volume 31, No 3 Fall 2003
Biofeedback is published four times per year and distributed by the Association for Applied Psychophysiology and Biofeedback Circulation 2,100 ISSN 1081-5937 Editor: Donald Moss PhD Associate Editor: Theodore J LaVaque, PhD sEMG Section Editor: Randy Neblett, MA EEG Section Editor: Dale Walters, PhD Reporter: Christopher L Edwards, PhD Reporter: John Perry, PhD Managing Editor: Michael P Thompson Copyright 2003 by AAPB Editorial Statement Items for inclusion in Biofeedback should be forwarded to the AAPB office Material must be in publishable form upon submission Deadlines for receipt of material are as follows: November 1 for Spring issue, published April 15 April 1 for Summer issue, published August 5 May 15 for Fall issue, published September 15
September 1 for Winter issue, published January 15 Articles should be of general interest to the AAPB membership, informative and, where possible, factually based The editor reserves the right to accept or reject any material and to make editorial and copy changes as deemed necessary Feature articles should not exceed 2,500 words; department articles, 700 words; and letters to the editor, 250 words Manuscripts should be submitted on disk, preferably Microsoft Word or WordPerfect, for Macintosh or Windows, together with hard copy of the manuscript indicating any special text formatting Also submit a biosketch 30 words and photo of the author All artwork accompanying manuscripts must be camera-ready Graphics and photos may be embedded in Word files to indicate position only Please include the original, high-resolution graphic files with your submission at least 266dpi at final print size TIFF or EPS preferred AAPB is not responsible for the loss or return of unsolicited articles
Biofeedback accepts paid display and classified advertising from individuals and organizations providing products and services for those concerned with the practice of applied psychophysiology and Biofeedback Inquiries about advertising rates and discounts should be addressed to Denise Townsend dytownsend@earthlinknet Changes of address, notification of materials not received, inquiries about membership and other matters should be directed to the AAPB Office: Association for Applied Psychophysiology and Biofeedback 10200 West 44th Ave, No 304 Wheat Ridge, CO 80033-2840 Tel 303-422-8436 Fax 303-422-8894 E-mail: aapb@resourcentercom Website: http://wwwaapborg
FROM THE EDITOR
From the Editor: Donald Moss, PhD 2
PROFESSIONAL ISSUES
Ethical Behavior and Other Issues in Complementary and Alternative Medicine Interventions Sebastian Striefel, PhD 4
COMPLEMENTARY AND ALTERNATIVE MEDICINE AND INTEGRATIVE MEDICINE
Manifesto for a New Medicine James Gordon, MD and Donald Moss, PhD Biofeedback
and the CAM Consumer Adam Burke, PhD, MPH Complementary and Alternative Care for Heart Disease Jessica Depozo, PhD, and Richard Gevirtz, PhD The Promise of Heart Rate Variability HRV Biofeedback: Some Preliminary Results and Speculations Richard Gevirtz, PhD Taking Control: Strategies to Reduce Hot Flushes and Premenstrual Mood Swings Erik Peper, PhD, and Katherine H Gibney QEEG and EEG Biofeedback in the Diagnosis and Treatment of Psychiatric and Neurological Disorders: An Authentic Complementary Therapy James Lake, MD, and Donald Moss, PhD 8 13 16 18 20 25
SERIES
Audio-Visual Entrainment, Part II, David Siever 29
CONTRIBUTIONS TO SURFACE ELECTROMYOGRAPHY
Shoulder SEMG Testing and Biofeedback / Re-education: A Segmental Motion and Regional Approach Gabriel E Sella, MD, MPH About the Authors 33
37
AAPB NEWS AND EVENTS
From the President From the Executive Director From the President-Elect AAPB Announces Partnership with American WholeHealth, Inc AAPB Winter Workshops 2003 1A 2A 3A
5A 7A
The articles in this issue reflect the opinions of the authors, and do not reflect the policies or official guidelines of AAPB, unless stated otherwise
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PROFESSIONAL ISSUES Ethical Behavior and Other Issues in Complementary and Alternative Medicine Interventions
Sebastian Seb Striefel, PhD, Logan, Utah
Abstract: Practitioners need to be aware of complementary and alternative treatment approaches, the support for such approaches, and the risks and benefits associated with such approaches so that they can help clients obtain the most appropriate help for their problem, can know when to accept or not accept a referral, and when to refer a client elsewhere Sometimes the risks are as yet largely unknown Different issues exist for the informed consent process when helping a client with a diagnosable illness versus when helping someone with a normal level of functioning to enhance their level of functioning and sometimes the rights of the individual conflict
with those of society Practitioners need to protect the rights of clients and this includes not exposing vulnerable individuals, eg, children, to unnecessary risks purely because the parent wants their child to have an advantage The best interests of the child also need to be considered Specific and common factors both play a role in positive outcomes in treatment and client belief systems are one factor that needs to be considered by the practitioner in deciding what treatment to offer and muscle re-education applications, rather I consider them to be mainstream treatment approaches Bassman and Uellendahl 2003 stated, and I quote, Hypnosis, meditation, and biofeedback are approaches that have largely made the transition from alternative to mainstream practice in recent history p 264 Perhaps some biofeedback approaches are still in the CAM camp Lake and Moss in this issue state that they consider EEG biofeedback and QEEGs to be CAM approaches Clearly the way most practitioners practice
biofeedback it does not fit the medical model but rather a selfempowerment model whose assumptions about health care differ considerably from mainstream medical practice Is that a CAM feature? Originally the AAPB journal included the words self-regulation and that set of words still describes a core aspect of biofeedback applications CAM approaches have varying degrees of support on effectiveness and safety, so practitioners need to educate themselves about the various CAM approaches available, even those outside of their own areas of competency so that they can make referrals, if, and as appropriate Bassman Uellendahl, 2003 are still considered to be CAM approaches As such, when dealing with CAM approaches, more care needs to be taken to ensure that the informed consent process is accurate and complete in terms of presenting the alternative treatment options available and the risks and benefits associated with each It is also important to remember that some CAM approaches are very
well supported by research data In deciding whether or not to accept a referral, the practitioner also needs to consider his or her own areas of competence, what is known about effective treatments for the clients problem, and which treatment is most likely to fit within the clients belief system In both rural and urban areas, the practitioner also needs to consider whether the referral might result in a problematic dual relationship that could interfere with effective treatment
Illness Versus Enhancement
Have you ever thought about what is acceptable ethical behavior when helping a client overcome an illness versus when helping a client to enhance his or her performance? From a traditional ethical viewpoint, some degree of risk to a client is acceptable in treatment to help a client overcome pain and suffering, with of course, client informed consent The acceptable level of risk may well be higher the more serious the illness and the greater the pain and suffering Exposing a client
to the same level of risk may well not always be acceptable when the goal of intervention is purely to enhance performance for a person who is not ill or who is functioning at what we call a normal level
Introduction
More and more clients are approaching practitioners asking for or about CAM approaches To ethically meet the requirements of informed consent, ie, to be able to discuss the pros and cons of the alternative treatments available for dealing with the clients condition, including those that would be considered CAM approaches, the practitioner must be aware of the current status of CAM approaches Bassman Uellendahl, 2003 I personally do not think that all biofeedback applications are still CAM approaches, especially relaxation
Referral Issues
Every referral received by a practitioner involves a host of decision-making issues Practitioners need to consider the source of the referral, financial and scheduling issues, and the practitioners impression of the client and his or
her problem Shapiro Ginzberg, 2003 CAM approaches are often considered to be more risky than more empirically supported treatments ESTs; that is one of the reasons that they
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Dilemmas
Practitioners are regularly faced with the ethical and practical dilemmas associated with choosing among alternative treatments to determine which one is the best for a particular client Deegear Lawson, 2003 Increasingly the emphasis is on choosing specific approaches for specific problems based on what is empirically supported or what have been called ESTs Deegear Lawson, 2003 So when, if ever, is it acceptable to use a complementary and alternative medicine CAM approach for treatment when the approach has little research support on efficacy, effectiveness, or safety? One might argue that using CAM approaches to treat illnesses is ethically acceptable, provided that one or more of the following guidelines is met: 1 when the use of the CAM approach has good research support,
eg, as being safe and effective; 2 there is no other known effective treatment available; 3 available treatments have associated high risks eg, the side effects of some medications; 4 the existing treatments are not acceptable for some good reason to the client, even after having the relevant facts; and 5 the CAM approach being proposed has no known serious side effects that would preclude its use
experienced for shortening the amount of time it takes to get a new drug or treatment approved, even though there are several FDA approved drugs on the market that have very dangerous side effects, eg, Viagra has resulted in the death of many individuals Some of these individuals were on the drug, not because they couldnt function sexually, but rather because they wanted enhanced sexual functioning
when a life threatening condition exists
Societal Versus Individual Rights
Where does societys right to supercede an individuals rights began or end? There is an ongoing case right now where a
prisoner accused of a serious crime and awaiting trial has refused treatment that would make him competent to stand trial Without treatment for his psychosis/schizophrenia he may well never be competent to stand trial and without a trial he may well spend the rest of his life incarcerated without any probability of being released Should he be treated in spite of his refusal to give consent? The US Supreme Court is in the process of deciding this issue Or take an example more directly relevant to biofeedback practitioners, especially those who use EEG biofeedback in the treatment of certain behavior in criminals There seems to be increasing support that the Peniston Protocol can be very effective in dealing with substance abuse drugs and alcohol and that it reduces the likelihood of paroled prisoners having future contact with the legal system Fahrion, 1998 There seem to be many implications for treating those who drink and drive, including possible reductions in the loss of life and
injuries caused by drunk drivers Does a societal goal of saving life and limb provide sufficient justification for society to decide that all individuals who have been convicted of a drinking or drug offense should be treated with EEG biofeedback even if they object or refuse to consent to such treatment? Would mandatory treatment of this sort work? Could a good working relationship be established with such a client? Can a client who is faced with giving consent and undergoing treatment, or going to, or staying in jail, really give informed consent or does such coercion violate the individuals rights? Court ordered treatments or going to jail have been part of our legal system for quite some time Does such forced treatment diminish the individual freedom of all of us and does it move us closer to government imposed paternalism of doing what society thinks is right for classes of people regardless of constitutional guarantees? As a practitioner would/do you treat court ordered
individuals? Is it morally and ethically acceptable 5
Moral and Ethical
So when you are considering using a CAM approach to helping a client with a problem or to enhance his or her level of functioning, what is morally right or wrong and ethically good or bad acceptable, and how do you decide Safire, 2002? Moral refers to conforming with long established codes of conduct that often are set by religious authorities and which seldom, if ever, change over time Safire, 2002 Ethical refers to whether something is fair good or bad at the present time in a particular society or group eg, AAPB Safire, 2002 Ethical views may well differ from society to society or over time, eg, not long ago in the United States it was ethically very acceptable for physicians to be paternalistic and to decide what was best for their patients, often without the patients involvement or consent, because it was believed that the physician knew better than the patient what was good for him or her Today paternalism
is no longer ethically acceptable and self-determination and informed consent have become critically essential factors in assessment and treatment Moreno, 2002 It is no longer ethically acceptable to provide treatment without informed consent unless a life threatening emergency exists where informed consent is not possible In a life threatening situation we generally consider intervention acceptable regardless of an individuals client rights because it is assumed that saving the clients life societys desired outcome supercedes the need to get informed consent For example, Caplan 2002 reported that the Amish believe that every child is a gift from God and they dont bring their children in for treatment, even when they have genetic anomalies and diseases p111 Sometimes the courts have to intervene to ensure that a child in such communities gets appropriate treatment Biofeedback
Unknown Risks
It is increasingly clear that the general public is regularly taking unknown risks by using
alternative treatments, often without the guidance of a professional practitioner, eg, by using nutritional supplements for which efficacy, effectiveness, and safety are unknown or difficult to discern because of all the advertising hype Individuals are seeking treatment for a wide variety of physical and mental conditions that traditional interventions have been ineffective in treating or where clients are dissatisfied with the outcomes, side effects, etc Albert 2002 stated that people are so desperate for changes in their current level of functioning and desirous of enhancements in functioning that they are accessing all sorts of alternative treatments and substances, regardless of risk She argues that they will not wait for clinical trials to determine effectiveness or safety This seems to go along with some of the pressure that the Food and Drug Administration FDA has Fall 2003
for you to do so? John Crosby stated that just because something is legal does not mean its ethical and
because something isnt illegal doesnt mean its ethical Smith, 2003, p 18 When one treats court ordered clients, it is very important to discuss the implications of their consenting or not consenting to treatment and to discuss what the practitioners responsibilities to the court are, eg, what information will be shared with the court
Churchland 2002 says that emotions and reason are on a continuum in decision making As such, a practitioner needs to be careful not to let excess emotions interfere with reason in making ethical and practical decisions about what is right and good for a particular client
Optimal Functioning
In essence, the young man wanted to end up with something better than he currently had Caplan 2002 discusses the distinction between repair or treatment and interventions that enhance or optimize functioning Several authors have argued that it is unfair to provide interventions that strive to improve, enhance, optimize, or make and individual function better if they
have no disability or problem because insurance companies will not pay for such interventions and so those with money will be able to access the interventions and those without will not Caplan, 2002 Realistically that is the American way, those with money have always tried to give their children and themselves the advantages that money can buy and today that includes peak performance via interventions such as biofeedback, mind enhancing drugs, private schools, tutors, etc As a practitioner do you think it is ethical to enhance the functioning of normally functioning individuals or do you think the unfairness of access makes it unethical? Should parents be allowed to expose their children to unnecessary risks, eg, many children who do not have ADD/ADHD are on drugs like Ritalin because it seems to enhance their performance Hyman, 2002a Is this ethically acceptable? The side effects of such drugs can be severe and the long-term effects are still largely unknown Hyman, 2002a The mental
health movement of the 1970s was designed to create equal access to mental health services by making a mental health center available in almost every community It did increase access for those with no previous access but those with money continue to access higher quality services by seeking out the best of the best in terms of providers and treatment options Maybe accessibility is a little fairer, but bills for parity in terms of insurance payments are an ongoing part of the congressional process to make mental health services more accessible for those who do not have the funds to access services privately with out of pocket funds Is there an ethical difference between, eg, artificially altering the neurotransmitters in the brain of a normally functioning individual and artificially lowering the choFall 2003
Personal Identity
As a practitioner you often muck with someones brain via, eg, changing their belief system or via a direct intervention such as EEG biofeedback When we muck
around in someones head we may well also threaten the persons sense of who they are Caplan, 2002 The intervention may well modify them in ways that change their personal identity Have you ever considered this as a risk factor when obtaining informed consent? I remember receiving a referral from a parent of a young man The young man had been diagnosed with Attention Deficit Hyperactivity Disorder ADHD with some associated conduct disorder problems He was regularly having conflicts with the legal system and had been in prison because of a lack of control over impulsive behaviors For example, one day he and some friends were throwing snowballs at cars When the police came all his friends ran away, but he stayed and threw snowballs at the police car The mother wanted him to get EEG biofeedback so that he would be less impulsive and less likely to end up back in prison Medications had not been successful in helping him control his behavior It quickly became clear that he liked the emotional
high that he experienced when he was out of control and he was concerned that the EEG biofeedback would take that high away He was not willing to participate in treatment nor was he willing to change his identity in that way In fact, he was not willing to listen to an explanation about how EEG biofeedback would not take away his option to experience a high, but rather how it would create options for him on when, or if, to be in or out of control After nine months in the state penitentiary he was more than willing to pursue treatment that would give him the option of being in control, regardless of whether it would or wouldnt change his personal identity or state of feeling high
Informed Consent
Caplan 2002, p 110 reports that sometimes parents push their children by exposing them to potentially dangerous interventions unnecessarily, eg, children, especially boys who are a little short, but not dysfunctionally short, are exposed to growth hormone which has dangerous side effects
because being short is not acceptable socially How does one protect those who cannot protect themselves? One function that informed consent is supposed to serve is that of protection Can a person experiencing pain and suffering ever really give informed consent or is their capacity for doing so clouded by the pain and suffering that they are experiencing? Moreno 2002 argues that a patient can handle the truth if they are told the truth In essence, patients can exercise self-determination or free will in the informed consent process by making appropriate judgments for themselves He argues that serious issues in giving competent informed consent arise when a parent is ask to consent to treatment for one of their children because of the conflict of interest raised by their emotions and their goals for the child Yet he argues that humans can exercise selfdetermination to a sufficient degree even in such situations just because they will it to be so Moreno, 2002, p 39 As such, the issue for
practitioners goes beyond what is right for this client in this situation to include, how have I gone about making the decision about what is right for this client Moreno, 2002? So the process of making the decision becomes as important or maybe sometimes even more important, than the decision itself A faulty decision making process can lead to a faulty decision Respect for the client and his or her rights is ethically important in the decision-making process 6
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lesterol of someone at risk for coronary heart disease Hyman, 2002b Probably so, but again good informed consent seems to be the key and that informed consent has to be an ongoing educational process throughout treatment to enhance performance In some cases it may be necessary to have tighter controls on risk, especially for those who cannot protect themselves, eg, children Caplan, 2002 Perhaps professional associations like the American Medical Association have to establish more definitive guidelines for the use
of risky interventions, especially if it is purely for performance enhancement If professional groups do not establish the controls the legal system eventually will Are there areas where the Association for Applied Psychophysiology and Biofeedback should have more definitive guidelines? As practitioners we must take responsibility for ensuring that we do not provide interventions that have high risk when less risky interventions are available for treating the same problem or for enhancing the same area of functioning We probably should not ask a client to consent to the use of a highly risky intervention when other less risky options exist Are there any biofeedback interventions with severe or high levels of risk? I cannot think of any, can you?
Specific Versus Common Factors
One caveat in all of this is related to the outcome data concerning psychotherapy Research has shown that when treatments are compared, the outcomes on efficacy of treatment tend to be uniform, ie, one treatment
works as well as another Deegear Lawson, 2003; Elkin, 1994; Smith Glass, 1977; Wampold et al, 1997 It is argued that it is not specific factors, techniques, and treatments that account for the positive outcomes achieved, but rather the outcomes are due to the factors common to all of the treatments eg, therapeutic alliance Deegear Lawson, 2003 Specific ingredients seem to account for only 8 of the variance in positive outcomes from psychotherapy and common factors account for about 70 of the variance Deegear Lawson, 2003; Garfield, 1992 The findings seem similar to those reported by Wickramasekera 1999 He
reported that biofeedback is often no more effective than placebos Placebos are really those things that could be called common factors in all treatments So does this mean that specific techniques like biofeedback do not work? Not really, because it could well be that we are not measuring the right variables in the outcome studies Practically, clinicians and clients alike are
both interested in getting positive outcomes regardless of whether it is the specific factors, the common factors, or some combination of both that account for the outcomes Shadish et al 2000, and Shaw et al 1999 report that the specific ingredients in ESTs have questionable utility and that strict adherence to EST protocols may well not be related to outcomes and may in fact have detrimental effects Deegear and Lawson, 2003; Castonquay et al, 1996 In fact, EST protocols have serious flaws and are very questionable as best practices Wampold, 2001; Garfield, 1998 Part of the problem is that much of the research on treatment are related to studies of efficacy which are often not carried out in clinical settings with clinical subjects rather than on effectiveness studies that show it works in clinical settings with those clients seeking help Are you familiar with the status of the research findings on various CAM approaches?
Flexibility
The medical community seems to increasingly define
both physical and mental disorders as having a biological basis see the DSM-IV for examples and as such seems to be emphasizing pharmacological treatments for everything in spite of evidence that behavioral approaches often work just as well Deegear Lawson, 2003 Most practitioners know that to be effective in treating clients one must be flexible and select and adjust the treatments used to the characteristics and problems of the client Deegear Lawson, 2003, the practitioners competencies, and what he or she believes will work because this will influence the clients belief system In fact, Frank and Frank 1991 argue that the most critical factor in treatment effectiveness is the ability of the practitioner to apply treatments flexibly to accommodate the clients beliefs They state that the four
necessary components in treatment seem to be: 1 having a good trusting therapeutic alliance, 2 the client believing that the practitioner will work for his or her betterment, 3 a rationale and
framework for explaining the clients problem and for supporting the particular intervention being used, and 4 the participation of both the client and the practitioner within that framework Frank Frank, 1999 Informed consent and support of other client rights such as autonomy are helpful in establishing a good working relationship, in adhering to ethical principles, and in providing the educational information needed for modifying the clients belief system so that she or he believes that the practitioner is working in her or his best interests and thus being motivated to participate in the proposed treatment According to Deegear and Lawson 2003, Frank and Franks 1991 four components support an argument for selecting treatments that are consistent with the clients world views rather than considering only those that seem relevant to the particular problem being addressed Practitioners tend to use the treatments that have worked with similar clients in the past and a good education
program is one way to increase the likelihood that the proposed treatments will fall within the clients view of the world and what will work for them
References
Albert, M S 2002 Questions and answers In S J Marcus Ed, Neuroethics: Mapping the Field pp 167-191 New York: The Dana Press Bassman, L E, Uellendahl, G 2003 Complementary/alternative medicine: Ethical, professional, and practical challenges for psychologists Professional Psychology, 343, 264-270 Caplan, A 2002 No-brainer: Can we cope with the ethical ramifications of new knowledge of the human brain In S J Marcus Ed, Neuroethics: Mapping the Field pp 93-131 New York: The Dana Press Castonquay, L G, Goldfried, M R, Wiser, S, Raue, P J, Hayes, A M 1996 Predicting the effect of cognitive therapy for depression: A study of unique and common factors Journal of Consulting and Clinical Psychology, 64, 497-504 Deegear, J, Lawson, D M 2003 The utility of empirically supported treatments Professional Psychology, 343, 2
71-277
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COMPLEMENTARY AND ALTERNATIVE MEDICINE AND INTEGRATIVE MEDICINE
Manifesto for a New Medicine
James S Gordon, MD, Washington, DC, and Donald Moss, PhD, Grand Haven, Michigan
Abstract: The general public has shown an increasing desire for complementary and alternative forms of healing Medicine has pursued a variety of alternative paradigms in recent decades, including the biopsychosocial model, behavioral medicine, holistic health, mindbody medicine, complementary and alternative medicine, and integrative medicine The present article summarizes the new medicine paradigm of James Gordon, Director of the Center for Mind-Body Medicine This approach emphasizes seven pillars in health care, including: uniqueness, holism, healing partnerships, self-care, other health care systems, group support, and spirituality and transformation This approach sees mind-body techniques, including biofeedback, hypnosis, and visualization as
central
James S Gordon, MD
Donald Moss, PhD
Complementary and Alternative Medicine
For at least a decade public interest in the United States has grown dramatically in Complementary and Alternative Medicine or CAM The National Center for Complementary and Alternative Medicine 2002 has defined CAM as medical care systems, practices and products that are not presently considered to be a part of either conventional medical practice or the medical school curriculum Because CAM is making inroads within both health care and medical school education, James Gordon now refers to CAM as therapies and interventions that physicians over 30 did not learn in medical school 2003
Over 40 of Americans today are using complementary and alternative therapies as part of their ongoing health care, even though CAM therapies are largely paid out of pocket CAM is not just a trendy pursuit of the affluent and relatively well population Rather, current research shows that 69 of cancer patients are using
some form of complementary and alternative therapy for their illness, and over 80 of cancer patients are interested in learning more about CAM Richardson, Sanders, Palmer, Greisinger, Singletary, 2000; Gordon Curtin, 2000 Similar trends are evident in the use of alternative therapies by individuals with disabilities Krauss, Godfrey, Kirk, Eisenberg, 1998, AIDS Standish, et al, 2001, and with chronic illnesses and conditions Burke, 2003
Manifesto for a New Medicine
If patients are restless and hungry for an alternative in health care, then professionals are challenged to define a paradigm for that new medicine Over the past three decades, a variety of models have been proposed, calling for a biopsychosocial model Engel, 1977, behavioral medicine Ader, Weiner, Baum, 1988, holistic medicine/nursing Trossman, 1998, mind-body medicine Moss, McGrady, Davies, Wickramaskera, 2003, and complementary and alternative medicine Lake, 2003 Each of these labels captures some essential aspects
of what is missing in mainstream
medicine, yet each has failed to convey the larger picture of what medicine should become More recently, Gaudet 1998 has called for an integrative medicine, which would encompass conventional mainstream medicine, CAM, mind-body therapies, and other alternative approaches Gordon 1996 simply calls for a new medicine, which includes the best of many approaches under one roof This article overviews Gordons approach to the new medicine, as expressed in his works Manifesto for a New Medicine Gordon, 1996, and Comprehensive Cancer Care Gordon Curtin, 2000 The old medicine focused diagnosis primarily on the use of laboratory tests and imaging procedures to identify specific pathophysiologic conditions that could in turn be alleviated by medication and surgical procedures The old medicine has been highly successful in treating acute conditions, eliminating infections, and correcting structural injuries However, the patient population presenting in primary care
today has shifted dramatically, and medical care must accommodate Patients are more likely today to present with symptoms that fall into several overlapping categories: somatization disorder, psychophysiological disorders related to psychosocial stress, symptoms of chronic disease, and somatic symptoms of psychiatric disorders Moss, 2003a
Seven Pillars
James Gordon identifies seven pillars which serve to define the new medicine Fall 2003
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The Center for Mind-Body Medicine
James Gordon, MD, directs the Center for Mind-Body Medicine, located at 5225 Connecticut Ave, NW, Suite 414, Washington, DC 20015 Phone 202-966-7338 Information about the Center is available online at wwwcmbmorg The Center is a non-profit educational organization dedicated to reviving the spirit and transforming the practice of medicine The Center is working to create a more effective, comprehensive and compassionate model of healthcare and education, especially through its professional training
program The Professional Training Program in MindBodySpirit Medicine, now in its ninth year, is the most comprehensive training program in mind-body medicine in the United States The program provides an intensive retreat where health professionals can begin the process of transforming their practices Our program is unique because we work with small groups to enhance practical learning as well as a lecture format There will be 15 full-time faculty and a limited enrollment of 150 participants This allows the program to provide an intimate level of interaction and experience to enhance learning The lectures provide the scientific basis for the MindBodySpirit model, powerful experiences of these techniques and the most important research in the field The program includes an added emphasis on the role of nutrition in mind-body health This comprehensive material and hands-on experience will prepare you to integrate the model into your work in a wide variety of settings, including private
practice with individuals and groups, hospital work, educational programs and work with populations affected by war, terrorism and other forms of trauma Each of these pillars addresses a need felt by individuals seeking alternative therapies, a strength within the new medical approaches, and a kind of empowerment for selfdirected health and wellness 1 Uniqueness The new medicine respects the radical uniqueness of each human being It is not only personality and identity which are unique in human beings Rather, as Gordon 1996, p 58 notes, Though the diagnostic label may be the same, each persons illness is different from everyone elses Irritable bowel syndrome is an entirely different condition when it occurs in a 60 year old man with heart disease, than it is in a 24 year old woman who is anxious but otherwise healthy The research of Roger Williams emphasizes the biochemical individuality of human beings Williams, 1980 The divergent nutritional requirements from one person to the next
provides an example of this individuality Williams research indicates that the needs for vitamins, minerals and amino acids varies enormously from person to person Similarly, medication responses vary greatly, with one patient showing rapid recovery using a specific medication, and the next patient suffering nausea, fatigue, and disorientation on the same medication Biochemical individuality dictates that treatments must be individualized for each patient, that patients reports of feeling worse on a new therapy be carefully heeded 2 Holism The new medicine is holistic, from holos, the Greek word for whole Holism regards health as a state of harmony and wellness in body, mind, and spirit Jan Christian Smuts, the South African biologist, developed the concept of holism, emphasizing that each biological organism is greater than the sum of its parts The new medicine agrees with the words of the Swiss psychiatrist, Medard Boss 1975, who wrote that health consists of the total haleness and
wholeness of the human being Holistic medicine is inclusive; it includes within its focus the familial, social, economic, environmental and ethnic dimensions of each patients life Above all, holistic medicine recognizes the central role of spirituality Spirit is integral to health, not something separate from bodies and emotions 3 Healing Partnerships The new medicine rests on the healing partnership between healer and patient This partnership is a collaborative one, in which the
patient participates fully and actively in his/her own movement toward wellness The healers role is powerful, but catalytic: The healers strength lies in awakening healing resources within the patient Inviting the patient to be a full partner is particularly powerful in transcending the old problem of patient non-compliance the failure of patients to carry out the medical orders of the physician Research consistently shows that about 50 of medical patients do not take medications as prescribed One study
found that only one week after a clinic visit, only 22 of patients were taking the medication as prescribed Boyd, Covington, Stanaszek, Coussons, 1974 In contrast, an extensive review of research studies on patient involvement in treatment conclusively found that patients want to participate in decisions about treatment Guadagnoli Ward, 1998 When the patient actively develops strategies for behavioral changes relevant to diabetes or asthma, that patient experiences more ownership and commitment to the action plan 4 Self Care Individuals learning to care for their own health and wellness lie at the core of the new medicine The old medicine has drugs and surgery at the core, and treats psychosocial therapies and CAM therapies as peripheral In the new medicine, self care is the true primary care, and deserves equal attention from the health provider Many of the factors leading to ill health and physical symptoms lie within the person and his or her behavior; the healing process must
begin with the patient learning to change these behavioral pathways to disease Self care means that each patient must become more aware of the powerful role of mind and emotion on the human body and its functions Biomedical research has established the physiological and neuroendocrine pathways of the human stress response, and its powerful role in producing disease Similarly, research shows the power of relaxation and related techniques to reverse the stress response Approaches for self care and self healing include: relaxation, meditation, biofeedback, imagery, hypnosis/self-hypnosis, exercise, nutrition, and prayer 5 Other Healing Systems Western biomedicine is not alone on this earth, and must develop the humility of learning from its elders In the initial hubris of modern
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medicines victories over infectious diseases, and the power of its surgical procedures, the entire approach and tool chest of traditional medicine were dismissed as ignorance and
superstition Yet, the majority of the worlds population continues to turn for everyday guidance on maintaining health to a variety of traditional medical systems, ranging from the ancient Vedantic medicine of India, to the shamans of the Navaho, to the bush doctors of the Caribbean The new medicine respects, and borrows both specific tools and broader attitudes from these older healing systems, whenever they show themselves to be effective Methodologically guided research is now proceeding to identify therapeutic effects within a variety of traditional herbal preparations Acupuncture, for example, is steadily gaining acceptance as a mainstream tool for chronic pain and a variety of other disorders Stein, 2003 The new medicine also respects and draws on the efficacious elements within alternative healing systems in Western society, such as chiropractic and osteopathy, with their manual therapies, as well as the humanistic body therapies such as the Alexander technique, bio-energetics,
and the Feldenkrais technique Moss and Shane, 1998 6 Group Support The new medicine draws on the power of small groups to provide the milieu for healing and personal change Many of the most successful studies showing the power of CAM therapies and mind-body methods in restoring health have imparted these healing strategies within a small cohesive therapeutic group The group provides emotional support, encouragement, and connectedness for the sufferer, and may be a hidden source of the therapeutic outcomes in these research studies Irvin Yalom 1985, the American existential therapist, noted the power of group process to install hope in the individual defeated by lifes problems, and to restore universality to persons who feel isolated in their illness When I observe others with similar complaints, and then triumph over them, I feel less alone with my own problem, and it becomes easier to visualize myself triumphing over my problems Traditional medicine typically views the family and
community as playing an active
and integral role in the healing of an individual Indigenous healers often gather the entire clan network around the sick individual to assist in restoring balance within this ill persons psyche and world In todays world of geographically mobile individuals, in which many persons live far from extended family and community, the therapeutic group can serve an important role as a substitute network for healing In addition to these powerful group dynamic influences on the patient, the group provides an encouraging culture within which the individual can learn a variety of active coping strategies The physician/therapist can teach specific skills in the group setting, such as relaxation, visualization, assertiveness, and cognitive reframing The group then encourages the individual to practice and master these skills, first in the group, and then in daily life 7 Spirituality and Transformation The new medicine respects the integral role of spirituality in
healing and transforming human beings Traditional healing systems are closely integrated with the spirituality of their cultures, and may have much to teach Western medicine in this regard Krippner 2003, p 191 noted that: spirituality is an integral part of the healing models of the indigenous healers who handle the health care needs of some 70 per cent of the current world population A growing number of empirical studies show the powerful effect of spiritual practices, church attendance, and religious beliefs on health Dossey, 1993, 1999; Moss, 2002, 2003b; Koenig, McCullough, Larson, 2001 Individuals who feel a sense of purpose and direction in life, and who experience a connection to a larger spiritual universe, exhibit greater physical well-being, reduced incidence of illness, more positive mood and mental state, and a greater ability to face adversity and discover hope for the future Medicine must learn to mobilize the beliefs and spiritual resources of the individual patient, as
powerful factors for enhancing health Medicine is also challenged to find ways to offer a spiritual window for individuals who lack such resources, while respecting the autonomy of each person
Mind-Body Therapies in the New Medicine
The new medicine is biopsychosocial and holistic in approach, and recognizes the power of mind-body approaches to enhance health and combat disease Lifestyle, stress, and human behavior play a critical role in many of the illnesses and conditions that bring patients into the medical clinic today One example is the so-called metabolic syndrome McGrady, Bourey, Bailey, 2003, the convergent problem of obesity, diabetes, hypertension, and hyperlipidemia Sedentary lifestyle, nutrition, and behavior play a role in the onset of each of the component conditions within the metabolic syndrome, and modifications in lifestyle, nutrition and behavior must play a role in reversing or even managing these conditions Similarly, inactivity, stress, and negative emotion the
hostility factor play a major role in the onset of cardiovascular disease, and exercise, stress management and emotional healing are critical to long term survival with heart disease Blumenthal, Jiang, Babyak, et al, 1997 The so-called mind-body therapies offer powerful tools to assist the new medicine in enabling behavioral change Biofeedback The paradigm of bio-feedback is simple yet powerful Feedback about a biological process enables awareness and control Biofeedback involves the use of electronic instruments to provide an individual with feedback about his or her own bodily processes This feedback increases the individuals awareness of processes such as muscle tension or breathing, and enables the individual to gain control over the same bodily processes Biofeedback is a natural technology for the new medicine The modality of biofeedback supports a philosophy of self-regulation and the acquisition of voluntary controls over ones own body and life Moss, 2001, 2003a With biofeedback
the individual gains control initially over a muscle, hand temperature, or brain wave activity, and frequently goes on to experience greater control over personal health, behavior at work, and other aspects of everyday life In the past three decades, research and clinical practice have shown the capacity of individuals to self-regulate their physiology
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in ways that reduce the symptoms and effects of countless disease conditions, ranging from anxiety to hypertension to depression and seizure disorders Schwartz Andrasik, 2003 Hypnosis Hypnosis includes the use of a variety of direct and indirect inductions to create a hypnotic state, which then provides an opportunity for psychotherapeutic exploration, recovery and processing of painful repressed memories, and the delivery of therapeutic post-hypnotic suggestions The patient goes through a process of induction, and then enters a condition we call hypnosis or trance Current outcomes research shows that
hypnosis produces effective results with a variety of disorders and conditions Burrow, Stanley, Bloom, 2001; Rhue, Lynn, Kirsch, 1993 Most familiar is the powerful role of hypnosis in relieving pain, including the management of chronic pain, analgesia during surgery and childbirth, relief of acute pain in burn victims, and relief of pain in terminal cancer patients In addition, research supports applications of hypnosis to habit change, including weight management and smoking cessation, and to asthma, eating disorders, wound healing following surgery, and a host of other conditions Breuer, 2000; Kirsch, Capafons, Cardena-Buelna, 1999; Sugarman, 1996; Spiegel, 2000 Visualization Visualization is also a powerful tool at the interface between body and mind Spiritual visions have played a role in the healing practices of shamans and spiritual healers in many traditional cultures Achterberg, 1985, 1994 Modern schools of relaxation have drawn heavily on the power of visual imagery Brigham,
1994 Research has shown many effects of deliberately cultivating positive mental imagery Positive imagery exercises can reduce anxiety and tension, reduce blood pressure, decrease headaches, shrink gastric ulcers, and reduce back pain
ditions, and psychiatric conditions with physical symptoms This shift in the diseases to be treated calls for a new medicine, which is more holistic in approach and more integrative in its methods James Gordons work has identified a number of pillars of this new medicine: He calls for the new medicine to: 1 respect the patients uniqueness, 2 adopt a holistic approach, 3 utilize a healing partnership between healer and patient, 4 empower and educate the patient to engage in self-care, 5 draw on the power of group support, 6 borrow techniques and approaches from healing systems, other than Western biomedicine 7 draw on the patients spiritual resources for healing and transformation
References
Achterberg, J 1985 Imagery in healing:Shamanism and modern
medicine Boston: Shambhala/New Science Achterberg, J 1994 Rituals of healing: Using imagery for health and wellness NY: Bantam Books Ader, R, Weiner, H, Baum, A Eds 1988 Experimental foundations of behavioral medicine: Conditioning approaches pp 47-66 New Jersey: Lawrence Earlbaum Associates Blumenthal, J A, Jiang, W, Babyak, MA, Krantz, DS, Frid, D J, Coleman, R E, Waugh, R, Hanson, M, Appelbaum, M, OConnor, C, Morris, J J 1997 Stress management and exercise training in cardiac patients with myocardial ischemia Effects on prognosis and evaluation of mechanisms Archives of Internal Medicine, 157 19, 2213-23 Boss, M 1975 Grundriss der Medizin und der Psychologie Foundations of medicine and psychology Bern, Switzerland: Verlag Hans Huber Breuer, W C 2000 The use of hypnosis in a primary care setting CRNA: The Clinical Forum for Nurse Anesthetists, 11 4, 186-9 Brigham, D D 1994 Imagery for getting well: Clinical applications of behavioral medicine NY: W W Norton Burrow, G, Stanley, R,
Bloom, P Eds, 2001 International handbook of clinical hypnosis Wiley Sons Dossey, L 1993 Healing words: The power of prayer and the practice of medicine San Francisco: HarperSanFrancisco Dossey, L 1999 Reinventing medicine: Beyond mind-body to a new era of healing NY: HarperSanFrancisco Eisenberg, DM, Davis, RB, Ettner, S, Appel, S, Wilkey, S, Van Rompay, M, Kessler, RC 1998 Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey Journal of the American Medical Association, 280, 1569-1575
Conclusion
The illnesses and conditions which bring patients into the medical clinic today are most often related to lifestyle, nutrition, and stress Todays patients typically present with somatization disorders, functional illnesses, stress related disorders, chronic con-
Eisenberg, DM, Kessler, RC, Foster, C, Norlock, F E, Calkins, D R, Delbanco, T L 1993 Unconventional Medicine in the United States: Prevalence, costs and patterns of use, New
England Journal of Medicine, 328, 246-52 Gaudet, T 1998 Integrative Medicine: The evolution of a new approach to medicine and to medical education Integrative Medicine, 1, 67-73 Gordon, J S 1996 Manifesto for a new medicine: Your guide to healing partnerships and the wise use of alternative therapies Reading, MA: AddisonWesley Gordon, J S, Curtin, S 2000 Comprehensive cancer care: Integrating alternative, complementary and conventional therapies Cambridge, MA: Perseus Gordon, J S 2003, March Mind-body medicine and the future of health care Keynote address to the Association for Applied Psychophysiology and Biofeedback, Jacksonville, Florida Guadagnoli, E, Ward, P 1998 Patient participation in decision-making Social Science Medicine, 47 3, 329-339 Kirsch, I, Capafons, A, Cardena-Buelna, S 1999 Clinical hypnosis and self-regulation: Cognitive-behavioral perspectives Washington, DC: American Psychological Association Koenig, H G, McCullough, M E, Larson, D B 2001 Handbook of religion
and health NY: Oxford University Press Krauss, HH, Godfrey, C, Kirk, J, Eisenberg, DM 1998 Alternative health care: its use by individuals with physical disabilities Archives of Physical Medicine and Rehabilitation, 79 11, 1440-7 Krippner, S 2003 Spirituality and healing In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind body medicine for primary care pp 191-201 Thousand Oaks, CA: Sage Lake, J 2003 Complementary, alternative, and integrative medicine In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind body medicine for primary care pp 57-68 Thousand Oaks, CA: Sage McGrady, A, Bourey, R, Bailey, B 2003 The metabolic syndrome: Obesity, type 2 diabetes, hypertension, and hyperlipidemia In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind body medicine for primary care pp 275-297 Thousand Oaks, CA: Sage Moss, D, and Shane, P 1998 Body therapies in humanistic psychology In D Moss Ed, Humanistic and transpersonal psychology: A
historical and biographical sourcebook pp 85-94 Westport, CT: Greenwood Press Moss, D 2001 Biofeedback In S Shannon Ed, Handbook of complementary and alternative therapies in mental health San Diego, CA: Academic Press Moss, D 2002 Presidential address: The circle of the soul: The role of spirituality in health care Applied Psychophysiology and Biofeedback, 27 4, 273-287
Continued on page 19
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From the Editor
continued from Page 2 grating behavioral interventions, CAM, mind-body medicine, and traditional medical therapeutics, in one system Today, patients shuttle back and forth among primary care physicians, CAM practitioners, behavioral practitioners, and health food stores, attempting to craft their own personal response to illness Further, they often dont trust their primary care physician enough to disclose the alternative therapies they are using, which risks adverse interactions among herbal supplements and mainstream medications Eisenberg, et al,
1998 Or worse yet, effective behavioral and CAM interventions often come into play only after the patients condition has become chronic and resistant to intervention As health professionals, we owe it to patients to design integrative health care systems which offer the best documented therapies from day one of treatment Moss, 2003 CAM Articles in this Special Issue This special issue is packed with an interesting selection of articles illustrating the potential contributions of biofeedback and neurofeedback to CAM and integrative medicine Sebastian Striefel highlights some of the special ethical challenges facing CAM practitioners By definition, therapies outside the mainstream can be more vulnerable for patient complaints James Gordon has allowed Biofeedback Magazine editor Don Moss to adapt and expand Dr Gordons March 2003 keynote on the future of health care into an article highlighting a new paradigm for health care Adam Burke presents a demographic overview of current CAM users,
and identifies strategies for promoting biofeedback and advancing its integration both into mainstream primary care and into the practice of integrative medicine Jessica Depozo and Richard Gevirtz introduce current applications of heart rate variability HRV biofeedback to heart disease, and in a second article Dr Gevirtz reviews a wider variety of promising new applications of HRV biofeedback to medical disorders Erik Peper and Katherine Gibney present a fascinating approach to womens health problems, using biofeedback and respiration training to assist women to self-regulate
both menopausal hot flashes and premenstrual mood swings They build on the earlier research of Robert Freedman and Suzanne Woodward James Lake and Don Moss review emerging applications of neurofeedback and QEEG to psychiatric and neurological issues; they argue that neurofeedback is a genuine complementary therapy Feature Articles David Siever continues his special series on audio-visual entrainment AVE; his
second article features dental applications of AVE Gabe Sella contributes an article on SEMG testing and treatments for disorders of the shoulder AAPB News and Events Section Finally, AAPB President Lynda Kirk, President-Elect Steve Baskin, and Executive Director Francine Butler offer their current perspectives on events shaping professional research and practice today In addition, readers will find information about the March AAPB meeting in Colorado Springs, Colorado Proposals and Abstracts are now invited for two special issues of the Biofeedback Magazine: Case Studies in Clinical Psychophysiology for Spring 2004, and Integrating Life Style Change into Applied Psychophysiological Therapies for Fall 2004
The editor also welcomes proposals for future special issues of the Biofeedback Magazine
References:
Burke, A 2003 Biofeedback and the CAM consumer Biofeedback Magazine, 31 3 Eisenberg, DM, Davis, RB, Ettner, SL, Appel, S, Wilkey, S, Van Rompany, M, Kessler, RC 1998 Trends in
alternative medicine use in the United States, 1990-1997: Results of a followup national survey Journal of the American Medical Association, 280, 1569-1575 Gordon, J S, Moss, D 2003 Manifesto for a new medicine Biofeedback Magazine, 31 3 Koenig, H G 2000 Religion, spirituality, and medicine: Application to clinical practice, Journal of the American Medical Association, 284 13, 1708 Lake, J 2003 Lake, J 2003 Complementary, alternative, and integrative medicine In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind body medicine for primary care pp 57-68 Thousand Oaks, CA: Sage Moss, D 2002 Presidential address: The circle of the soul: The role of spirituality in health care Applied Psychophysiology and Biofeedback, 27 4, 273-287 Moss, D 2003a Mind-body medicine, evidence-based medicine, clinical psychophysiology, and integrative medicine In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind body medicine for primary care pp 3-18 Thousand Oaks, CA:
Sage Moreno, J D 2002 Gaging ethics In S J Marcus Ed, Neuroethics: Mapping the Field pp 34-60 New York: The Dana Press Safire, W 2002 Visions for a new field of Neuroethics In S J Marcus Ed, Neuroethics: Mapping the Field pp 2-9 New York: The Dana Press Shadish, W R, Matt, G E, Navarro, A M, Phillips, G 2000 The effects of psychological therapies in clinically representative conditions: A meta-analysis Psychological Bulletin, 126, 512-529 Shapiro, E L, Ginzberg, R 2003 To accept or not accept referrals and the maintenance of boundaries Professional Psychology, 343, 258-263 Smith, D 2003 Psychologists discuss developing corporate ethics Monitor in Psychology, 345, 18 Smith, M L, Glass, G V 1977 Metaanalysis of psychotherapy outcome studies American Psychologist, 32, 752-760 Wampold, B E 2001 The great psychotherapy debate: Models, methods, and findings Mahwah, NJ: Erlbaum Wampold, B E, Mondin, G W, Moody, M, Stich, F, Benson, K, Ahn, H 1997 A metaanalysis of outcome studies
comparing bona fide psychotherapies: Empirically, All must have prizes Psychological Bulletin, 122, 203-215 Wickramasekera, I 1999 The faith factor, the placebo, and AAPB Biofeedback, 271, 1A-3A 3
Ethical Behavior and Other Issues
continued from Page 7
Elkin, I 1994 The NIMH treatment of depression collaboration research program: Where we began and where we are In A E Bergin S L Garfield Eds, Handbook of psychotherapy and behavior change 4th ed, pp 114-139 New York: Wiley Fahrion, S 1998 Neurofeedback, states of consciousness and personal transformation Presented at the 10th International Conference on The Psychology of Health, Immunity and Disease at Hilton Head Island, South Carolina Garfield, S L 1992 Eclectic psychotherapy: A common factors approach In J C Norcross M R Goldfried Eds, Handbook of psychotherapy integration pp 169-201 New York: Basic Books Garfield, S L 1998 Some comments of empirically supported treatments Journal of Consulting and Clinical Psychology, 66, 121-125
Hyman, S 2002a Questions and answers In S J Marcus Ed, Neuroethics: Mapping the Field pp 167-191 New York: The Dana Press Hyman, S 2002b Ethical issues is pharmacology: Research and practices In S J Marcus Ed, Neuroethics: Mapping the Field pp 135-143 New York: The Dana Press
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COMPLEMENTARY AND ALTERNATIVE MEDICINE AND INTEGRATIVE MEDICINE
Biofeedback and the CAM Consumer
Adam Burke, PhD, MPH, LAc, San Francisco, Californiai
Abstract: A dramatic growth of complementary and alternative medicine CAM is occurring in the US, including significant increases in utilization and in expenditures for professional services Three demographic categories are associated with use of CAM: being from a culture where traditional medicine is common; having a chronic, complex or serious health problem; or possessing alternative lifestyle values Biofeedback is in an excellent position to contribute to this national movement as one of the better researched mindbody therapies
Strategies for successful integration are proposed examines the role of biofeedback in this healthcare, self-care revolution
Adam Burke, PhD, MPH, LAc
What is CAM?
In 1998 the National Center for Complementary and Alternative Medicine NCCAM was established by the NIH in response to the increasing role of CAM in healthcare This new institute, an outgrowth of the earlier Office of Alternative Medicine, was created to research alternative medicine and to evaluate its effectiveness and safety The Centers operating budget for fiscal year 2002 was 105 million, up from 2 million in 1993 NCCAM 2002b defines CAM as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine In an effort to organize the myriad methods that fall within this broad definition NCCAM established five categories of CAM resources: 1 alternative medical systems; 2 mind-body interventions; 3 biologically-based treatments; 4
manipulative and body-based methods; and 5 energy therapies Biofeedback is considered to be one of the mind-body interventions
and possessing alternative lifestyle values, or experiencing dissatisfaction or conflict with conventional western treatments
1 Cultural Backgrounds that Include Traditional Medicine
The term CAM denotes that conventional western medicine is primary and that other traditional medical systems are secondary Such language is actually inappropriate for many communities These so called complementary or alternative approaches can be the most culturally relevant medicine for some people, and as such they play a significant role in service delivery Becerra Iglehart, 1995 At times these traditional medicines may even be the patients primary care for reasons of linguistic isolation, availability and affordability Indeed, conventional western medicine may truly be the alternative form in such cases Traditional medicine is still a significant component of healthcare in
many ethnic communities in the US Biofeedback, however, is not historically a part of those medical traditions Consequently this cohort of CAM consumers may either be a population that is difficult to access or one that provides a great undeveloped service opportunity
The CAM Revolution
The US is witnessing dramatic growth in the use of complimentary and alternative medicine CAM For several decades interest in alternative health practices and products has been increasing Alternative medical systems, such as oriental medicine, have also become more widely accepted Between 1991 and 1997 total visits to alternative providers grew from 427 million to 629 million Expenditures for these professional services also increased 45, with 21 billion spent in 1997, 12 billion of that being out-of-pocket Eisenberg et al, 1998 This development of CAM is the result of converging social and economic forces including patient dissatisfaction with drug side-effects, invasive treatments and impersonal
institutional care It is also driven by the needs of individuals facing complex, chronic health problems that are not always responsive to conventional western medical care Burke, 2001; Eisenberg et al, 1998; Flaherty et al 2001 This paper
What is Biofeedbacks Role in CAM?
National surveys indicate that CAM utilization is common, but varies across demographic segments Three unique factors potentially affect utilization: 1 being from a culture where some form of traditional medicine was practiced; 2 having a chronic, complex or serious health problem; 3
2 Chronic, Complex and Serious Health Problems
Chronic pain is highly associated with CAM use One study observed highest use among pain patients with severe pain, osteoarthritis and fibromyalgia Ineffectiveness of prescription medications was also reported as a significant reason for use by almost half of those respondents
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Rao, Mihaliak Kroenke, 1999 CAM treatments for pain conditions include mind-body
therapies, acupuncture and manipulative therapies Berman Swyers, 1997; Wright Sluka, 2001 CAM use is also high among individuals managing complex health problems, such as fibromyalgia syndrome FMS FMS affects an estimated 6-10 million Americans Wolfe et al, 1995 and is considered to be one of the most clinically and economically costly chronic pain syndromes White et al, 1999 No successful western medical treatment for FMS currently exists and prognosis is generally poor Kennedy Felson, 1996; Ledingham, Doherty Doherty, 1993 Alternative therapies offer treatment options for such patients, with evidence of some utility for exercise, relaxation, CBT and acupuncture Berman Swyers, 1999; Sim Adams, 1999, 2002 New studies exploring biofeedback treatment for FMS are showing promise Buckelew, Conway, Parker, Deuser, Read, Witty, Hewett, et al, 1998, and a team led by Donaldson reports alleviation of both pain and cognitive deficits accompanying fibromyalgia through a combination of
biofeedback and neurofeedback Donaldson, Sella, Mueller, 1998; Donaldson Sella, 2003 Finally, CAM use is high among individuals dealing with the side-effects of western medicine used to treat serious health problems, such as AIDS and cancer, or those just seeking additional support for such illnesses One large national CAM survey conducted with HIV positive men and women reported use of 1,600 different types of CAM therapies, substances and providers The most commonly used CAM providers were massage therapists 49, acupuncturists 45, nutritionists 37 and psychotherapists 35 Standish et al, 2001 Cancer patients similarly report high use ranging from 6-64 for all cancers generally, and 67-83 for breast cancer specifically Bernstein Grasso, 2001; Ernst Cassileth, 1998; Richardson, Sanders, Palmer, Greisinger, Singletary, 2000 Biofeedback may be a very important modality for people dealing with chronic, complex and serious health problems Biofeedback has been shown to be useful in the
treatment of AIDS symptoms
Haythornthwaite Benrud-Larson, 2001, cancer Floratos et al, 2002 and with many types of chronic pain conditions, such as headache Penzien, Rains Andrasik, 2002 This is a logical population segment for biofeedback practitioners to work with either independently or within integrative healthcare settings
Opportunities and Challenges
CAM is growing, and with our aging population and continually challenging health problems, the demand for CAM will continue Biofeedback is in a good position to contribute to this revolution, being one of the more well-recognized and wellresearched mind-body therapies To this end it may be prudent for biofeedback practitioners and biofeedback organizations to develop strategies to advance the profession through the following means: 1 Advocate for NIH grant sponsorship of more well-funded, randomized, clinical controlled studies in several appropriate areas NCCAM has funded just one study on biofeedback and hypertension NCCAM,
2002a; 2 Integrative medicine is growing, partly as a function of the CAM movement It would be productive to increase biofeedbacks role in primary care settings generally and in integrative medical practices specifically; 3 Develop a focused research agenda on CAM-relevant health issues including complex, chronic conditions like FMS, Irritable Bowel Syndrome and AIDS; 4 In an era of increasingly cost conscious healthcare future biofeedback research should include outcome measures on cost and cost containment, changes in utilization, patient satisfaction, and disease prevention and self-care when possible; 5 The majority of medical school programs in the US now offer CAM courses in their curriculum, as do several nursing and public health programs Bhattacharya, 2000; Burke, Gordon Bhattacharya, 2001 Palsson and Davies 2003 report an innovative program exposing medical students personally to biofeedback and mindbody learning It would benefit the profession in the long-term if we
informed future healthcare providers more effectively about biofeedbacks important place in the healing process
3 Alternative Values, Dissatisfaction, Conflicts with Conventional Treatment
Alternative values have been posited as another reason for the use of alternative medicine Astin, 1998 Demographers Ray and Anderson 2000 estimated that 50 million Americans can be characterized as having alternative lifestyle values and that these individuals are more committed to alternative health practices They are attracted to social justice, feminism, environmentalism, Eastern spirituality and natural healing CAM use is high for this cohort Dissatisfaction with conventional therapies has also been proposed as another motive for CAM use Burke, 2001; Chandola, Young, McAlister, Axford, 1999; Nayak, Matheis, Agostinelli, Shifleft, 2001; Shumay, Maskarinec, Kakai, Gotay, 2001 Finally, conflicts with conventional western treatments can also motivate individuals to seek alternative forms of care
For example, pharmacological treatments for high blood pressure, such as beta-blockers, can produce fatigue, sexual dysfunction and other problems Biofeedback may be an appropriate option for individuals motivated by alternative values, dissatisfaction with conventional care, or experiencing treatment conflicts Biofeedback gained public notoriety in the 1970s as a vehicle for consciousness exploration and research Schwartz Olson, 1995 As such, it is a culturally congruent therapy for alternatively-oriented individuals It may also be a compelling therapy for patients dissatisfied with conventional care, those who seek to avoid drug side-effects or invasive treatments, or those who want to increase their sense of personal control in the healing process
References
Astin, J 1998 Why patients use alternative medicine: results of a national study Journal of the American Medical Association, 279, 1548-1553
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Becerra, R, Iglehart, A Folk 1995 Medicine use:
diverse populations in a metropolitan area Social Work in Health Care, 21, 37-58 Berman, BM, Swyers, JP 1997 Establishing a research agenda for investigating alternative medical interventions for chronic pain Primary Care, 24, 743-58 Berman, BM, Swyers, JP 1999 Complementary medicine treatments for fibromyalgia syndrome Baillieres Best Practice Research in Clinical Rheumatology, 13, 487-492 Bernstein, BJ Grasso, T 2001 Prevalence of complementary and alternative medicine use in cancer patients Oncology, 15, 1267-1272, Bhattacharya, B 2000 MD programs in the United States with complementary and alternative medicine education opportunities: an ongoing listing Journal of Alternative and Complementary Medicine, 6, 77-90 Blumenthal, M 1999 The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines German Commission E Monographs Newton, MA: Integrative Medicine Communications Buckelew, SP, Conway, R, Parker, J, Deuser, WE, Read J, Witty TE, Hewett JE, Minor M,
Johnson JC, Van Male L, McIntosh MJ, Nigh M, Kay DR 1998 Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial Arthritis Care Research, 11, 196209 Burke, A, Gordon, R, Bhattacharya, B 2001 A preliminary examination of complementary and alternative medicine courses in graduate public health curricula Complementary Health Practice Review, 6, 165-171 Burke, A 2001 Alternative health care and customer service Complementary Health Practice Review, 7, 183 Chandola, A, Young, Y, McAlister, J Axford, J 1999 Use of complementary therapies by patients attending musculoskeletal clinics Journal of the Royal Society of Medicine, 92, 13-16, Donaldson, S, Sella, G, Mueller, H 1998 Fibromyalgia: A retrospective study of 252 consecutive referrals Canadian Journal of Clinical Medicine, 5 6, 116-127 Donaldson, S, Sella, G 2003 Fibromyalgia In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mindbody medicine for primary care pp 323-332
Thousands Oaks, CA: Sage Eisenberg, DM, Davis, RB, Ettner, SL, Appel, S, Wilkey, S, Van Rompany, M, Kessler, RC 1998 Trends in alternative medicine use in the United States, 1990-1997: Results of a followup national survey Journal of the American Medical Association, 280, 1569-1575 Ernst, E 2000 Complementary and alternative medicine in rheumatology Baillieres Best Practice Research Clinical Rheumatology, 14, 731-49 Ernst, E Cassileth, BR 1998 The prevalence of complementary/alternative medicine in cancer: a systematic review Cancer, 83, 777-782
Flaherty, JH, Takahashi, R, Teoh, J, Kim, JI, Habib, S, Ito, M, Matsushita, S 2001 Use of alternative therapies in older outpatients in the United States and Japan: prevalence, reporting patterns, and perceived effectiveness Journal of Gerontology, 56, 650-655 Floratos, DL, Sonke, GS, Rapidou, CA, Alivizatos, GJ, Deliveliotis, C, Constantinides, CA, Theodorou, C 2002 Biofeedback vs verbal feedback as learning tools for pelvic muscle
exercises in the early management of urinary incontinence after radical prostatectomy British Journal of Urology International, 89, 714-719 Haythornthwaite, JA, Benrud-Larson, LM 2001 Psychological assessment and treatment of patients with neuropathic pain Current Pain Headache Report, 5, 124-129 Huang, KC 1993 The Pharmacology of Chinese Herbs Boca Raton, FL: CRC Press Kennedy, M, Felson, DT 1996 A prospective long-term study of fibromyalgia syndrome Arthritis Rheumatology, 39, 682-685 Ledingham, J, Doherty, S, Doherty, M 1993 Primary fibromyalgia syndrome an outcome study British Journal of Rheumatology, 32, 139-142 NCCAM 2002a Hypertension: Prediction of Biofeedback Success URL: http://www clinicaltrialsgov/ct/gui/c/w2r/show/NCT00026065? order1JServSessionIdzone_ctrd02fm5sc1 NCCAM 2002b What is Complementary and Alternative Medicine? URL: http://nccamnihgov/health/whatiscam/1 Nayak, S, Matheis, R, Agostinelli, S Shifleft, S 2001 The use of complementary and alternative
therapies for chronic pain following spinal cord injury: a pilot survey Journal of Spinal Cord Medicine, 24, 54-62, Palsson, O S, Davies, M 2003 Medical education for mind-body medicine In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind-body medicine for primary care pp 443-448 Thousands Oaks, CA: Sage Penzien, DB, Rains, JC Andrasik, F 2002 Behavioral management of recurrent headache: three decades of experience and empiricism Applied Psychophysiology and Biofeedback, 27, 163-181 Philipp, M Kohnen, R, Hiller, KO 1999 Hypericum extract versus imipramime or placebo in patients with moderate depression: randomised multicentre study of treatment for eight weeks British Medical Journal, 319, 1534-1539 Rao, JK, Mihaliak, K, Kroenke, K, Bradley, J, Tierney, WM Weinberger, M 1999 Use of complementary therapies for arthritis among patients of rheumatologists Annals of Internal Medicine, 131, 409-416 Ray, P Anderson, SR 2000 The Cultural Creatives New York: Harmony
Books, Richardson, MA, Sanders, T, Palmer, JL, Greisinger, A, Singletary, SE 2000 Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology Journal of Clinical Oncology, 18, 25052514
Schwartz, M, Olson, RP 1995 A historical perspective on the field of biofeedback and applied psychophysiology In Schwartz, M ed Biofeedback a Practitioners Guide NewYork: Guilford Press Shumay, DM, Maskarinec, G, Kakai, H Gotay, CC 2001 Why some cancer patients choose complementary and alternative medicine instead of conventional treatment The Journal of Family Practice, 50, 1067 Sim, J, Adams, N 1999 Physical and other non-pharmacological interventions for fibromyalgia Baillieres Best Practice Research in Clinical Rheumatology, 13, 507-523 Sim, J, Adams, N 2002 Systematic review of randomized controlled trials of nonpharmacological interventions for fibromyalgia Clinical Journal of Pain, 18, 324-336 Standish, LJ, Greene, KB, Bain, S, Reeves, C,
Sanders, F, Wines, RC, Turet, P, Kim, JG Calabrese, C 2001 Alternative medicine use in HIV-positive men and women: demographics, utilization patterns and health status AIDS Care, 13, 197-208 White, KP, Speechley, M, Harth, M, Ostbye, T 1999 The London Fibromyalgia Epidemiology Study: direct health care costs of fibromyalgia syndrome in London, Canada Journal of Rheumatology, 26, 885-9 Wolfe, F, Ross, K, Anderson, J, Russell, IJ, Hebert, L 1995The prevalence and characteristics of fibromyalgia in the general population Arthritis Rheumatology, 38, 19-28 Wright, A Sluka, KA 2001 Nonpharmacological treatments for muculoskeltal pain Clinical Journal of Pain, 17, 33-46 Yucha, C 2002 Hypertension: Prediction of Biofeedback Success National Center for Complementary and Alternative Medicine NCCAM http://wwwclinicaltrialsgov/ct/gui/c/w2r/show/ NCT00026065?order1JServSessionIdzone_ctrd 02fm5sc1
Acknowledgements
This investigation was supported by a Research Infrastructure in Minority
Institutions award from the National Center for Research Resources with funding from the Office of Research on Minority Health, Nation Institutes of Health 5 P20 RR11805
iContact Information: Address all correspondence to Adam Burke, PhD, MPH, LAc, Institute for Holistic Healing Studies, San Francisco State University, 1600 Holloway Ave, San Francisco, CA 94132 Phone 415-338-1774, aburke@sfsuedu
Note
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COMPLEMENTARY AND ALTERNATIVE MEDICINE AND INTEGRATIVE MEDICINE
Complementary and Alternative Care for Heart Disease
Jessica Del Pozo, PhD, Miami, Florida, and Richard Gevirtz, PhD, San Diego, California
Abstract: Complimentary care for heart disease is an important area for research to prevent relapse and death, and increase quality of life Biofeedback is one treatment tool that may be useful for cardiac patients in several ways, but especially as it targets cardiac variability Cardiac variability, the moment-tomoment fluctuation in heart rate, measured in
milliseconds, is an important predictor of morbidity and mortality for cardiac patients Our study found that patients treated with cardiac variability biofeedback training were able to increase their overall cardiac variability compared to baseline and compared to controls
Jessica Del Pozo, PhD
Richard Gevirtz, PhD
vide more specific training of biological processes
Heart Rate Variability Biofeedback
One physiological measure that is gaining more widespread use in biofeedback is heart rate variability, or cardiac variability Cardiac variability is the moment-tomoment change in heart rate measured in milliseconds Task Force, 1996 This fluctuation reflects autonomic flexibility and adaptability Biological factors influencing cardiac variability are baroreceptor sensors in the carotid arteries and aorta, the sinoatrial node, and chemoreceptors In the 1960s, moment-to-moment heart rate fluctuations were observed in fetal distress Hon Lee, 1965 More recently, cardiac variability has
been found to correlate with a number of illnesses including depression, generalized anxiety disorder, post traumatic stress disorder, diabetes, asthma, cardiac-related illness It is actually a strong predictor of cardiac-related morbidity and mortality, as well as all-cause mortality Krittayaphong, et al, 1997; Yeragani, Balon, Pohl, Ramesh, 1995; Cohen, Kotler, Matar, Kaplan, 1997; Lyon-fields, Borkovec, Thayer, 1995; Kleiger, Miller, Bigger, Moss, 1987 Cardiac variability is gaining more widespread use as a measure of cardiac response and overall health Cardiac variability
Complementary and Alternative Care for Coronary Artery Disease
Patients and health professionals seek complementary care for cardiovascular disease in addition to traditional pharmacological treatments for cardiovascular disease Wetzel, Eisenberg, Kaptchuk, 1998; Wetzel, Kaptchuk, Haramati, Eisenberg, 2003 Not surprisingly, exercise, diet, and relaxation are commonly discussed as ways to prevent, control,
and reverse heart disease Dietary supplements such as fish oil and garlic have become more popular, and the Ornish diet has shown considerable efficacy in reversing coronary artery blockage Ornish, 1990 In addition, biofeedback has been used to assist relaxation and pro-
biofeedback has been used to train patients to increase their cardiac variability through respiratory sinus arrhythmia breathing retraining As we inhale, heart rate naturally increases, and as we exhale, heart rate naturally decreases This fluctuation is healthy Patients may be able to learn to increase the variability in their heart rate, with the potential to improve their health status and outcomes This is especially important for cardiac patients who often have extraordinarily low cardiac variability Several studies have attempted to change cardiac variability using biofeedback as a treatment intervention Leher, Vaschillo, Vaschillo, 2000; Reyes del Paso, Godoy, Vila, 1992; and Cowan, Kogan, Burr, Hendershot,
Buchanan, 1990 Recently, we randomized 61 patients with coronary artery disease from Scripps Center for Integrative Medicine and Scripps Green Hospital in La Jolla, California Half of them, the treatment group, received specific cardiac variability biofeedback training with diaphragmatic breathing retraining The other half, the control group, received regular care and no biofeedback All participants cardiac variability was measured at week 1, 6, and 18 on the CardioproTM developed by Thought Technology; Montreal, Canada Blood pressure was also measured at each of these sessions A follow-up visit was scheduled 18 weeks after the first treatment session
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The treatment groups received biofeedback treatment once a week for 45 minutes during weeks 1 through 6 Biofeedback treatment sessions consisted of breath retraining with an emphasis on abdominal breathing, as well as cardiac and respiratory feedback This was accomplished using a C2TM biofeedback system
developed by J J Engineering; Poulsbo, Washington and a 15-inch laptop computer Physiological feedback was monitored visually on the computer screen Participants were trained to practice breathing at their peak respiratory sinus arrhythmia, attempting to increase peak/valley amplitude of the heart rate signal Various color screens were displayed reflecting depth and frequency of respiration, heart rate, and cardiac variability A 3Dimensional screen showed heart rate frequencies and grouped them into high, low, or very low frequency ranges Each participant was given a weekly chart on which to log daily breathing practice, exercise, other stress management techniques, and any change in medications Participants were encouraged to practice abdominal breathing for at least 20 minutes per day, and received written material to help facilitate home practice With the breathing held constant, the treatment group significantly increased cardiac variability across the 18 weeks p0004, while the
control group did not This increase in cardiac variability for the treatment group may reflect an increase in parasympathetic function, an increase in sympathetic/parasympathetic balance, or improved baroreceptor sensitivity Although we have no clinical outcome data from this group, we are hopeful that these improvements will contribute to an improved homeostatic function that leads to improved morbidity and mortality rates for patients with coronary artery disease Our clinical results to date lead us to be optimistic that similar results will be obtained for other disease populations in the future, showing biofeedback to be an efficacious treatment to improve health outcomes for a variety of illnesses This study, in its entirety, has been submitted to a cardiology journal for publication Subjective symptom reports were also anonymously obtained from participants
Eight participants reported a reduction in angina, 17 reported a reduction in blood pressure, 12 reported an increase in
energy, 4 reported a decrease in chronic pain, and 1 reported irritable bowl symptoms improving Other reports included feeling more relaxed, more alert, less stressed, and able to do more A variety of heart patients may seek biofeedback for treatment to improve their current quality of life Some may wish to decrease hypertension, improve anger management, decrease Type A personality characteristics, or decrease their general anxiety or health-related issues It can be rewarding for them to learn to control various physiological functions available during biofeedback training It may be possible for some to lesson angina symptoms or reduce arrhythmias Other patients may feel palpitations that doctors have assured them are benign, yet the patients experience a lingering fear that something is wrong Biofeedback can help these people reduce anxiety and feel more in control Finally, some may have essential hypertension and have tried many traditional and alternative treatments to reduce it,
with no success Research shows mixed results for biofeedback treatment for hypertension, and it may not work for every case of hypertension JNC, 1997 However, a portion of these hypertensive individuals will obtain clinically significant reductions in blood pressure Again, biofeedback treatment may also reduce anxiety that compounds the problem of hypertension
References
Cohen, H, Kotler, M, Matar, M A, Kaplan, Z 1997 Power spectral analysis of heart rate variability in posttraumatic stress disorder patients Biological Psychiatry, 41 5, 627-629 Cowan, M J, Kogan, H, Burr, R, Hendershot, S, Buchanan, L 1990 Power spectral analysis of heart rate variability after biofeedback training Journal of Electrocardiology, 23, 85-93 Kleiger, RE, Miller, JP, Bigger, JT, Moss, AJ, the multicenter post-infarction research group 1987 Decreased heart rate variability and its association with increased mortality after acute myocardial infarction The American Journal of Cardiology, 59, 256-262
Krittayaphong, R, Cascio, W E, Light, K C, Sheffield, D, Golden, R N, Finkel, J B, Glekas, G, Koch, G G, Sheps, D S 1997 Heart rate variability in patients with coronary artery disease: differences in patients with higher and lower depression scores Psychosomatic Medicine, 59 3, 231-235 Lehrer, PM, Vaschillo, E, Vaschillo, B 2000 Resonant frequency biofeedback training to increase cardiac variability: rationale and manual for training Applied Psychophysiol Biofeedback, 25 3, 177-191 Lyonfields, J D, Borkovec, T D, Thayer, J F 1995 Vagal tone in generalized anxiety disorder and the effects of aversive imagery and worrisome thinking Behavior Therapy, 26 3, 457-466 Ornish, D 1990 Dean Ornishs program for reversing heart disease New York: Ballantine Books Reyes del Paso, GA, Godoy, J, Vila, J 1992 Self-regulation of respiratory sinus arrhythmia Biofeedback and self-regulation, 17 4, 261-275 Task Force of the European Society of Cardiology and the North American Society of Pacing and
Electrophysiology 1996 Special report: Heart rate variability standards of measurement, physiological interpretation, and clinical use Circulation, 93, 1043-1065 Wetzel, M S, Eisenberg, D M, Kaptchuk, T J 1998 Courses involving complementary and alternative medicine at US medical schools Journal of the American Medical Association, 280 9, 784787 Wetzel, M S, Kaptchuk, T J, Haramati, A, Eisenberg, D M 2003 Complementary and alternative medical therapies: implications for medical education Annals of Internal Medicine, 138 3, 191-196 Yergani, V K, Balon, R, Pohl, R, Ramesh, C 1995Depression and heart rate variability Biological Psychiatry, 38 11, 768-770
Conclusion
Biofeedback is a useful tool to integrate into traditional and supplementary cardiac rehabilitation It may be useful for overall reduction sympathetic activity related to anxiety and tension, but also for specific training to increase cardiac variability It is a non-invasive, takes relatively little effort, and provides
instant feedback for patients to check their progress during training
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COMPLEMENTARY AND ALTERNATIVE MEDICINE AND INTEGRATIVE MEDICINE
The Promise of HRV Biofeedback: Some Preliminary Results and Speculations
Richard Gevirtz, PhD, San Diego, CA
Abstract: Heart Rate Variability HRV is not only of interest as a powerful predictor of cardiac and other health outcomes, but can be used in a new and promising mode of biofeedback This article describes some recent promising applications in HRV biofeedback quently Paul Lehrer introduced us to a Russian physiologist named Evgeny Vaschillo who had worked out an elaborate theory of what happens in RSA biofeedback, which we now call HRV Biofeedback The theory is spelled out in other publications Gevirtz, 2000; Giardino, 2000; Lehrer, Vaschillo, Vaschillo, 2000; Vaschillo, Lehrer, Rishe, Konstantinov, 2002, but the core concept is as follows: Regular practice in increasing HRV, guided initially by biofeedback, can
produce strengthened homeostatic reflexes in the autonomic nervous system ANS By increasing HRV we mean that the subject learns to increase the amplitude of variations in heart rate The swings in heart rate during training are driven primarily by slow, effortless respiration According to Dr Vaschillos model, there is a natural resonant frequency for each individual, at which respiration and heart rate variations have an optimal effect on the autonomic self-regulation of the organism For most individuals this resonant frequency involves breathing at a rate of about six times per minute, with about six cycles of heart rate variation within the same time period If this model is correct, it identifies mediational pathways responsible for many mind/body and physical disorders Furthermore, if this model is correct the HRV Biofeedback then emerges as a very powerful tool for treatment
Richard Gevirtz, PhD
Some Applications
Thus far HRV biofeedback has been applied to the following
disorders: asthma Lehrer, Smetankin, Potapova, 2000, cardiac rehabilitation Del Pozo, 2002, IBS Gevirtz, 2000, sports Performance Strack, 2003, and hypertension Herbs, 1994 In each case 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 Paul Lehrer and his colleagues has shown that 68 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 and we may expect a published report fairly soon This work should be recognized
as one of the most convincing examples of biofeedbacks efficacy in the literature since a credible control group alpha EEG feedback produced no changes in disease status, medication usage, or symptom severity My student, Jessica Del Pozo recently completed a study with coronary artery dis-
Emerging Model of Heart Rate Variability Biofeedback
In recent years there has been increased interest in heart rate variability HRV In Cardiology, this interest has mostly involved methodological issues surrounding variability measures such as the standard deviation of normal to normal heart beats SDNN Some AAPB colleagues and I have also been interested in using HRV as a clinical biofeedback modality In 1993, Diane Herbs and I reported data comparing RSA biofeedback to temperature training with Hypertension RSA refers to Respiratory Sinus Arrhythmia, a phenomenon in which respiratory activity and heart rate changes enter a phasic relationship Each inspiration is accompanied by an increase in heart
rate, and each expiration is accompanied by a decrease in heart rate with some phase differences depending on the actual rate of breathing Both the finger temperature training group and the RSA group showed clinically significant reductions in BP At the time, we thought we were strengthening parasympathetic tone with the training, but subse-
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ease CAD patients using HRV biofeedback Sixty-one patients were randomly assigned to a self-monitor condition or an active training condition six 1-hour sessions The HRV training produced HRV increases at 18 weeks that indicated meaningful clinical cardiac status improvements As a side benefit, all of the CAD patients in the treatment group who were hypertensive pre-treatment, became normotensive at the 18 week follow-up Patients also found the HRV training relaxing and beneficial as a general stress coping tool In a different arena, my student Ben Strack recently applied HRV training to baseball batting performance in
skilled high school players He randomly assigned 61 subjects to either a standard visualization condition or to HRV training Both were incorporated into baseball pitching machine practice sessions While both groups improved on a batting performance contest pre to post, the HRV group had superior increases The successful subjects reported an improved sense of enjoyment/flow during the post-contest period Rollin McCraty of the HeartMath Institute has reported similar findings with corporate groups
order where autonomic regulation is thought to be important We have conducted successful clinical trials with patients suffering from Irritable Bowel Syndrome, Recurrent Abdominal Pain, Rheumatoid Arthritis, Migraine, Muscle Pain Syndromes, Fibromyalgia, and Chronic Fatigue Syndrome, Syncope, among other disorders
References
Del Pozo, J, Gevirtz, RN 2002 The effect of resonant frequency cardiac biofeedback training on heart rate variability in a cardiac rehabilitation population Applied
Psychophysiology and Biofeedback, 274, 311 Gevirtz, R 2000 Resonant frequency training to restore homeostasis for treatment of psychophysiological disorders Biofeedback, 27, 7-9 Giardino, A, Lehrer, P, Feldman, JM 2000 The role of oscillations in self-regulation: A revision of the classical model of homeostasis In J G C D Kenney, FJ McGuigan, JL Sheppard Ed, Stress and health: Research and clinical applications pp 27-52 Amsterdam: Harwood
Herbs, D, Gevirtz, RN, Jacobs, D 1994 The effect of heart rate pattern biofeedback for the treatment of essential hypertension Biofeedback and Self-regulation, 193, 281 Abstract Lehrer, P, Smetankin, A, Potapova, T 2000 Respiratory sinus arrhythmia biofeedback therapy for asthma: A report of 20 unmedicated pediatric cases using the Smetankin method Applied Psychophysiology and Biofeedback, 253, 193-200 Lehrer, P M, Vaschillo, E, Vaschillo, B 2000 Resonant frequency biofeedback training to increase cardiac variability: rationale and manual for
training Applied Psychophysiology and Biofeedback, 253, 177-191 Strack, B 2003 The effect of heart rate variability biofeedback on batting performance in baseball Unpublished Doctoral Dissertation, Alliant International University, San Diego Vaschillo, E, Lehrer, P, Rishe, N, Konstantinov, M 2002 Heart rate variability biofeedback as a method for assessing baroreflex function: a preliminary study of resonance in the cardiovascular system Applied Psychophysiology and Biofeedback, 271, 1-27
Manifesto for a New Medicine
continued from Page 11
Moss, D 2003a Mind-body medicine, evidence-based medicine, clinical psychophysiology, and integrative medicine In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind body medicine for primary care pp 3-18 Thousand Oaks, CA: Sage Moss, D 2003b Existential and spiritual dimensions of primary care: Healing the wounded soul In D Moss, A McGrady, T Davies, I Wickramaskera Eds, Handbook of mind-body medicine in primary care pp 477-488
Thousand Oaks, CA: Sage Moss, D, McGrady, A, Davies, T, Wickramaskera, I Eds, Handbook of mind-body medicine in primary care Thousand Oaks, CA: Sage National Center for Complementary and Alternative Medicine NCCAM 2002, July About clinical trials and complementary and alternative medicine NCCAM Publication No D162 Online version, retrieved July 8, 2003, NCCAM website http://nccamnihgov/clinicaltrials/factsheet/ indexhtmnote1 Richardson, M A, Sanders, T, Palmer, J L, Greisinger, A, Singletary, S E 2000 Complementary/alternative medicine use in a comprehensive cancer center and the implications for oncology Journal of Clinical Oncology, 18 13, 2505-14 Rhue, J W, Lynn, S J, Kirsch, I Eds 1993 Handbook of clinical hypnosis American Psychological Association: Washington, DC Schwartz, M, Andrasik, F 2003 Biofeedback: A practitioners guide third edition NY: Guilford Spiegel, B 2000 Exploring the use of hypnosis in surgery Alternative Therapies in Health and Medicine, 6 4, 21-2 Standish,
LJ, Greene, KB, Bain, S, Reeves, C, Sanders, F, Wines, RC, Turet, P, Kim, JG Calabrese, C 2001 Alternative medicine use in HIV-positive men and women: demographics, utilization patterns and health status AIDS Care, 13, 197-208 Smuts, J C 1926 Holism and evolution NY: McMillan Stein, E 2003 Acupuncture In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind body medicine for primary care pp 181-189 Thousand Oaks, CA: Sage Sugarman, L L 1996 Hypnosis in a primary care practice: developing skills for the new morbidities Journal of Developmental and Behavioral Pediatrics, 17 5, 300-5 Trossman, S 1998 Holistic nursing: The goal is the whole person The American Nurse, 30 5, 11 Williams, R J 1980 Biochemical individuality Austin, TX: University of Texas Press Yalom, I D 1985 The theory and practice of group psychotherapy, 3rd edition NY: Basic Books
Conclusion
If HRV training does in fact affect homeostatic reflexes as the preliminary reports have indicated, it would appear
to be a promising procedure for normalization or optimization of autonomic function This would offer hope for improved performance in many contexts and correction of any dis-
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COMPLEMENTARY AND ALTERNATIVE MEDICINE AND INTEGRATIVE MEDICINE
Taking Control: Strategies to Reduce Hot Flashes and Premenstrual Mood Swingsi
Erik Peper, PhD, and Katherine H Gibneyii San Francisco State University
Erik Peper, PhD
Katherine H Gibney
After the first week to my astonishment, I have fewer hot flashes and they bother me less Each time I feel the warmth coming, I breathe out slowly and gently To my surprise they are less intense and are much less frequent I keep breathing slowly throughout the day This is
quite a surprise because I was referred for biofeedback training because of headaches that occurred after getting a large electrical shock After 5 sessions my headaches have decreased and I can control them, and my hot flashes have decreased from 3-4 per day to 1-2 per week 50 year old client For the first time in years, I experienced control over my premenstrual mood swings Each time I could feel myself reacting, I relaxed, did my autogenic training and breathing I exhaled It brought me back to center and calmness 26 year old student
breathing, relaxation, and respiratory sinus arrhythmia Successful symptom reduction is contingent upon lowering sympathetic arousal utilizing slow breathing in response to stressors and somatic changes We recommend that effortless diaphragmatic breathing be taught as the first step to reduce hot flashes and PMS symptoms
no evidence of increased quality of life improvements general health, vitality, mental health, depressive symptoms, or sexual
satisfaction as claimed for HRT Hays et al, 2003
As a result of recent studies, we know that hormone therapy should not be used to prevent heart disease These studies also report an increased risk of heart attack, stroke, breast cancer, blood clots, and dementia Wyeth Pharmaceuticals 2003iii
A Long and Uncomfortable History
Women have been troubled by hot flashes and premenstrual syndrome for ages Hot flashes often result in red faces, sweating bodies, and noticeable and embarrassing discomfort They come in the middle of meetings, in the middle of the night, and in the middle of romantic interludes Premenstrual syndrome also arrives without notice, bringing such symptoms as severe mood swings, anger, crying, and depression Hormone replacement therapy HRT was the most common treatment for hot flashes for decades However, recent randomized controlled trials show that the benefits of HRT are less than previously thought and the risks–especially of invasive breast cancer, coronary artery
disease, dementia, stroke and venous thromboembolism–are greater Humphries Gill, 2003; Shumaker, et al, 2003; WassertheilSmoller, et al, 2003 In addition, there is
Abstract: Women have been troubled by hot flashes and premenstrual syndrome throughout the ages Hormone replacement therapy, historically the most common treatment for hot flashes, and other pharmacological approaches for pre-menstrual syndrome PMS appear now to be harmful and may not produce significant benefits This paper reports on a model treatment approach based upon the early research of Freedman and Woodward to reduce hot flashes and PMS using biofeedback training of diaphragmatic
Because of the increased long-term risk and lack of benefit, many physicians are weaning women off HRT at a time when the largest population of maturing women in history baby boomers is entering menopausal years The desire to find a reliable remedy for hot flashes is on the front burner of many researchers minds, not to mention the minds
of women suffering from these uncontrollable power surges Yet, many women are becoming increasingly leery of the view that menopause is an illness There is a rising demand to find a natural remedy for this natural stage in womens health and development For younger women a similar dilemma occurs when they seek treatment of discomfort associated with their menstrual cycle Is premenstrual syndrome PMS just a natural variation in energy and mood levels? Or, are women expected to adapt to a mascu-
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line based environment that requires them to override the natural tendency to perform in rhythm with their own psychophysiological states? Instead of perceiving menstruation as a natural occurrence in which one has different moods and/or energy levels, women in our society are required to perform at the status quo, which may contribute to PMS The feelings and mood changes are quickly labeled as pathology that can only be treated with medication Traditionally,
premenstrual syndrome is treated with pharmaceuticals, such as birth control pills or Danazol Although medications may alleviate some symptoms, many women experience unpleasant side effects, such as bloating or acne, and still experience a variety of PMS symptoms Many cannot tolerate the medications Thus, millions of women and families suffer monthly bouts of uncontrollable PMS symptoms For both hot flashes and PMS the biomedical model tends to frame the symptoms as a structural biological problem Namely, the pathology occurs because the body is either lacking in, or has an excess of, some hormone All that needs to be done is either augment or suppress hormones/symptoms with some form of drug Recently, for example, medicine has turned to antidepressant medications to address menopausal hot flashes Stearns, Beebe, Iyengar, Dube, 2003 The biomedical model, however, is only one perspective The opposite perspective is that the dysfunction occurs because of how we use ourselves Use in this
sense means our thoughts, emotions and body patterns As we use ourselves, we change our physiology and, thereby, may affect and slowly change the predisposing and maintaining factors that contribute to our dysfunction By changing our use, we may reduce the constraints that limit the expression of the self-healing potential that is intrinsic in each person The intrinsic power of self-healing is easily observed when we cut our finger Without the individual having to do anything, the small cut bleeds, clotting begin and tissue healing is activated Obviously, we can interfere with the healing process, such as when we scrape the scab, rub dirt in
the wound, reduce blood flow to the tissue or feel anxious or afraid Conversely, cleaning the wound, increasing blood flow to the area, and feeling safe and relaxed can promote healing Healing is a dynamic process in which both structure and use continuously affect each other It is highly likely that menopausal hot flashes and PMS mood swings are
equally an interaction of the biological structure hormone levels and the use factor sympathetic/parasympathetic activation
Uncontrollable or Overly Aroused?
Are the hot flashes and PMS mood swings really uncontrollable? From a physiological perspective, hot flashes are increased by sympathetic arousal When the sympathetic system is activated, whether by medication or by emotions, hot flashes increase and similarly, when sympathetic activity decreases hot flashes decrease Equally, PMS, with its strong mood swings, is aggravated by sympathetic arousal There are many self-management approaches that can be mastered to change and reduce sympathetic arousal, such as breathing, meditation, behavioral cognitive therapy, and relaxation Breathing patterns are closely associated with hot flashes During sleep, a sigh generally occurs one minute before a hot flash as reported by Freedman and Woodward 1992 Women who habitually breathe thoracically in the chest report much more discomfort and hot
flashes than women who habitually breathe diaphragmatically Freedman, Woodward, Brown, Javaid, and Pandey 1995 and Freedman and Woodward 1992 found that hot flash rates during menopause decreased in women who practiced slower breathing for two weeks In their studies, the control groups received alpha electroencephalographic feedback and did not benefit from a reduction of hot flashes Those who received training in paced breathing reduced the frequency of their hot flashes by 50 when they practiced slower breathing This data suggest that the slower breathing has a significant effect on the sympathetic and parasympathetic balance Women with PMS appear similarly able to reduce their discomfort An early study
utilizing Autogenic Training AT combined with an emphasis on warming the lower abdomen resulted in women noting improvement in dysfunctional bleeding Luthe Schultz, 1969, pp 144-148 Using a similar approach, Mathew, Claghorn, Largen, and Dobbins 1979 and Dewit 1981 found that
biofeedback temperature training was helpful in reducing PMS symptoms A later study by Goodale, Domar, and Benson 1990 found that women with severe PMS symptoms who practiced the relaxation response reported a 58 improvement in overall symptomatology as compared to a 272 improvement for the reading control group and a 170 improvement for the charting group
Teaching Control and Achieving Results
Teaching women to breathe effortlessly can lead to positive results and an enhanced sense of control By effortless breathing, the authors refer to their approach to breath training, which involves a slow, comfortable respiration, larger volume of air exchange, and a reliance upon action of the muscles of the diaphragm rather than the chest Peper, 1990 Slowing breathing helps to limit the sighs common to rapid thoracic breathing–sighs that often precede menopausal hot flashes Effortless breathing is associated with stress reduction–stress and mood swings are common concerns of women suffering
from PMS In a pilot study Bier, Kazarian, Peper, and Gibney 2003 at San Francisco State University SFSU observed that when the subject practiced diaphragmatic breathing throughout the month, combined with Autogenic Training, her premenstrual psychological symptoms anger, depressed mood, crying and premenstrual responses to stressors were significantly reduced as shown in Figure 1 In another pilot study at SFSU, Frobish, Peper, and Gibney 2003 trained a volunteer who suffered from frequent hot flashes to breathe diaphragmatically The training goals included modifying breathing patterns, producing a Respiratory Sinus Arrhythmia RSA, and peripheral hand warming RSA refers to a pattern of slow, regular breathing during which variations in heart rate enter into a synchrony with the
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reduction in symptoms Habitual rapid thoracic breathing tends to increase arousal while slower breathing, especially slower exhalation, tends to relax and reduce arousal Learning and
then applying effortless breathing reduces excessive sympathetic arousal It also interrupts the cycle of cognitive activation, anxiety, and somatic arousal The anticipation and frustration at having hot flashes becomes the cue to shift attention and breathe slower and lower This process stops the cognitively mediated self-activation Successful self-regulation and the return to health begin with cognitive reframing: We are not only a genetic biological fixed deficient structure but also a dynamic changing system in which all parts thoughts, emotions, behavior, diet, stress, and physiology affect and are effected by each other Within this dynamic changing system, there is an opportunity to implement and practice behaviors and life patterns that promote health
Figure 1 Students Individual Subjective Rating in Response to PMS Symptoms
Learning Diaphragmatic Breathing with and without Biofeedback
Although there are many strategies to modify respiration, biofeedback monitoring combined with
respiration training is very useful as it provides real-time feedback Chest and abdominal movement are recorded with strain gauges and heart rate can be monitored either by an electrocardiogram EKG or by a photoplethysmograph sensor on a finger or thumb Peripheral temperature and electrodermal activity EDA biofeedback are also helpful in training The training focuses on teaching effortless diaphragmatic breathing and encouraging the participant to practice many times during the day, especially when becoming aware of the first sensations of discomfort Learning and integrating effortless diaphragmatic breathingiv into daily life is one of the biofeedback strategies that has been successfully used as a primary or adjunctive/ complementary tool for the reversal of disorders such as hypertension, migraine headaches, repetitive strain injury, pain, asthma and anxiety Schwartz Andrasik, 2003, as well as hot flashes and PMS The biofeedback monitoring provides the trainer with a valuable tool
to: 1 Observe identify: Dysfunctional rapid thoracic breathing patterns, especially in response to stressors, are clearly displayed in real-time feedback 2 Demonstrate train: The physiological feedback display helps the person see that she is breathing rapidly and shallowly in her chest with episodic sighs Coaching with feedback helps her to change her breathing pattern to one that promotes a more balanced homeostasis 3 Motivate, persuade and change beliefs: The person observes her breathing patterns change concurrently with a felt shift in physiology, such as a decrease in irritability, or an increase in peripheral temperature, or a reduction in the incidence of hot flushes Thus, she has a confirmation of the importance of breathing diaphragmatically In addition, we suggest exercises that integrate verbal and kinesthetic instructions, such as the following: Exhale gently, and Breathe down your legs with a partner
respiration Each inspiration is accompanied by an increase in heart
rate, and each expiration is accompanied by a decrease in heart rate with some phase differences depending on the rate of breathing The presence of the RSA pattern is an indication of optimal balance between sympathetic and parasympathetic nervous activity During the 11-day study period, the subject charted the occurrence of hot flashes and noted a significant decrease by day 5 However, on the evening of day 7 she sprained her ankle and experienced a dramatic increase in hot flashes on day 8 Once the subject recognized her stress response, she focused more on breathing and was able to reduce the flashes as shown in Figure 2 Our clinical experience confirms the SFSU pilot studies and the previously referenced research by Freedman and Woodward 1992 and Freedman et al 1995 When arousal is lowered and breathing is effortless, women are better able to cope with stress and report a
Figure 2 Subjective Rating of Intensity, Frequency and Bothersomeness of Hot Flashes The increase in hot
flashes coincided with increased frustration about an ankle injury
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Session 1: Physiological assessment Observe the rapid breathing during relaxation
Session 5 Note the slower breathing with in-phase RSA and pulse amplitude
Figure 3 Physiological Recordings of a Participant with PMS This subject learned effortless diaphragmatic breathing by the fifth session and experienced a significant decrease in symptoms
Learning Strategies in Biofeedback Assisted Breath Training
Common learning strategies that are associated with the more successful amelioration of hot flashes and PMS include: 1 Master effortless diaphragmatic breathing, and concurrently increase respiratory sinus arrhythmia RSA Instead of breathing rapidly, such as at 18 breaths per minute, the person learns
to breathe effortlessly and slowly about 6 to 8 breaths per minute This slower breathing and increased RSA is an indication of sympatheticparasympathetic balance as shown in Figure 3 2
Practice slow effortless diaphragmatic breathing many times during the day and, especially in response to stressors 3 Use the physical or emotional sensa-
Breathe Down Your Legs with a Partner:
Sit or lie comfortably with your feet a shoulder width apart As you exhale softly whisper the sound Haaaaa Or, very gently press your tongue to your pallet and hexhale while making a very soft hissing sound Have your partner touch the side of your thighs As you exhale have your partner stroke down your thighs to your feet and beyond, stroking in rhythm with your exhalation Do not rush Apply gentle pressure with the stroking Do this for four or five breaths Now, continue breathing as you imagine your breath flowing through your legs and out your feet During the day remember the feeling of your breath flowing downward through your legs and out your feet as you exhale
tions of a hot flash or mood alteration as the cue to exhale, let go of anxiety, breathe diaphragmatically and relax 4 Reframe
thoughts by accepting the physiological processes of menstruation or menopause, and refocus the mind on positive thoughts, and breathing rhythmically 5 Change ones lifestyle and allow personal schedules to flow in better balance with individual, dynamic energy levels
Exhale Gently:
Imagine that you are holding a baby Now with your shoulders relaxed, inhale gently so that your abdomen widens Then as you exhale, purse your lips and very gently and softly blow over the babys hair Allow your abdomen to narrow when exhaling Blow so softly that the babys hair barely moves At the same time, imagine that you can allow your breath to flow down and through your legs Continue imagining that you are gently blowing on the babys hair while feeling your breath flowing down your legs Keep blowing very softly and continuously Practice exhaling like this the moment that you feel any sensation associated with hot flashes or PMS symptoms Smile sweetly as you exhale
Generalizing Skills and Interrupting
the Pattern
The limits of self-regulation are unknown, often held back only by the practitioners and participants beliefs Biofeedback is a powerful self-regulation tool for individuals to observe and modify their covert physiological reactions Other skills that augment diaphragmatic breathing are Quieting Reflex Stroebel, 1982, Autogenic Training Schultz Luthe, 1969, and mindfulness training KabatZinn, 1990 In all skill learning, generalization is a fundamental factor underlying successful training Integrating the learned psychophysiological skills into daily life can significantly improve health–especially in anticipation of and response to stress The anticipated stress can be a physical, cognitive or social trigger, or merely the felt onset of a symptom As the person learns and applies effortless 23
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breathing to daily activities, she becomes more aware of factors that affect her breathing She also experiences an increased sense of control: She can now take
action a slow effortless breath in moments when she previously felt powerless The biofeedbackmastered skill interrupts the evoked frustrations and irritations associated with an embarrassing history of hot flashes or mood swings Instead of continuing with the automatic self-talk, such as Damn, I am getting hot, why doesnt it just stop? language fueling sympathetic arousal, she can take a relaxing breath in response to the internal sensations, stop the escalating negative self-talk and allows more acceptance–a process reducing sympathetic arousal In summary, effortless breathing appears to be a non-invasive behavioral strategy to reduce hot flashes and PMS symptoms Practicing effortless diaphragmatic breathing contributes to a sense of control, supports a healthier homeostasis, reduces symptoms, and avoids the negative drug side effects We strongly recommend that effortless diaphragmatic breathing be taught as the first step to reduce hot flashes and PMS symptoms
I feel so much cooler
I cant believe that my hand temperature went up I actually feel calmer and cant even feel the threat of a hot flash Maybe this breathing does work –Menopausal patient after initial training in diaphragmatic breathing
References
Bier, M, Kazarian, D, Peper, E, Gibney, K 2003 Reducing the severity of PMS symptoms with diaphragmatic breathing, autogenic training and biofeedback Unpublished report Freedman, RR, Woodward, S 1992 Behavioral treatment of menopausal hot flushes: Evaluation by ambulatory monitoring American Journal of Obstetrics and Gynecology, 167 2, 436439 Freedman, RR, Woodward, S, Brown, B, Javaid, JI, Pandey, GN 1995 Biochemical and thermoregulatory effects of behavioral treatment for menopausal hot flashes Menopause: The Journal of the North American Menopause Society, 2 4, 211-218 Frobish, C, Peper, E, Gibney, K 2003 Diaphragmatic breathing to control menopausal hot flashes Unpublished report Goodale, IL, Domar, AD, Benson, H 1990 Alleviation of Premenstrual
Syndrome symptoms with the relaxation response Obstetrics and Gynecological Journal, 75 5, 649-55
Hays, J, Ockene, JK, Brunner, RL, Kotchen, JM, Manson, JE, Patterson, RE, Aragaki, AK, Shumaker, SA, Brzyski, RG, LaCroix, AZ, Granek, IA, Valanis, BG, Womens Health Initiative Investigators 2003 Effects of estrogen plus progestin on health-related quality of life New England Journal of Medicine, 348, 1839-1854 Humphries, K H, Gill, S 2003 Risks and benefits of hormone replacement therapy: The evidence speaks Canadian Medical Association Journal, 168 8, 1001-10 Kabat-Zinn, J 1990 Full catastrophe living New York: Delacorte Press Luthe, W Schultz, JH 1969 Autogenic therapy: Vol II: Medical applications New York: Grune Stratton Mathew, RJ; Claghorn, JL; Largen, JW; Dobbins, K 1979 Skin Temperature control for premenstrual tension syndrome:A pilot study American Journal of Clinical Biofeedback, 2 1, 7-10 Peper, E 1990 Breathing for health Montreal: Thought Technology Ltd Schultz, JH,
Luthe, W 1969 Autogenic therapy: Vol 1 Autogenic methods New York: Grune and Stratton Schwartz, MS Andrasik, F2003 Biofeedback: A practitioners guide, 3nd edition New York: Guilford Press Shumaker, SA, Legault, C, Thal, L, Wallace, RB, Ockene, J, Hendrix, S, Jones III, B, Assaf, AR, Jackson, R D, Morley Kotchen, J, Wassertheil-Smoller, S; Wactawski-Wende, J 2003 Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in post menopausal women: The Womens Health Initiative memory study: A randomized controlled trial Journal of the American Medical Association, 289 20, 2651-2662 Stearns, V, Beebe, K L, Iyengar, M, Dube, E 2003 Paroxetine controlled release in the treatment of menopausal hot flashes Journal of the American Medical Association, 289 21, 2827-2834
Stroebel, C F 1982 QR, the quieting reflex New York: G P Putnams Sons van Dixhoorn, JJ 1998 Ontspanningsinstructie Principes en Oefeningen Respiration instructions: Principles and exercises Maarssen,
Netherlands: Elsevier/Bunge Wassertheil-Smoller, S, Hendrix, S, Limacher, M, Heiss, G, Kooperberg, C, Baird, A, Kotchen, T, Curb, Dv, Black, H, Rossouw, JE, Aragaki, A, Safford, M, Stein, E, Laowattana, S, Mysiw, WJ 2003 Effect of estrogen plus progestin on stroke in postmenopausal women: The Womens Health Initiative: A randomized trial Journal of the American Medical Association, 289 20, 2673-2684 Wyeth Pharmaceuticals 2003, June 4 A message from Wyeth: Recent reports on hormone therapy and where we stand today San Francisco Chronicle, A11
Notes
iFor communications contact: Erik Peper, PhD, Institute for Holistic Healing Studies, San Francisco State University, 1600 Holloway Avenue, San Francisco, CA 94132; Tel: 415 338 7683; Email: epeper@sfsuedu iiWe thank Candy Frobish, Mary Bier and Dalainya Kazarian for their helpful contributions to this research iiiWyeth Pharmaceuticals produce Premarin, and other HRT products ivFor an excellent text on learning relaxation and breathing, see
van Dixhoorn 1998
AAPB Practice Brief: Feature of the Month
This months feature discusses some of the unique aspects of the AAPB professional liability coverage Defense Coverage: Malpractice legal defense costs are paid for covered claims–win or lose–in addition to the amount paid to settle claims or to satisfy judgments against you, subject to the limits of your policy 24-Hour Worldwide Protection: Youre protected 24 hours a day anywhere in the world As long as a claim or suit is filed in the United States or any of its territories or possessions, you are covered Portability: If you work in more than one location or change jobs during the policy period, your coverage goes with you Broad Definition of Incident: Your policy protects you from a broad range of claims that may arise as a result of your professional activities We insure you to the scope of practice as defined by the State Practice Act in your particular state Additional professional liability coverage highlights can be
located by going directly to: http://wwwaapb-inscom/pl/coverageHighlightshtml Information provided by Jeff Powers, National Professional Group
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COMPLEMENTARY AND ALTERNATIVE MEDICINE AND INTEGRATIVE MEDICINE
QEEG and EEG Biofeedback in the Diagnosis and Treatment of Psychiatric and Neurological Disorders: An Authentic Complementary Therapy
James Lake, MD
Donald Moss, PhD
James Lake, MD, Pacific Grove, CA, and Donald Moss, PhD, Grand Haven, MI
Abstract: EEG biofeedback and Quantitative EEG QEEG are gradually emerging into mainstream psychiatry and medicine as promising diagnostic and treatment approaches in Western Europe and North America In the US two professional societies are devoted to training and research in both approachesii Current research shows that QEEG can be a useful adjunct in the assessment of a variety of neurological and psychiatric disorders, and EEG biofeedback provides a useful therapy for a number of common disorders Both EEG and
QEEG represent truly complementary therapies, based on a targeted re-regulation of cortical and subcortical electrical rhythms not addressed by mainstream medical therapies seizures, attention deficit-hyperactivity disorder ADHD, depression, anxiety, and substance abuse Clinical EEG, 2000; Evans Abarbanel, 1999; Moss, 2001 Subsequently, the use of quantitative electroencephalography QEEG emerged as a method for identifying abnormal cortical rhythms associated with specific neurological or psychiatric disorders LaVaque, 2003; John et al, 1977; John Prichep, 1993 Today the quantitative EEG provides a functional map of brain processes identifying areas of electrophysiological underactivity and over-activity, disturbances in inter-hemispheric coherence, and other evidence of cortical dysregulation Normative data bases allow a detailed statistical comparison of the patients current QEEG to both normal brain function and typical patterns of dysregulation associated with specific disorders,
such as seizure disorders, closed head injury, depression, and others Drawing on EEG data bases showing pathological states, normative EEG databases and evidence-based markers, QEEG mapping is a method that provides adjunctive diagnostic evidence for the presence of specific disorders QEEG results can also facilitate selection of the optimum EEG biofeedback protocol by identifying areas of abnormal cortical function, which can then become the focus for intervention
Applications of Quantitative EEG
The Use of the QEEG in Diagnosis and Treatment Planning The QEEG includes many sophisticated methods for analysis of brain electrical activity with the goal of clarifying the differential diagnosis QEEG data help the clinician to determine the optimum treatment for a given patient, including EEG biofeedback or psychopharmacological therapies In its early years, QEEG had limited success as a clinical tool because of the absence of standard EEG recording techniques and failed attempts to
confirm correlations between specific EEG abnormalities and discrete psychiatric or neurological diagnoses Because of these issues many physicians and psychologists were initially reluctant to adopt QEEG or EEG biofeedback In recent years, however, several QEEG databases have been developed and validated This has led to the elaboration of therapeutic EEG biofeedback protocols targeting discrete psychiatric or neurological disorders Databases containing both normative EEG activity patterns and abnormal patterns associated with specific psychiatric or
Historical Introduction
EEG biofeedback, also known as neurofeedback, emerged as a treatment modality from early research by Joe Kamiya 1969, which demonstrated the human capacity to gain awareness and voluntary control over cortical electrical rhythms Initially EEG biofeedback was utilized to facilitate deeper states of relaxation and meditative awareness, but the past three decades have seen a proliferation of clinical and research
reports showing that EEG biofeedback has efficacy for a variety of conditions, including
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neurological disorders have been created For example, Prichep et al 1993 utilized QEEG to identify cortical signatures for subtypes of obsessive compulsive disorder However, at present there are no widely accepted standards of practice regarding diagnostic uses of QEEG in clinical practice QEEG as Tool in Selecting Medication Considerable renewed interest in QEEG has come from recently published studies in the mainstream medical literature showing that response rates to certain anti-depressants can be predicted on the basis of differences in brain electrical activity evoked by sounds of various intensities The brains response to an auditory signal is called an auditory evoked potential AEP In one study Gallinat, et al, 2000, relatively greater auditory evoked potentials AEP corresponded to lower activity of brain serotonin, and predicted increased response rates of
depressed patients to serotonin reuptake inhibitors SSRIs This finding has been corroborated by other studies examining the relationship between cordance and response to antidepressants that affect serotonin Cordance is a measure of localized electrical brain activity relative to absolute EEG patterns Several studies have established a correlation between cordance and measures of brain perfusion or regional metabolic activity as shown by functional MRI and PET In a study at UCLA School of Medicine Demott, 2002b; Cook, et al, 2002], more than one half of patients with major depression who eventually showed the highest response rates to serotonin reuptake inhibitors, showed significant decreases in pre-frontal cordance during the first 48 hours of therapy Interestingly, non-responders in both the active and placebo groups did not show negative pre-frontal cordance QEEG as an adjunct in the Diagnosis of Attention Deficit-Hyperactivity Disorder In at least two well controlled studies, one
of them a multi-site study of more than 480 cases at 8 clinics, researchers have established that QEEG criteria can successfully distinguish individuals with Attention Deficit Hyperactivity Disorder from control subjects Monastra, Lubar, Linden, VanDeusen, Green, Wing, Phillips,
Fenger, 1999; Monastra, Lubar, Linden, 2001 Measuring the ratio of percent Theta power to percent Beta power, at the vertex of the scalp location Cz in the International 10-20 EEG system, the ADHD subjects could be differentiated from controls with an accuracy of at least 90 percent Lubar, 2003 Studies by Clarke and colleagues independently support the ability of QEEG to discriminate individuals with ADHD Clarke, Barry McCarthy, Selikowitz, 2001a, and also identify a subgroup of children with ADHD who display a divergent EEG pattern, featuring an excess of beta range activity, primarily in frontal regions Clarke, Barry, McCarthy, Selikowitz, 2001b QEEG in the Detection of Mild Cognitive Impairment and
Alzheimers Disease QEEG and EEG evoked potentials are also promising diagnostic tools for the early detection of mild cognitive impairment and early Alzheimers Disease AD or Alzheimers like dementia In recent pilot studies researchers reliably differentiated patients with mild cognitive impairment MCI or Alzheimers Disease from intact subjects on the basis of QEEG findings alone In the first study, Benvenuto, Jin, Casale, Lynch, and Granger 2002 used visual evoked potentials VEPs, and identified reliable EEG signal features discriminating the Alzheimers patients In a second study, the researchers found correlations between auditory evoked potentials AEPs and mild cognitive impairment, possibly a precursor to AD The same study identified a consistent EEG signature in patients with mild cognitive impairment, indicating degeneration in the pre-frontal cortex Demott, 2002a These results were interpreted as pre-frontal cortical dis-inhibition, a typical finding in AD and other kinds of
dementia As a significant percentage of mildly cognitively impaired adults eventually progress to frank dementia, early EEG evaluation of at-risk individuals may facilitate early aggressive treatment
EEG Biofeedback
Both the International Society for Neuronal Regulation and the Neurofeedback Division within AAPB were established to further research, promote
standardized recording techniques, refine databases and suggest protocols for clinical applications using EEG biofeedback for the entire spectrum of neuropsychiatric disorders EEG biofeedback, also known as neurofeedback or neurotherapy, has the goal of modifying general or specific parameters of brain electrical activity in order to eliminate abnormal cortical patterns or normalize patterns that are believed to be associated with a particular neurological or psychiatric disorder The patient is instructed to modify a visual or auditory feedback signal that provides information about real-time brain electrical activity, including
frequency, amplitude, coherence and other parameters EEG biofeedback takes place gradually over many sessions and when successful, results in shifts in EEG activity associated with diminished severity of the target symptom or disorder being treated EEG Biofeedback Applications The use of electroencephalography EEG in biofeedback to treat psychiatric disorders dates to the mid-1960s Budzynski, 1999; Evans Abarbanel, 1999 Commonly used protocols initially entailed the modification of averaged EEG activity with the goal of increasing activity or coherence in the Alpha frequency bands between 8 and 12 cycles/sec, or increasing activity in a portion of the Beta frequency band between 15 and 20 Hz while inhibiting activity in the Theta frequency band between 4 and 8 Hz Psychologists and psychiatrists use QEEG and EEG biofeedback singly or in combination with more conventional methods in the diagnosis and treatment of numerous psychiatric and neurological disorders including Attention
Deficit/Hyperactivity Disorder ADHD, PTSD, depression, substance abuse and alcoholism, traumatic brain injury, and post-stroke rehabilitation One of the best-documented applications of EEG biofeedback is the treatment of Attention Deficit/Hyperactivity Disorder ADHD Numerous uncontrolled studies have reported the evolution of this treatment paradigm, as reviewed by Lubar 2003 More recently, three controlled studies have shown that the efficacy of EEG biofeedback in reducing the symptoms of ADHD is equivalent or superior to psy-
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chostimulants Rossiter LaVaque, 1995; Monastra, Monastra, George, 2002; Fuchs, Bierbaumer, Lutzenberger, Gruzelier, Kaiser, 2003 Recent Advances in EEG Biofeedback Significant recent advances in EEG biofeedback include: 1 a report by Ibric 2002 showing a reduction in the symptoms of Parkinsons disease, when neurofeedback is enhanced by light stimulation and low level electromagnetic stimulation, guided by real time EEG feedback;
2 case reports and research reports showing reduction in the severity of depressed mood using an alpha asymmetry EEG biofeedback protocol Rosenfeld, 2000; Baehr, Rosenfeld, Baehr, 2001; Baehr Rosenfeld, 2003, 3 a case report by Hammond in press of positive outcomes with EEG biofeedback training for obsessive compulsive disorder OCD; and 4 promising early reports on the treatment of eating disorders Smith, 2002 and trigeminal neuralgia Sime, 2002 Many of these reports are based on clinical case studies and small pilot studies, and require verification from large controlled studies QEEG and EEG Biofeedback in Current Practice At present, most clinicians still rely primarily on clinical history when evaluating a new patient and determining when to use a specific EEG-biofeedback protocol The QEEG offers the hope of more strategic selection of specific training protocols, which should reduce the total duration of biofeedback training and improve the overall magnitude of symptom
reduction
EEG Biofeedback Is a Complementary Therapy
QEEG and, EEG Biofeedback are complementary to the Western Biomedical Paradigm The scientific principles, technology and treatment protocols of EEG biofeedback derive from fundamental theories of cortical electrophysiology and neuroscience As such, the theoretical bases of both QEEG and EEG biofeedback fall well within the paradigm of conventional Western biomedicine Using accepted Western scientific methods, research in QEEG is gradually identifying cortical and sub-cortical patterns of dysregulation associated with many common disorders in psychiatry, neurology, and medicine in general
While based on accepted Western biomedical theory, EEG biofeedback is outside of the domain of accepted biomedical practices, and therefore qualifies as a complementary therapy By definition, complementary therapies are based on principles that are congruent with the core precepts of Western medicine, but are not yet accepted in mainstream medical
practice because of ideological or institutional biases Lake, 2003 EEG biofeedback is an established complementary therapy in most Western countries, as it rests on accepted theories of brain function EEG biofeedback seeks to strategically re-regulate cortical electrical activity in a manner not accomplished by existing conventional medical therapies Perhaps the closest approximation to this approach to cortical re-regulation is the use of pharmacotherapy to modulate abnormal rhythms in epilepsy, or to enhance inhibition and attention in attention deficit-hyperactivity disorder However, at its present level of evolution, pharmacotherapy is a crude method by comparison to EEG biofeedback, which is able to strategically target specific brain regions or frequency ranges for conditioning When treated with antiseizure medications, the epileptic brain shows progressively more abnormal electrical activity patterns over decades, whereas the brain treated by EEG biofeedback shows significant
normalization in the course of treatment Similarly, the ADHD child treated with stimulant medication will often show greater self-control and improved attention in school, yet often continues to display an abnormally elevated Theta to Beta ratio, one marker of an inattentive brain Lubar, Swartwood, Swartwood, Timmerman, 1995iii Treatment of the same child using EEG biofeedback typically normalizes that ratio Lubar, et al, 1995 In addition, the use of EEG biofeedback avoids the risks associated with adverse effects of many medications, resulting in frequent non-compliance during long-term medication treatment
Evidence Based Evaluation of EEG Biofeedback Protocols
Many practitioners of neurofeedback argue that the de facto scientific validity Biofeedback
of this method has been established by a series of studies demonstrating its efficacy in the treatment of attention deficit disorder, cognitive deficits following stroke, relapse prevention in alcoholism, improved functioning in
chronic fatigue syndrome, and others However, the uses and efficacy of neurofeedback continue to be disputed by many physicians Because of this, the majority of EEG biofeedback practitioners are psychologists In response to this concern, ISNR and AAPB created a joint taskforce in mid-2001 with the goals of developing standards of research methodology and establishing empirical evidence of treatment efficacy for EEG and peripheral biofeedback Moss Gunkelman, 2002 This work has led to the adoption of guidelines establishing five discrete levels of evidence LaVaque et al, 2002 Level 1 includes EEG biofeedback protocols that presently lack any empirical basis Level 5 protocols are those for which available evidence establishes both efficacy and specificity of a proposed treatment Intermediate levels correspond to intermediate degrees of evidence Current Advances in Evidence-Based Biofeedback Practice At the time of this writing, a new AAPB clinical efficacy book is in preparation The new
publication rates the efficacy and specificity of EEG biofeedback protocols for common neurological and psychiatric disorders, based on the efficacy guidelines discussed above Yucha Gilbert, in press for 2003 Adding to this effort, a joint AAPB/ISNR research task force is preparing a series of white papers based on exhaustive literature reviews The White papers will include evidence-based recommendations for use of specific EEG biofeedback protocols in the management of specific disorders The white papers, edited by Moss, LaVaque, and Hammond in preparation, are scheduled for release starting in 2003 The AAPB guidelines and the forthcoming White Papers will significantly advance the field of EEG biofeedback by providing evidence-based tools to assist both health professionals and patients in identifying and selecting the most efficacious EEG biofeedback protocols for specific disorders
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Conclusion
Since the inception of EEG biofeedback, numerous specific EEG
biofeedback treatment protocols have been developed Prior to selecting an EEG biofeedback treatment protocol some neurotherapists perform an initial diagnostic QEEG map on every patient Others select EEG biofeedback treatment methods strictly on the basis of the patients presenting complaints The necessity for QEEG guided treatment in all cases remains controversial However, the field seems to be slowly moving toward a standard of practice that will include QEEG brain mapping followed by the elaboration of a specific treatment protocol based on QEEG findings The ideal approach to treatment planning in neurotherapy should entail use of QEEG mapping to correlate abnormal EEG findings with neurological or psychiatric symptoms and clinical history This approach will lead to a rigorous evidence-based treatment plan that is customized for each patient and targets specific treatment goals of shifting dynamic pathological brain-wave activity toward normal functioning and amelioration of
clinical symptoms Different types of abnormal electrophysiological brain activity have been treated using EEG biofeedback These abnormal or pathological patterns include EEG interhemispheric asymmetries, relative imbalances between specific cortical brain regions in selected EEG frequency ranges, and abnormal ie, reduced or elevated EEG frequency, amplitude or coherence measures corresponding to specific brain regions Successful treatment requires a series of sessions, typically over a period of weeks or longer It is common practice for therapists to combine other biofeedback modalities with neurobiofeedback in order to facilitate re-conditioning of the abnormal symptom pattern to a more adaptive level of functioning Useful kinds of feedback correspond to different physiologic parameters that are associated with the target neurological or psychiatric symptom Although few controlled studies support this view, many therapists believe that a combined feedback approach may facilitate more
rapid re-conditioning of abnormal EEG states, and corresponding neurological
or psychiatric symptom patterns, to more adaptive levels of functioning
References
Baehr, E, Rosenfeld, J P 2003 Mood disorders In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind body medicine for primary care pp 377-392 Thousand Oaks, CA: Sage Baehr, E, Rosenfeld, J P, Baehr, R 2001 Clinical use of an Alpha asymmetry neurofeedback protocol in the treatment of mood disorders: Follow-up study one to five years post therapy Journal of Neurotherapy, 4 4, 3, 11-18 Benvenuto, J, Jin, Y, Casale, M, Lynch, G, Granger, R 2002 Identification of diagnostic evoked response potential segments in Alzheimers disease Experimental Neurology, 176 2, 269-76 Budzynksi, T 1999 From EEG to neurofeedback In J R Evans A Abarbanel Eds, Introduction to quantitative EEG and neurofeedback pp 65-79 San Diego, CA: Academic Press Clarke, A R, Barry, R J, McCarthy, R, Selikowitz, M 2001a Age and sex effects in
the EEG: Differences in two subtypes of attentiondeficit/hyperactivity disorder Clinical Neurophysiology, 112 5, 815-826 Clarke, A R, Barry, R J, McCarthy, R, Selikowitz, M 2001b Excess beta activity in children with attention-deficit/hyperactivity disorder: An atypical electrophysiological group Psychiatry Research, 103 2-3, 205-218 Clarke, A R, Barry, R J, Bond, D, McCarthy, R, Selikowitz, M 2002 Effects of stimulant medications on the EEG of children with attentiondeficit/hyperactivity disorder Psychopharmacology Berl, 164 3, 277-84 Clinical EEG 2000 Special Issue on The state of EEG biofeedback therapy EEG operant conditioning in 2000 Electroencephalography, 31 1, vviii, 1-55 Cook, I A, Leuchter, A F, Morgan, M, Witte, E, Stubbeman, W F, Abrams, M, Rosenberg, S, Uiitdehaage, S H 2002 Early changes in prefrontal activity characterize clinical responders to antidepressants Neuropsychopharmacology, 27 1, 120-31 Demott, K 2002a, November Can EEG auditory test detect early
Alzheimers? Clinical Psychiatry News, 29 Demott, K 2002b, December The ideal antidepressant may be an EEG away Clinical Psychiatry News, 17 Evans, J R, Abarbanel, A Eds 1999 Introduction to quantitative EEG and neurofeedback San Diego: Academic Press Fuchs, T, Birbaumer, N, Lutzenberger, W, Gruzelier, J H, Kaiser, J 2003 Neurofeedback treatment for attention deficit/hyperactivity disorder in children: A comparison with methylphenidate Applied Psychophysiology and Biofeedback, 28 1, 1-12 Gallinat J, Bottlender, R, Juckel, G, MunkePuchner, A, Stotz, G, Kuss, H J, Mavrogiorgou, P, Hegerl, U 2000 The loudness dependency
of the auditory evoked N1/P2-component as a predictor of the acute SSRI response in depression Psychopharmacology Berl, 148 4, 404-11 Hammond, D C in press QEEG-guided neurofeedback in the treatment of obsessive-compulsive disorder Journal of Neurotherapy, 26 2 Ibric, V 2002, September Neurofeedback enhanced by light and electromagnetic closed-loop EEG in Parkinsons
disease Presentation to the annual meeting of the International Society for Neuronal Regulation, Scottsdale, AZ John, E R, Karmel, B Z, Corning, W C, Easton, P, Brown, D, Ahn, H, Harmony, T, Prichep, L, Toro, L, Gerson, I, Bartlett, F, Thatcher, R, Kaye, H, Valdes, P, Schwartz, E 1977 Neurometrics: numerical taxonomy identifies different profiles of brain functions within groups of behaviorally similar people Science, 196, 1393-1410 John, E R, Prichep, L S 1993 Principles of neurometric analysis of EEG and evoked potentials In E Niedermeyer F Lopes da Silva Eds, Electroencephalography: Basic principles, clinical applications, and related fields third ed, pp 9891003 Baltimore: Williams Wilkins Kamiya, J 1969 Operant control of the EEG alpha rhythm In C Tart Ed, Altered states of consciousness NY: Wiley Lake, J, 2003 Complementary, alternative, and integrative medicine In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind-body medicine for primary care pp 57-68
Thousand Oaks, CA: Sage LaVaque, T J 2003 Neurofeedback, neurotherapy, and QEEG In D Moss, A McGrady, T Davies, I Wickramasekera Eds, Handbook of mind body medicine for primary care pp 123-135 Thousand Oaks, CA: Sage LaVaque, T J, Hammond, D C, Trudeau, D, Monastra, V, Perry, J, Lehrer, P, Matheson, D, Sherman, R 2002 Template for developing guidelines for the evaluation of the clinical efficacy of psychophysiological evaluations Applied Psychophysiology and Biofeedback, 27 4, 273-281 Lubar, J F, Swartwood, M O, Swartwood, J N, Timmermann, D L 1995 Quantitative EEG and auditory event-related potentials in the evaluation of Attention-Deficit/Hyperactivity disorder: Effects of methylphenidate and implications for neurofeedback training Journal of Psychoeducational Assessment Monograph Series Advances in Psychoeducational Assessment Assessment of Attention-Deficit/Hyperactivity Disorders, 143-204 Lubar, J F 2003 Attention Deficit Hyperactivity Disorder In In D Moss, A McGrady, T
Davies, I Wickramasekera Eds, Handbook of mind body medicine for primary care pp 347-357 Thousand Oaks, CA: Sage Monastra, V J, Lubar, J F, Linden, M 2001 The development of a QEEG scanning process for ADHD: Reliability and validity studies Neuropsychology, 15 1, 136-144
Continued on page 36
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SERIES Audio-Visual Entrainment: II Dental Studies
David Siever1, Edmonton, Alberta, Canada
David Siever
Abstract: A great deal of temporomandibular joint dysfunction and myofascial pain dysfunction is activated in relation to anxiety and fear responses to challenging tasks, self-criticism and daily hassles AVE, like passive meditation, appears to effectively alleviate these symptoms
Historical Background
The first few studies of visual entrainment VE involved a device called the Brain Wave Synchronizer The seminal hypnosis study by Kroger and Schneider in 1959 prompted more research along hypnosis lines Shortly thereafter VE was used as an analgesic for
gastro-intestinal surgery, where it was found that over 90 of patients entered useable levels of trance induction prior to surgery Sadove, 1961 The Sadove study caught the interest of the dental profession, which was awakening to the role of anxiety in temporo-mandibular joint TMJ and myofascial pain dysfunction and during dental procedures
5 VE made post-hypnotic anesthesia possible 6 VE controlled gagging 7 VE reduced fear and anxiety in the dental situation TMJ dysfunction is an affliction that affects many people In order to understand the scope of the VE studies with TMJ, it is important to have a deeper understanding of TMJ dysfunction and myofascial pain dysfunction
Theories of TMJ Dysfunction
Two theories exist to explain the origins of bruxism, TMJ dysfunction and myofascial pain dysfunction MPD, a condition involving severe pain in facial regions The tooth-muscle theory ascertains that disharmony in occlusion produces altered proprioceptive information that activates the
occlusal pattern generator which activates the masticatory jaw-closing muscles, which in turn grind down the dentition until a satisfactory occlusion is reached Manns, etal, 1981, Moulton, 1966, Laskin, 1969 Certainly, many people can recall a time when a poorly made dental filling or orthotic has activated this response, quickly resulting in jaw tension and pain The psychophysiologic theory implies that emotional factors such as stress and anxiety manifest in increased muscle tension Manns, etal, 1981, Laskin, 1969, Moulton 1966 and increased perception of pain Christensen, 1981 It has also been shown that all people show high levels of masseter tension during initial exposures to a stimulus-response task Yemm, 1971 Further, it has been shown that masseter
Dental Studies
VE was shown to reliably drive dental patients into a hypnotic induction during dental work in a short period of time, if the VE frequency was set near the dominant natural alpha frequency of the patient Margolis,
1966 Margolis placed the synchronizer near the patient during a dental procedure He noted several positive effects 1 VE reduced the amount of anesthetic used 2 In some cases, hypno-anesthesia could be used exclusively 3 Anesthesia could be terminated immediately following surgery 4 VE produced no depressing physiologic side-effects
muscle activity increases during challenging tasks, primarily when the subjects made errors Yemm, 1969 The Yemm study implies a direct relationship between selfcritical thoughts and tension Controls show a trend towards relaxation with repeated exposures to the task, whereas those suffering with TMJ dysfunction show an initial relaxation phase during the first few exposures followed by a marked increase in masseter muscle tension with repeated exposures to stimulus-response tasks This performance anxiety was termed TMJ personality by Yemm Anxiety and stress, and the consequent impact on trait arousal are a major part of a variety of dental disorders
Spielberger, etal1970, Rugh Solberg, 1975, Yemm, 1971, Weinstein, et al, 1971 Some additional disorders relating to stress are gingivitis, osteoporosis of the alveolar bone in animals, alterations in the chemical composition of saliva, and ulcerative oral legions in dogs Giddon, 1966 A further investigation of subjects with gingivitis revealed reduced salivary output, increased gingival arterial dilation and increased sublingual temperature in response to stress Rugh and Solberg devised a study where the participants used a small data-logging EMG on the masseter to measure nighttime or nocturnal bruxism Hard clenches activated the recorder This device could log several days worth of data, which was displayed as the amount of time of bruxing, in brux seconds/hour Figure 1 shows a typical example of the relationship between life stressors and jaw tension, in this case, in a young lady When experienced Transcendental Meditators were exposed to photic stimula-
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Symptom
Figure 1 Stressful Life Events and Nocturnal Bruxism
tion near natural alpha frequencies, they reported subjective experiences similar to their usual experience during meditation Williams West, 1975 A comparison of various strategies aimed at reducing trait anxiety have shown that passive meditation techniques such as TM are considerably more effective than other strategies such as progressive relaxation or concentration meditation Eppley Abrams, 1989 This connection between the ability to entrain a brain wave pattern similar to that of meditators, combined with the subjective meditative experience of AVE, and the fact that meditation produces a pronounced reduction in trait anxiety, may explain why AVE produces such striking reductions in anxiety as measured in AVE studies The next study demonstrates this point Audio entrainment AE has shown promise as a singular therapeutic modality for treating tension and pain Manns, Miralles, Adrian, 1981 In
this study, people suffering with myofascial pain and TMJ dysfunction were split into two groups — group A, those with symptoms for less than one year n14, and group B, those with symptoms for longer than one year n19 They received 15 minute sessions of auditory entrainment AE consisting of isochronic, pure evenly pulsed sine wave tones, followed by 15 minutes of EMG feedback and concluding with 15 minutes of AE and EMG feedback combined, for an average of 14 sessions The study clearly shows greater reductions in EMG activity during AE Table 1 shows the reduction in MPD/TMJ symptoms following treatment A study involving 10 people Figure 2 with long histories of TMJ dysfunction was
Bruxism Emotional tension Muscle fatigue Insomnia Dizziness Headache TMJ Pain Masticatory muscle pain Neck muscle pain Otalgia Mastoid process pain Articular clicking Mandibular deviation Restricted opening
Group A n14 Participants with symptoms Pre Tx Post Tx 100 7 100 14 93 0 57 0 21 0 93 0 64 0 71 0 79
9 79 9 43 0 50 29 79 36 43 0
Group B n 19 Participants with symptoms Pre Tx Post Tx 100 32 100 21 74 21 53 0 53 0 74 0 47 0 58 9 79 26 32 17 16 0 68 54 84 56 16 0
Table 1 TMJ Symptoms Following Audio Entrainment and EMG Feedback
conducted to see whether they would relax to a guided imagery exercise Just prior to the guided imagery, they were given the suggestion of entering deep relaxation by the end of the guided imagery Thomas Siever, 1988 With this expectation in mind, all of the subjects showed bracing or dysponesis as indicated by a drop in hand temperature and a short fall in masseter muscle EMG tension followed by a considerable increase in tension until the relaxing guided imagery ended at which time they did begin to relax moderately Interestingly, all members subjectively reported feeling very relaxed, even though they all had tensed up somewhat The group then underwent 10 minutes of 10 Hz AVE from a DAVID1 system Within five minutes masseter muscle tension became
very
relaxed and hand temperature increased, signs of sympathetic deactivation and parasympathetic activation the meditation response Dental patients often suffer anxiety before and during dental appointments Lazarus, 1966, Dewitt, 1966, Corah Pantera, 1968 Of all the dental procedures, root canal endodontic therapy is the most feared Morse 1993 Audio-analgesia using white noise and/or music as produced by a commercially marketed unit has been shown to effectively increase pain threshold and pain tolerance during a dental procedure Gardner Licklider, 1959; Gardner, Licklider, Weisz, 1960; Schermer, 1960; Monsey, 1960; Sidney, 1962; Morosko Simmons, 1966 A study implementing AVE to reduce
Figure 2 Masseter Muscle Tension and Hand Temperature during a Guided Imagery and AVE
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Figure 3 Heart Rate during a Root-Canal Procedure
Figure 4 Muscle Spindle
anxiety during a root-canal procedure has also shown promising results Morse 1993 This study involved three
groups of 10 subjects The groups consisted of a group receiving 10 Hz AVE, a group receiving 10 Hz AVE plus an alpha relaxation tape developed by Shealy simultaneously, and a control group Figure 3 The study confirmed that the part of a root-canal procedure that produces the greatest anxiety is the NovocaineTM injection, pushing average heart rate up to 107 bpm The group using AVE had an average heart rate of 93 bpm, while the group that was further dissociated AVE and music, had an average heart rate of 84 bpm AVE may settle down jaw tension through muscle spindle de-activation Siever, 1992 Muscle spindles regulate body tone and posture as well as facilitate the myotatic reflex McClintic, 1978 They are fibers that are directly attached to either the muscle fibers extrafusal fibers or to the filaments of tendons As shown in Figure 4, the spindle consists of two parts, the nuclear chain fiber and the nuclear-bag fiber Spiral sensory endings called afferent neurons wrap around the
central portion of
both fibers The fibers receive gamma efferent neurons These serve to set the tone or sensitivity of the spindle The spindle responds when it is stretched, by sending off a stream of pulses As shown in Figure 5, the primary endings alert the nervous system that a stretch is occurring, whereas the secondary endings indicate a fair approximation of actual amount or objective measure of stretch of the muscle Bradley, 1981 This has important implications in dentistry When the mouth is opened wide for dental work, the spindles within the masticatory or jaw-closing muscles stretch, sending output down the afferent fibers, which synapse with the alpha motor neuron of the muscle Thus the muscle tightens up and attempts to return to its original length Bradley, 1981 Therefore, the jaw muscles become very tight on wide openings This in turns loads the temporo-mandibular joint and can damage the cartilage, or interarticular disc in the joint and cause TMJ dysfunction To make
matters worse from a dental perspective, the gamma efferent fibers receive input from the basal ganglia The basal ganglia are a set of structures that
surround the limbic system They are involved with integrating feelings, thoughts and movement and help to smooth motor behavior The basal ganglia regulate the bodys idle speed, affecting anxiety level Amen, 1998, p 43 So how does this all tie together? When we are relaxed we have a small space of 1 3 mm between our teeth when we are sitting or standing When we get anxious or scared, the basal ganglia sends output to the gamma efferent neurons, which in turn make the spindle hyper-sensitive A hyper-sensitive spindle behaves as if the spindle is stretched, and before we realize it, we are clenching our teeth watch the coaches and general managers during sporting events Not only are they often clenching, but they have large, well developed masseter muscles seen as large lumps on the sides of their face The basal ganglia / spindle
mechanism causes severe jaw tension in patients who are scared when visiting a dentist, which in turn can damage the temporo-mandibular joint, leading to a lifetime of jaw and facial pain Now heres the critical study In this simple jaw-open study, six participants were
Figure 5 Muscle Spindle Output
Figure 6 Masseter Muscle Tension during Wide Mandibular Openin
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asked to open their mouth near maximal openings to activate muscle spindles within the masseter muscle The participants indicated that they had no reasons to be anxious during this study, so activation of the basal ganglia should not have been a confounding factor The participants served as their own controls EMG activity involving primarily fast-twitch muscle 100-300 Hz, and TMJ symptoms such as muscle soreness, stiffness of jaw and TMJ clicking sounds, was collected on the left masseter muscle during wide opening on both trials The following day, the exercise was repeated during 10 Hz AVE from a
DAVID Paradise The results show a marked reduction in muscle tension and symptoms of TMJ dysfunction in the AVE trial Figure 6 shows the EMG results of the study
Conclusion
A great deal of TMJ and MPD symptoms are directly related to stress, fear and anxiety Both meditation and AVE have been shown to effectively reduce these symptoms Furthermore, AVE may also de-activate muscle spindle tone and the resulting muscle tension through two processes: 1 calming related basal ganglia activity, and 2 de-activating the reflex loop that controls muscle tone in relation to muscle stretch
References
Amen, D 1998 Change your brain, change your life New York: Three Rivers Press Anderson, D 1989 The treatment of migraine with variable frequency photic stimulation Headache, 29, 154-155 Bradley, R 1981 Basic oral physiology Chicago London: Year Book Medical Publishers Christensen, LV 1981 Jaw muscle fatigue and pains induced by experimental tooth clenching: A Review Journal of Oral Rehabilitation,
8, 27-36 Corah, N Pantera, R 1968 Controlled study of psychologic stress in a dental procedure Journal of Dental Research, 47, 154-157 Dewitt, C 1966 An investigation of psychological and behavioral responses to dental extraction in children Journal of Dental Research, 45, 16371651 Eppley, K Abrams, A 1989, November Differential effects of relaxation techniques on trait anxiety: A meta-analysis Journal of Clinical Physiology, 5 6, 957-973 Gardner, W, Licklider, J 1959 Auditory analgesia in dental operations Journal of the American Dental Association, 59, 1144-1149 Gardner, W, Licklider, J Weisz, A 1960
Suppression of pain by sound, Science, 132, 32 Giddon, D, 1966 Psychophysiology of the oral cavity Journal of Dental Research, 6 Supplement, 1627-1636 Kroger, W S, Schneider, S A 1959 An electronic aid for hypnotic induction: A preliminary report International Journal of Clinical and Experimental Hypnosis, 7, 93-98 Laskin, D 1969 Etiology of the pain-dysfunction syndrome Journal of
the American Dental Association 79, 147 Lazarus, R 1966 Some principles of psychological stress and their relation to dentistry Journal of Dental Research, 45, 1620-1626 Manns, A, Miralles, R, Adrian, H 1981 The application of audiostimulation and electromyographic biofeedback to bruxism and myofascial pain-dysfunction syndrome Oral Surgery, 52 3, 247-252 Margolis, B 1966, June A technique for rapidly inducing hypnosis CAL Certified Akers Laboratories, 21-24 McClintic, J 1978 Physiology of the human body New York: John Wiley Sons Monsey, H 1960 Preliminary report of the clinical efficacy of audio-analgesia Journal of the California Dental Association, 36, 432-437 Morosko, T Simmons, F 1966 The effect of audio-analgesia on pain threshold and pain tolerance Journal of Dental Research, 45, 1608-1617 Morse, D Chow, E 1993 The Effect of the RelaxodontTM brain wave synchronizer on endodontic anxiety: evaluation by galvanic skin resistance, pulse rate, physical reactions, and
questionnaire responses International Journal of Psychosomatics, 40 1-4, 68-76 Moulton, R 1966 Emotional factors in nonorganic temporomandibular pain Dental Clinics of North America, 10, 609 Rugh, J Solberg, W 1975 Electromyograpgic studies of bruxist behavior, before and during treatment Journal of California Dental Association, 3, 56-69 Sadove, MS 1963, July Hypnosis in anaesthesiology Illinois Medical Journal, 39-42
Schermer, R 1960 Analgesia using the Steregesic Portable Military Medicine, 125, 843848 Sidney, B 1960 Audio-analgesia in pediatric practice: a preliminary study Journal of the American Pediatric Association, 7, 503-504 Siever, D, 1992 Tension occurring in muscles of mastication during jaw opening Unpublished manuscript Spielberger, C, Gorsuch, R Lushene, R 1970 Manual for state-trait anxiety inventory Consulting Psychologists Press Palo Alto, CA Weinstein, P, Smith, T Packer, M 1971 Method for evaluating patient anxiety and the interpersonal effectiveness of dental
personnel: An exploratory study Journal of Dental Research, 50 5, 1324-1326 Williams, P, West, M 1975 EEG responses to photic stimulation in persons experienced at meditation Electroencephalograpy and Clinical Neurophysiology, 39, 519-522 Yemm, R 1969 Variations in the electrical activity of the human masseter muscle occuring in association with emotional stress Archives of Oral Biology, 14, 873-878 Yemm, R 1971 Comparison of the activity of left and right masseter muscles of normal individuals and patients with mandibular dysfunction during experimental stress Journal of Dental Restoration, 50, 1320
iFor more information, address all correspondence to: David Siever, Mind Alive/Comptronic, 9008-51 Avenue, Edmonton, Alberta, Canada T6E 5X4 Toll Free: 800-661-6463, Phone: 780-461-9551, Web: http://wwwcomptroniccom/, Email: info@comptroniccom
Notes:
Revised Ethical Guidelines for AAPB
The Ethical Guidelines for AAPB were revised and approved by the AAPB Board on March 27, 2003 Members
may request a copy from AAPB or download a copy from the AAPB web site wwwAAPBorg
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CONTRIBUTIONS TO SURFACE ELECTROMYOGRAPHY
Shoulder SEMG Testing and Biofeedback / Re-education: A Segmental Motion and Regional Approach
Gabriel E Sella, MD, MPH, MSc, Morgantown, WVi
Abstract: This article presents an overview of 17 shoulder muscles tested with dynamic SEMG protocols from the point of view of regional balances The shoulder may be divided into four regional parts Those components are compared in terms of overall SEMG activity potentials through six segments of motion Inferences for SEMG investigation and a new outlook for muscular re-education/ biofeedback are presented anterior lateral, extension posterior, and external and internal rotation The muscles tested were sub-divided by anatomic regions for the purpose of the illustration The anterior shoulder group includes the anterior deltoid, pectoralis major minor The lateral shoulder group includes the
middle deltoid The superior shoulder group includes the upper trapezius, supraspinatus and levator scapulae The posterior shoulder group includes the infraspinatus, latissimus dorsi, teres major minor, serratus anterior, middle trapezius, lower trapezius, rhomboid major minor This classification has minor limitations However, the overall aim is to illustrate the point that SEMG investigation of the different regional shoulder groups can lead to an overall conclusion of equilibrium and stabilization of the shoulder, facts which can help in the biofeedback process and in the ergonomic endeavor An understanding of the different vectors of forces is based on the general anatomic localization of the shoulder muscles described above This presentation is paramount to the understanding of functional factors such as fatigue, related to repeated motion Clinical problems such as repetitive motion injury on one hand and ergonomic factors of optimizing shoulder related activities may find better
solutions by utilizing the presented data Ideally, such motions should be performed at the level of least effort and fatigue Workers or army personnel can also use the data presented in this article in
Gabriel E Sella, MD, MPH, MSc
terms of optimization of shoulder motion in athletic endeavors and other activities
Materials and Methods
551 muscles were tested with SEMG dynamic protocols involving the following shoulder segmental motions: anterior flexion, abduction, external rotation, internal rotation, lateral flexion and posterior flexion The degrees of motion were complete for the individuals tested and are documented in the peer-reviewed literature Gerhardt Sella, 2002; Cocchiarella Anderson, 2001 The muscles were tested at the minimal level of effort of movement or contraction Thus, the data below refer only to the activity potentials elicited from a minimal effort of contraction with or against gravity, while the individuals tested were in the standing position The testing
was performed with Myovision 3000 equipment according to established and published protocols Sella, 1998a; Sella, 1998b; Sella, 2002 The complete statistics obtained from the study are published elsewhere Sella, 2003 The data cited in the present article are modified from the original data Testing was done through the shoulder ROM segmental activities and rest Sella, 1998a, 1998b, 2000, 2002 The data refer only to activity potentials measured in V RMS The tables below refer to anatomical analysis of the muscular activity derived from the SEMG dynamic shoulder protocol The shoulder region has been divided among the anterior, lateral, superior and posterior aspects
Introduction
Traditionally, surface EMG SEMG biofeedback has focused on individual muscles and not on myotatic units Thus, the biofeedback practitioner is used to focusing on the re-education of one muscle at a time and is not used to viewing a muscle as a component of a larger, myotatic group or vector In reality, muscles do
not function singly but as components of myotatic groups and vectors Practitioners should strive to recognize this reality and use it to the best of their ability during the processes of SEMG investigation and biofeedback and within the strengths and limitations of the SEMG dynamic methodology The present article aims to illustrate the point of recognizing one joint and the muscles subtending it as a unit of concerted action, thus allowing the SEMG biofeedback practitioner to utilize this knowledge within the rehabilitation and ergonomic perspectives The shoulder is the joint described in this article SEMG studies have been conducted on 551 shoulder muscles through the range of motion segments of abduction, flexion
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Results
Seventeen discrete shoulder muscles were tested with SEMG through six shoulder ROM segments The results are documented in the six tables below Table I represents the data of the average potentials of 118 anterior shoulder muscles Table
II represents the data of the average potentials of 138 superior shoulder muscles Table III represents the data of the average potentials of 55 lateral shoulder muscles Tables IV A B represent the data of the average potentials of 240 posterior shoulder muscles Table V represents a ranking from high to low of the SEMG activity potentials averaged from the different segmental shoulder motions tested for the 551 muscles described in the tables above Table VI represents a ranking from high to low of the SEMG average activity potentials of the four anatomic shoulder regions tested
Muscle number ROM Anterior Flexion Abduction External Rotation Internal Rotation Lateral Flexion Posterior Flexion Sum Avg Group Sum
Anterior Shoulder Group N55 N33 Anterior Deltoid Pectoralis Major 398 219 125 94 486 279 95 56 313 201 65 29 205 206 75 41 338 205 72 39 128 15 115 57 1867 1261 547 316 311 21 91 53 3094 1919 Group Avg
N30 Pectoralis Minor 176 112 132 83 79 21 89 39 77 31
128 56 68 342 113 57 1031 64
Table I: Shoulder Anterior Muscle Group SEMG Segmental Motions Sum Average Activity Potentials V RMS Muscle number ROM Anterior Flexion Abduction External Rotation Internal Rotation Lateral Flexion Posterior Flexion Sum Avg Group Sum Superior Shoulder Group N37 N84 Upper Trapezius Supraspinatus 149 113 157 149 253 21 221 136 37 317 229 179 239 231 187 179 219 171 265 184 233 239 151 111 1464 1281 1211 938 244 213 202 156 4386 3454 Group Avg N17 Levator Scapulae 148 94 328 282 332 257 3501 229 299 208 255 165 1711 1236 285 206 1462 1151
Discussion
Tables I to IV show that each individual muscle tested with SEMG through the shoulder segmental motions above has its own activity amplitude level In terms of overall ranking, the middle deltoid muscle lateral shoulder region shows the highest activity potentials, while the teres minor posterior shoulder region shows the least level of activity Ergonomic considerations would point to
the fact that the middle deltoid would be expected to fatigue earlier than other muscles since it is the lone ranger in terms of being the only muscle of its shoulder region In rehabilitation terms,
Table II: Shoulder Superior Muscle Group SEMG Segmental Motions Sum Average Activity Potentials V RMS Lateral Shoulder Muscle, N55 ROM Middle Deltoid Anterior Flexion 373 302 Abduction 445 268 External Rotation 368 244 Internal Rotation 255 267 Lateral Flexion 334 237 Posterior Flexion 29 232 Sum 2065 155 Avg 344 258 Table III: Shoulder Lateral Muscle Group SEMG Segmental Motions Sum Average Activity Potentials V RMS Posterior Shoulder Group N46 N30 Infraspinatus Latissimus Dorsi 278 185 114 98 264 124 132 87 303 113 111 62 164 118 97 59 221 137 76 25 239 165 233 186 1468 842 764 517 245 14 127 86 Group Avg N15 Teres Major 76 26 101 17 127 79 83 24 75 17 15 66 612 229 102 38 935 19 N15 Teres Minor 75 37 94 24 10 69 62 23 63 21 92 33 487 205 81
34
Muscle Number ROM Anterior Flexion Abduction External Rotation Internal Rotation Lateral Flexion Posterior Flexion Sum Avg Group Sum
N57 Posterior Deltoid 122 84 222 14 204 124 187 138 301 191 31 22 1346 897 224 149 4676 951
Table IV A: Shoulder Posterior Muscle Groups SEMG Segmental Motions Group Sum Average Activity Potentials V RMS
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Muscle Number N17 ROM Serratus Anterior Anterior Flexion 1 37 58 Abduction 121 48 External Rotation 108 4 Internal Rotation 52 23 Lateral Flexion 105 4 Posterior Flexion 152 132 Sum 675 341 Avg 113 57 Group Sum 53463 21587
Posterior Shoulder Group N15 N15 N15 Middle Trapezius Lower Trapezius Rhomboid Major 137 66 184 9 143 66 2602 151 288 14 26 113 404 23 332 156 293 167 323 187 92 44 187 119 313 114 175 75 221 115 208 83 116 92 173 85 1644 831 1186 597 1276 665 274 138 198 10 213 111 Group Avg 13366 5397
N15 Rhomboid Minor 172 86 285 132 291 128 131 62 198 99 162 76
1239 582 207 97
Table IV B: Shoulder Posterior Muscle Groups SEMG Segmental Motions Group Sum Average Activity Potentials V RMS Segmental Motion External Rotation Abduction Lateral Flexion Posterior Flexion Ranking 1 2 3 4 Sum SD 4028 2415 3987 229 3352 1908 3135 2147 Legend: sum total refers to the summation of all 17 muscles by segmental activity potentials V RMS Anterior Flexion 5 2962 1879 Internal Rotation 6 2777 1981
Table V: Shoulder Muscle Groups Ranking by SEMG Segmental Motions Sum Total Activity Potentials V RMS Shoulder Group N muscles in group Sum SD Avg SD Lateral I 1 2065 155 2065 155 Superior II 3 4386 3454 1462 1151 Posterior III 10 10696 34502 107 345 Anterior IV 3 3169 1976 1056 659
Table VI: Shoulder Muscle Groups Ranking by SEMG ROM Average of Activity Potentials V RMS
the superior shoulder region is the one most frequently associated with pain and dysfunction such as in myofascial trigger point pain syndromes and in rotator cuff injuries
Travell, 1983; Sella Finn, 2001; Sunderland, 1991 The clinician involved in SEMG biofeedback of the shoulder muscles may utilize the above data and the more comprehensive data found in Sella, 2000a, 2002, 2003 in order to design individual surface EMG treatment plans Thus, logic and common sense direct the biofeedback practitioner to treat in a ranking pattern following the principle of least resistance In quantitative terms, the practitioner may want to utilize the data described above by choosing the easiest muscle to work with first In other words, the practitioner would choose first the muscle that expends the least energy and start the neuromuscular reeducation in the segmental motion that has shown the least electrical amplitude of contractions When working with the anterior shoulder group muscles, one would choose pectoralis major to start with and would start the biofeedback process in the lateral flexion segment of motion The anterior flexion motion shows the highest
electric
potentials of effort, thus, it would be chosen last, after the pectoralis major has been well trained in the art of biofeedback performance of activity and rest Within the same group, the next muscle in sequence of least amplitude of contraction would be pectoralis minor One would also start the reeducation process in the lateral flexion motion and end it in the anterior flexion segment of motion Within the framework of segments of motion for all the muscles tested, the data from Table V show that external rotation requires the greatest energy of activity and internal rotation requires the least Thus, the biofeedback practitioner, be it in the rehabilitation field or in the ergonomic field, would be well advised to start the biofeedback program in internal rotation and move through the progression of anterior flexion, posterior flexion, lateral flexion, abduction and external rotation From an ergonomic standpoint, the data shown in Table V point clearly to the fact that since
the greatest effort is required in external rotation, any machinery or equipment should be built such that it requires that particular motion for the least amount of time in the course of any vocation The
data in Table VI point to the fact that the average activity of the anterior shoulder region is the lowest Most human shoulder motions are really performed most frequently within the anterior functional quadrant If one adds up all the data of the anterior, superior and lateral regions sum total of amplitude potentials, one finds 962 V RMS for the segments of motion described above Those numbers are more than balanced by the sum total of amplitude potentials of the posterior shoulder region 1070 V RMS Thus, one can conclude that since most shoulder motions occur in the anterior, superior and lateral regions, the posterior shoulder muscles perform not only an active role but also a sustaining role in terms of equilibrium of overall activity The strength of this study lies in the fact
that the data of 551 muscles now exist which makes it possible to draw a number of functional inferences not only in terms of SEMG dynamic protocol investigations, but also in terms of the muscular reeducation process with SEMG biofeedback Furthermore, the data presented can help infer the preferential sequence of testing and reeducating muscles in terms of the
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segmental motions of the shoulder The biofeedback practitioner should choose the sequence leading from the motion requiring least effort and move slowly up in terms of the different motions requiring more muscular effort Finally, the SEMG practitioner may decide which anatomic region of the shoulder one would work with in terms of either the SEMG investigation or the neuromuscular reeducation It is highly likely that different levels of shoulder muscle effort are required for different vocations Thus, the data presented in this article can serve as both a means of comparison as well as a goal in
terms of the final levels of activity amplitudes at minimal effort of contraction The limitations of this study involve the following: Some shoulder region muscles are not amenable to SEMG testing These include coracobrachialis and subscapularis It would be useful to repeat the study at different levels of effort These should include testing with different weights/resistances attached to the wrist Thus, the equilibrium tendency between the posterior shoulder region muscles and the other regions may change with different levels of resistance Finally, the testing would need to be done in different ergonomic or athletic conditions in order to assess the changes in the effort level required by different muscles, different shoulder regions or different shoulder motions Finally, the segmental motion of adduction was excluded from this study Results of muscular effort involving this motion may change to a limited extent the overall pattern of effort and regional
equilibrium
References
Cocchiarella, L, Andersson, G B J Editors 2001 AMA guides to the evaluation of permanent impairment, 5th Edition Chicago: American Medical Association Press Gerhardt, JJ, Sella, GE 2002 Inclinometry, SEMG, hand dynamometry in clinical and disability medicine, 2nd edition, revised Martins Ferry, OH: GENMED Publishing Sella, GE 1998a Surface EMG analysis of the shoulder range of motion Disability: The International Journal of the American Academy of Disability Evaluating Physicians, 7 2, 171-181 Sella, GE 1998b Muscular activity of the shoulder range of motion: Surface EMG analysis Europa Medicophysica, 34 4, 19-36 Sella, GE 2000a Muscular dynamics: Electromyographic assessment of energy and motion Martins Ferry, OH: GENMED Publishing Sella, GE 2000b Guidelines for neuro-muscular re-education with SEMG biofeedback Martins Ferry, OH: GENMED Publishing, Martins Ferry
Sella, GE, Finn, RE 2001 Myofascial pain syndrome: Manual trigger point and SEMG biofeedback
therapy methods Martins Ferry, OH: GENMED Publishing Sella, GE 2002 Muscles in motion: Surface EMG analysis of the human body range of motion, 3rd Edition, revised, Vols I II Martins Ferry, OH: GENMED Publishing Sella, GE 2003 SEMG muscular assessment reference manual, 2nd edition Martins Ferry, OH: GENMED Publishing Travell, JG, Simons, DG 1983 Myofascial pain and dysfunction: The trigger point manual, Vols 1 2 Baltimore: Williams Wilkins Sunderland, S 1991 Nerve injuries and their repair: A critical appraisal Edinburgh: Churchill Livingstone
Note
iAll correspondence should be addressed to the author at: GE Sella, MD, Ohio Valley Disability Institute, 92 N 4th Street, Martins Ferry, OH, 43935, email: Paris10@aolcom
QEEG and EEG Biofeedback
continued from page 28
Monastra, V J, Lubar, J F, Linden, M, VanDeusen, P, Green, G, Wing, W, Phillips, A, Fenger, T N 1999 Assessing Attention Deficit Hyperactivity Disorder via Quantitative Electroencephalography: An Initial Validation
Study Neuropsychology, 13, 3, 424-433 Monastra, V J, Monastra, D M, George, S 2002 The effects of stimulant therapy, EEG biofeedback, and parenting style on the primary symptoms of attention deficit/hyperactivity disorder Applied Psychophysiology, and Biofeedback, 27 4, 231-249 Moss, D, Gunkelman, J 2002 Task force report on methodology and empirically supported treatments: Introduction Applied Psychophysiology and Biofeedback, 27 4, 261-262 Moss, D, LaVaque, T J, Hammond, D C Eds in preparation White papers on psychophysiological treatments of clinical disorders: Series Wheat Ridge, CO: Association of Applied Psychophysiology and Biofeedback Prichep, L S, Mas, F, Hollander, E, Liebowitz, M, John, E R, Almas, M, et al 1993 Quantitative electroencephalography QEEG subtyping of obsessive compulsive disorder Psychiatry Research, 50 1, 25-32 Rosenfeld, J P 2000 An EEG biofeedback protocol for affective disorders Clinical Electroencephalography, 31, 7-12 Rossiter, T R, La Vaque, T J
1995 A comparison of EEG biofeedback and psychostimulants in treating attention deficit hyperactivity disorders Journal of Neurotherapy, 1, 48-59 Sime, A 2002, September Case study of trigeminal neuralgia using neurofeedback and peripheral biofeedback Presentation to the annual meeting of the International Society for Neuronal Regulation, Scottsdale, AZ Smith, P 2002, September Preliminary findings of effectiveness of biofeedback and neurofeedback modalities in an integrative treatment program for eating disorders Presentation to the annual meeting of the International Society for Neuronal Regulation, Scottsdale, AZ Yucha, C, Gilbert, C in press for 2003 Clinical efficacy of biofeedback therapy Wheat Ridge, CO: Association for Applied Psychophysiology and Biofeedback
Notes
Conclusions
An SEMG dynamic study of 551 muscles was performed for the purpose of assessing the different levels of effort and patterns of electrical activity through six shoulder segmental motions The results
allow for construing data referring to different segmental motions and muscular anatomic regions of the shoulder joint The SEMG activity potentials averages and summations of the shoulder muscles and motions allow clinical and ergonomic inferences both in the investigative realm and in the biofeedback/ muscular reeducation field
iAddress all correspondence to James Lake, MD, at Egret4@mindspringcom iiThe Association for Applied Psychophysiology and Biofeedback AAPB, 10200 W 44th St, 304, Wheat Ridge, CO 80033-2840, Phone 1-800-477-8296, web address wwwaapborg, e-mail aapb@resourcentercom, and the International Society for Neuronal Regulation ISNR, 394 Road 34, Merino, CO 80741, Phone 1-800-488-3867, web address http://wwwisnrorg/ iiiAt least one study reports some normalization of this ADHD electrophysiology by stimulant medications Clarke, Barry, Bond, McCarthy, R, Selikowitz, 2002
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ABOUT THE AUTHORS
Adam Burke, PhD, MPH, LAc, received a masters in
health education and a PhD in social psychology from the University of California, and acupuncture training in California and Sichuan, China He is currently assistant professor/associate director, Department of Health Education/Institute for Holistic Healing Studies, at San Francisco State University Dr Burke is actively engaged in acupuncture/mind-body healing research and policy work He also conducts workshops on the use of imagery and suggestion for optimal performance and runs a private practice in mind-body healing offering services in acupuncture, hypnosis and biofeedback Jessica Del Pozo, PhD is currently a postdoctoral fellow at the University of Miami in cardiovascular research at the Behavioral Medicine Research Center She received her doctorate in Health Psychology from the California School of Professional Psychology–San Diego in 2002 In San Diego, she used biofeedback in several medical settings including Scripps Center for Integrative Medicine in cardiac rehabilitation,
Sharp Hospital in pain rehabilitation, and Kaiser Permanente–Positive Choice Wellness Center Richard Gevirtz, PhD, is a professor in the Health Psychology Program at the California School of Professional Psychology at Alliant International University in San Diego He has been in involved in research and clinical work in applied psychophysiology for the last 25 years His primary interests are in understanding the physiological and psychological mediators involved in disorders such as chronic muscle pain and gastrointestinal pain He is the author of many journal articles and chapters on these topics Katherine Gibney is a biofeedback therapist and Clinic Manager at NovaCare Rehabilitation in Oakland, California She collaborates with Erik Peper in student research and Risk Management Prevention Programs at San Francisco State University She is co-author of two books, Healthy Computing with Muscle Biofeedback and Make Health Happen: Training Yourself to Create Wellness, of numerous articles
and research papers, and co-producer of Healthy Computing Email Tips She is co-director of Work Solutions, USA, which provides work-site prevention and employee training utilizing biofeedback James S Gordon, MD, is the Founder/Director of the Center for MindBody Medicine in Washington, DC, and Clinical Professor in Psychiatry and Family Medicine at the Georgetown University School of Medicine Dr Gordon served as Chairman of the White House Commission on Complementary and Alternative Medicine Policy, and as the first Chair of the Program Advisory Council of the National Institutes of Healths Office of Alternative Medicine and is a former member of the Cancer Advisory Panel on Complementary and Alternative Medicine of the NIH His most recent books are Comprehensive Cancer Care: Integrating Alternative, Complementary and Conventional Therapies and Manifesto for a New Medicine: Your Guide to Healing Partnerships and the Wise Use of Alternative Therapies He has written or edited nine other
books, and more than 120 articles His work has been featured on Good Morning America, The Today Show, CNN, CBS Sunday Morning, FOX News and National Public Radio, as well as in The Washington Post, USA Today, Newsweek, People, Town and Country, Hippocrates, Psychology Today, Vegetarian Times, Natural Health, Health and Prevention James Lake, MD, is a Board Certified psychiatrist who attended medical school at University of California, Irvine, and completed a residency in psychiatry at Stanford University Hospital His long-standing interests include studying the interface between mental health and culture, and examining philosophical and scientific perspectives of different systems of medicine as they pertain to diagnosis and treatment of psychiatric disorders Presently, he is in private practice in Pacific Grove, California, where he integrates conventional biomedical therapies and evidence-based alternative therapies for adult psychiatric disorders From 1998 through 2000 he was an
attending physician at Stanford University Hospital, where he consulted on psychiatric cases in the Complementary Medicine Clinic Donald Moss, PhD, is a partner in Western Michigan Behavioral Health in Grand Rapids and Grand Haven, Michigan, and directs their chronic pain services He is Editor of the Biofeedback Newsmagazine and Consulting Editor for the Journal of Neurotherapy and the Journal of Phenomenological Psychology He is adjunct graduate faculty for the Saybrook Graduate School and Research Center in San Francisco and the new applied psychophysiology program at the University of Natural Medicine in New Mexico He is senior editor of Handbook of Mind/Body Medicine for Primary Care Sage Erik Peper, PhD, is Professor and Director of the Institute for Holistic Healing Studies at San Francisco State University He is President of the Biofeedback Foundation of Europe and past President of the Biofeedback Society of America, now AAPB His most recent books are Healthy Computing with
Muscle Biofeedback and Make Health Happen: Training Yourself to Create Wellness He is coproducer of Healthy Computing Email Tips His research interests focus on psychophysiology of healing, healthy computing, respiratory psychophysiology and voluntary self-regulation Correspondence can be directed to ihhs@sfsuedu Gabriel E Sella, MD, MPH, MSc, has carried out research and clinical work in biofeedback for over ten years, published 85 articles, ten textbooks, and a technical CD
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ROM He has written chapters in several scientific textbooks and publications He has conducted over 250 international conferences and seminars, many of them in the area of SEMG investigation and neuromuscular rehabilitation, as well as soft tissue injury and pain He is a founding member of the Biofeedback Foundation of Europe, and is on the editorial board of several journals, including Europa Medicophysica David Siever graduated in 1978 as an engineering technologist He later worked
in the Faculty of Dentistry at the University of Alberta designing TMJ Dysfunction related diagnostic equipment and research facilities He organized research projects, and taught basic physiology and a TMJ diagnostics course Dave observed anxiety issues in many patients suffering with TMJ dysfunction, prompting him to learn and practice biofeedback and design biofeedback devices In 1984, Dave designed his first audio-visual entrainment AVE devicethe DAVID1 Since then he has researched and refined AVE technology, specifically for use in relaxation, and treating anxiety, depression, PMS, ADD, FMS, SAD, hypertension and insomnia He presents AVE technology applications regularly at conferences and for special interest groups Sebastian Seb Striefel, PhD, became a Professor Emeritus in the Department of Psychology at Utah State University in September 2000 For twenty six years he taught graduate level courses in ethics and professional conduct, clinical applications of biofeedback, clinical
applications of relaxation training and behavior therapy He was also the Director of the Division of Services at the Center for Persons with Disabilities at Utah State University In that role he
managed a variety of programs, including an outpatient clinic, a biofeedback lab and an early intervention program He is a past president of the Association for Applied Psychophysiology and Biofeedback AAPB, past president of the Neurofeedback
Division of AAPB and regularly writes an ongoing ethics column and conducts workshops on ethics, standards, and professional conduct
AAPB Practice Brief: Top Ten Most Common Mistakes Healthcare Professionals Make
1 Altering a clients records under any circumstances 2 Failing to document what you did or did not do and why 3 Failing to follow your own policies and procedures even when your actions fall within the standard of care 4 Treating a client improperly Never let the client feel like his or her opinion is unimportant or insignificant 5 Speaking in
a superior manner to a client using terminology he or she may not understand 6 Refusing to treat a client because of his/her condition 7 Telling a client that a co-worker made the error that caused the clients problem 8 Failing to obtain informed consent from the client 9 Breaching the clients confidentiality by discussing individual cases with friends or family members 10 Speaking in reference to a clients confidential information in an environment where unsuspecting family members or others may overhear the content of the information Please remember, no matter how cautious your approach, no matter how carefully you perform your job, the activities you are involved in on a daily basis can put your career and financial stability on the line Professional liability insurance is the only true way to protect yourself in the event of a lawsuit For information on the AAPB endorsed professional liability insurance program, please visit: http://wwwaapb-inscom Guidelines provided by Jeff
Powers, National Professional Group
Does AAPB have your e-mail address?
e-mail communications enable AAPB to communicate better with members E-mail communications also save AAPB money, and enable the Association to use your dues money for other critical activities
Please send your e-mail address today to the following address: aapb@resourcentercom
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Association for Applied Psychophysiology and Biofeedback 10200 W 44th Ave Suite 304, Wheat Ridge CO 80033-2840
Canadian Publication Agreement 1583581
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Association for Applied Psychophysiology and Biofeedback 35th Anniversary Annual Meeting April 2-4, 2004 Pre-Conference Workshops March 30 April 1, 2004 The Adams Mark Hotel Colorado Springs, CO
The experts are gathering in the Colorado Rockies this spring Come be a part of the rewarding learning experience and share in the fun when AAPB presents its 35th Anniversary
Annual Meeting Launching New Mind-Body Paradigms Because its our anniversary, the meeting is going to be especially exciting, with special events, a dance and other celebrations Gain valuable insight from our Workshops, Short Courses, Keynote Addresses, Special Presentations and Symposia representing the wide range of biofeedback, basic and applied psychophysiology, behavioral medicine, health psychology, and alternative, complementary or integrative medicine Harness the power behind various selfregulation methods, including EEG biofeedback, QEEG, EMG and SEMG, relaxation training, temperature regulation, and GSR Plus, get a closer look at the effects of alternative or complementary approaches such as hypnosis, Eastern and Western energy therapies, and others Many of the Sections/Divisions are sponsoring captivating Keynote speakers, such as Richard Davidson, PhD and Luciano Bernardi, MD Dont miss out Seize this opportunity to absorb the dynamic and thought-provoking research and
knowledge from professionals in your field STUDENTS: We encourage you to apply for the AAPB Foundation Student Scholarship Program, which provides 400 travel and complimentary registration to the Annual Meeting, to those selected The deadline to apply is December 1, 2003 For complete details, visit http://wwwaapborg/public/articles/detailscfm?id112 AAPB also has made available a limited number of free AAPB memberships for qualifying students To apply, please visit our website at wwwaapborg
aapb
FROM THE PRESIDENT
Lynda Kirk, MA, LPC, BCIA-C, QEEGT
As I glanced at the cover of the August 4th issue of Time magazine, the word MEDITATION jumped out at me Wow, I thought, Meditation made the cover of Time On the cover was a blissful-looking photo of actress Heather Graham meditating The covers big headline was The Science of Meditation The byline read: New Age mumbo jumbo? Not for millions of Americans who meditate for health and wellbeing Its time for Biofeedback to become a household
word Its time or should I say Time for Biofeedback to change from being in the shadows and mostly misunderstood to becoming a familiar friend After all, were coming up on our 35th Anniversary Its time for a change But how do we get from mostly misunderstood to the cover of Time? I suggest we borrow from the ideas of Malcolm Gladwell in his recent book, The Tipping Point Little, Brown and Company, 2000 In Gladwells book, the word Tipping Point comes from the science of epidemiology Its the name given to that moment in an epidemic when a communicable agent reaches critical mass Its the boiling point, that moment on the graph when the line starts to shoot straight upwards Gladwell applies what is known about epidemiology to non-medical contexts He argues that ideas, behavior,
News Events
Lets Start An Epidemic
messages and products sometimes behave just like outbreaks of communicable disease To understand how these social epidemics happen requires that we throw out our old beliefs
about how change comes about Gladwell says that we human beings expect everyday change to happen slowly and steadily But, he emphasizes, we need to be open to a new understanding that social epidemics can happen quickly and that even the smallest change like one child with something as communicable as chickenpox in a kindergarten class can get them started Things can happen almost all at once, and little changes can make a huge difference in reaching the tipping point So how does this new understanding help us get to the cover of Time? For one thing, it emphasizes the importance of little changes Most of us think that the little things we do wont really make much of a dent in the status quo But if we want to get the word out about the often profound and sometimes miraculous differences that we and our biofeedback technology can make in the lives of the people we touch, we each need to be agents of change, no matter how small We each need to be the contagious kid in the kindergarten
class who starts the epidemic And what are we infected with thats communicable? What is it that we want to spread? How about ease instead of dis-ease? How about increased immunity instead of vulnerability? How about wellness instead of illness? How about self-regulation instead of dysregulation? How about eustress instead of distress? How about peak performance instead of routine performance? How about optimal function instead of dysfunction? Like infectious optimism and infectious laughter, we can spread infectious information about the powerful effects of our technologies of transformation We Biofeedback practitioners have been too long in the shadows All of us need to take every opportunity to bring Biofeedback out into the sun Every time a local TV station runs a story, every time a newspaper prints something relevant, we need to respond And if we ask, we can get many of our clients and patients to respond too, both locally and nationally Ill share with you one example of a small
personal change that I made last week A member of AAPBs Marketing Task Force emailed me and asked if I had seen the televised segment about ADHD on CNNs Housecall The show was primarily slanted toward medication as the answer for ADHD and made no mention of EEG
Continued on page 4A
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FROM THE EXECUTIVE DIRECTORS DESK
Its That Time Again
Francine Butler PhD Executive Director, AAPB
We are about to have a Birthday AAPB will celebrate its 35th birthday at our Meeting in Colorado Springs on April 1-4, 2004 Somehow it is fitting that we will be in Colorado Springs, home of many past and memorable AAPB meetings Alas we wont be at the Broadmoor but those of you who want a taste of that venerable hotel can take a short drive and walk around the stately grounds or have dinner there or hoist a yard long beer at the Golden Bee Theres a bridge across the lake now but other than that, the memories abound Older usually comes with wiser and with more respect for the
elderly Without question I think we are wiser and weve learned a lot We make fewer assumptions and we have a sense of our worth Respect is another thing–we still are told that biofeedback is experimental and the reimbursement problems have not gone away Progress has been made and we should recognize the many achievements and accomplishments made by individual members and the organization Too often we focus on the negatives and forget the positives So thanks to all of you who have kept AAPB in the forefront and to those of who have supported AAPB through the years by continuing your membership and your volunteer efforts As to the future–we have a few challenges ahead of us and one, I believe, is to revisit and possibly redefine our identity For years we were a bit of a renegade in the healthcare world, sort of forging upstream and laying a path for others to follow I submit that biofeedback, while not a household word, is relatively mainstream now Itis still within the defined role of
alternative and complementary It is the oldest and most well established of that family of therapies We should use this fact to our advantage Interestingly the other half of our name has not fared so well Applied Psychophysiology is not a household word A name denotes meaning and while none of us question the term biofeedback, the AP part lacks definition in the eyes of users In other words, while it might have meaning to us, it does not have consumer identity In this world, consumer identity is critical If we want consumers to identify with AAPB we need a name they can identify with Some of you may not realize that we have changed names a few times evolving historically from the Biofeedback Research Society to the Biofeedback Society of America to AAPB There is a lot of history in those transitions In the first change we dropped the word Research and added a statement of geography In the second we tried to encompass a wider range of application and indeed, applied psychophysiology is
likely a more exact and appropriate name for what we do it is just that nobody understands it But note we did not drop the word biofeedback Try saying Association for Applied Psychophysiology and Biofeedback three times fast Try saying it once The emerging term is mind-body, a name that seems to better encompass what we are about Maybe it is time to revisit and incorporate that wording Now theres a vision for the next 35 years
Call for Nominations for 2004 Board Positions
The AAPB Nominations Committee has the responsibility for presenting a slate of individuals to serve as officers and board members The Nominating Committee seeks your suggestions for the following positions: President-Elect, Treasurer and two openings on the Board of Directors Board positions are for a term of three years Criteria for board positions include: current membership in AAPB; committee, chapter or section service; contributions to biofeedback and the field; and past association governance experience Board
members are required to attend two meetings per year, and abide by AAPB ethical principles, including signing a conflict of interest statement In the event that an individuals name is not on the official ballot, AAPB has a mechanism whereby a member, by using a petition process, may have his/her name placed on the ballot in addition to the Nominating Committees slate Members who wish to use the petition process to place their name on the ballot must use the official petition form, available from the AAPB office Only the official form will be accepted by the Nominating Committee Deadline for submission of petitions to the Nominating Committee is November 1, 2003
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FROM THE PRESIDENT-ELECT
A Cautionary Note
Steve Baskin, PhD
I am pleased to see this edition of Biofeedback devoted to applications involving Complementary and Alternative or Integrative Medicine I believe that biofeedback is the original CAM therapy, so original that many health care
professionals consider it mainstream now Biofeedback and self-regulation therapies help mobilize natural resources to better control our internal milieu Our clients learn voluntary control by getting information fed back about biologic processes that are normally beyond their awareness and control to help return to homeostasis or increase performance In my practice, over the years, Ive worked to enhance individuals ability to self-regulate; giving them a better sense of control over their internal and external environments I was drawn to biofeedback and behavioral medicine because I thought that the interplay between biologic processes and behavioral, cognitive, and emotional factors was an exciting development The concept of locus of control from social learning theory seemed beautifully tailored for this new field Individuals with an internal locus of control have the perception that life-events and circumstances, including their health, are the results of ones own actions while
externals believe that these same events are beyond ones own control relying on fate, chance, or other people Many interventions that blossomed in the biofeedback/behavioral medicine/health psychology world gave clients and patients more control as they addressed their health issues Many of the chronic headache sufferers Ive treated over the years have endured sinus and TMJ surgeries, invasive nerve blocks, IV antibiotics, lumbar punctures, and numerous MRI and CT scans to get that magical diagnosis or treatment that would make them all better Many in their search for a cure became analgesic over-users, obese, out of shape, helpless and mostly frustrated No doctor could fix them There was rarely a single magic pill They often improved when they began setting realistic goals, became an active participant in their care, began undoing maladaptive behaviors that maintained their headaches, and maximized their abilities to self-regulate They improved when they changed from embracing a
disease model to a coping skills model Recently Ive noticed a subset of patients taking numerous vitamins, minerals, and herbs everything I take is organic as well as being massaged, manipulated, energized, and balanced Many are looking for that new age magic pill They seem to believe that this is the alternative medicine that theyve been reading about The hospital where Im on the staff decided to develop an integrative medicine program The pharmacist has put in the most time trying to make sense out of the myriad of drug-drug interactions that some of these organic substances have precipitated Some aspects of this new program are gaining hospital acceptance We have a relaxation program for kids having elective surgery The children respond, feel less afraid and more in control, require less pain medication, and have better outcomes Sounds like a selfregulation coping skills model to me What is most interesting to me is that most initial successes in this new program are in approaches
that have fostered self-regulation and actual behavior change outside the treatment session The quick fix, either traditional or alternative, hasnt worked well with people with chronic health concerns My point in all this is that biofeedback and applied psychophysiology are the heart and soul of mind-body medicine There is nothing alternative about it Of course, we need to investigate scientifically the plethora of alternative medicine treatments that are emerging Many therapies outside the traditional standards of care are showing great promise However, we need to move away from a culture that guides people to take a statin, magnesium, niacin, three Chinese herbs, Viagra TM, and spa treatments yet remain overweight and sedentary while eating a big steak daily Im on the Atkins diet So I advise a cautionary note Lets help shape CAM/Integrative Medicine by gathering data and measuring outcome, and using our knowledge of self-regulation and behavior change to develop this field I believe
that the papers in this special issue are doing just that, integrating CAM with a self-regulation model
Award Nominations Invited
The AAPB membership is encouraged to submit nominations for the AAPB Distinguished Scientist Award and the Sheila Adler Distinguished Service Award These awards recognize outstanding contributions to research in applied psychophysiology and biofeedback and service and by a biofeedback professional Nominating letters should include the name and address of the nominees, name and address of the nominator and a brief statement describing why the person is being nominated for the award Letters should be addressed to the Awards Committee, and received at the offices of AAPB no later than November 15, 2003 The awards will be presented at the 2004 Annual Meeting
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From the President
continued from Page 1A biofeedback neurofeedback So I shot off an email to CNN and included Dr Vince Monastras study on EEG Biofeedback and ADHD that
appeared in the December 2002 AAPB Journal My email to CNN is at the end of this article for those interested in what I sent I wonder what might have happened if CNN had received letters, emails and calls from EEG biofeedback practitioners and their clients and patients from all over the country after their show I think we would have moved closer to the tipping point Together we can do it The key words are DO IT Lets start an epidemic Now
Dear CNN Housecall Crew, Thank you so much for featuring the important problem of Adult ADD today I would like to bring to your attention a non-drug alternative to the treatment of ADD/ADHD This treatment, EEG biofeedback, is equally successful with both adults and children An example study in the peer-reviewed journal Applied Psychophysiology and Biofeedback was recently featured in Reuters Health I have copied it for you below There are other studies but in the interest of time and space, I have included only the one below Perhaps your viewers would
like to know that there is an effective, non-drug alternative for adults and children with ADHD May I also suggest that this non-drug alternative would make an interesting and informative public interest story? Please feel free to contact me or AAPB if we can be of help to you with more information, more studies, etc Best regards, Lynda Kirk, MA, LPC, BCIA-C President Association of Applied Psychophysiology and Biofeedback
We Encourage Submissions
Send chapter meeting announcements, section and division meeting reports, and any non-commercial information regarding meetings, presentations or publications which may be of interest to AAPB members Articles should generally not exceed 750 words Remember to send information on dated events well in advance we may be able to publicize your event more than once if you get your calendar to us early enough Send Word doc or text files by e-mail to the News and Events Editor: Ted LaVaque, PhD tlavaque@gbonlinecom
Association of Applied
Physiology and Biofeedback Cooperates in New Membership Benefit Promoting Biofeedback Specialists
AAPB has joined with American WholeHealth AWH in a program to promote BCIA Certified Biofeedback practitioners to members of associations and health plans AARP, a nonprofit, nonpartisan membership organization for people 50 and better, has selected American WholeHealth to be the exclusive provider for the AARP Alternative Health and Wellness Network For AARP members the program provides excellent access to quality practitioners and wellness facilities at a discounted rate Based on industry and public surveys, people 50, who control 50 of US discretionary income, are increasingly seeking alternatives to maintain and promote health and fitness By joining the AWH Platinum Participating Practitioner program and paying an annual member fee, BCIA certified practitioners receive multiple direct to member program promotions and exposure on AARPs web site to over 35 million AARP members In
addition the program offers a listing on the award-winning AWH consumer website, WholeHealthMDcom, plus exposure to an additional 20 national and regional corporate clients of AWH, who direct their cashpaying members to the AWH network for services not covered by conventional health insurance The initial annual fee of 125 for the Platinum Participating Practitioner program also includes other membership benefits website building software, discounts on publications, practice management tools AWH has established a Biofeedback practitioner specialty listing for BCIA certificate holders This program offers BCIA certified members of AAPB an opportunity to highlight their specialty training and accomplishments within the AWH networks marketing exposure to the general public AAPB members in good standing receive a 20 discount on the annual membership fee when joining this AWH Platinum Participating Practitioner program Support this unique marketing initiative and send in your application
today For more information contact: Platinum Program customer service :888 893-4639 or visit the AWH professional website: wwwWholeHealthProcom American WholeHealth Networks 45999 Center Oak Plaza, Suite 100 Sterling, VA 20166
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Association for Applied Psychophysiology and Biofeedback Announces Strategic Partnership with American WholeHealth, Inc
The Association for Applied Psychophysiology and Biofeedback AAPB is pleased to announce a new program available through American WholeHealth, Inc, a provider of a nationwide network that integrates conventional and complementary health and wellness practitioners American WholeHealth has been selected by AARP as the exclusive provider for the AARP Alternative Health and Wellness Network As a BCIA certified AAPB practitioner you can also be part of this network Some of the services available through the AARP Alternative Health and Wellness Network include chiropractic care, pain management specialists,
massage/bodywork, mind/body therapies, acupuncture, nutrition, exercise/movement, holistic physicians and nurse practitioners, yoga, tai chi, chi gong, homeopathy, naturopathy, Feldenkrais, Pilates, and personal training Information is available on the AARP website at wwwaarporg/alternatives and wwwaarphealthcarecom As part of this program, AWH provides AARP members with information on alternative health practices and practitioner specialties via the award winning consumer content of WholeHealthmdcom American WholeHealth is proud to be the organization selected by Americas leading organization for people 50 and over, AARP, said Bill Lubin, PA, MBA, DrPH, President and CEO of American WholeHealth, Inc We are delighted to enter into this relationship with AARP This program is important for members, practitioners, and the industry For AARP members the program provides excellent access to quality practitioners and wellness facilities at a discounted rate The program also provides members
a wealth of information through American WholeHealths award winning site, WholeHealthMDcom For practitioners and wellness facilities, the program provides a new path to inform and serve the public as the industry moves into the mainstream of health care delivery Many AARP members select alternative health and wellness therapies to complement traditional medicine for a range of benefits including pain management, stress reduction, enhanced fitness or just to boost energy Were pleased to offer this new member benefit to help make this type of health care alternative more affordable to those members who select it, said Laura Weber Rossman, Director of New Products and Marketing, AARP Services Inc AARP is a nonprofit, nonpartisan membership organization for people 50 and better It provides information and resources; advocates on legislative, consumer, and legal issues; assists members to serve their communities; and offers a wide range of unique benefits, special products, and services for
its members These benefits include the AARP Web place at wwwaarporg, AARP, the Magazine, and the monthly AARP Bulletin Active in every state, the District of Columbia, Puerto Rico, and the US Virgin Islands, AARP celebrates the attitude that age is just a number and life is what you make it AARP Services Incorporated ASI is a wholly owned and independently operated subsidiary of AARP ASI is responsible for the management of various services and programs, which provide value to the AARP membership Practitioners in the Alternative Health and Wellness Network pay an annual fee and undergo screening of their credentials to become Platinum Participants with AWH in this special marketing of their services to AARP members Participating Practitioners agree to give a discount to AARP members for health and wellness services many of which are not covered by traditional insurance AWH has included a number of practice management tools and services in the cost of the annual Platinum program AAPB
has agreed to place a representative on the AWH Business Advisory Council to support and advise AWH in its program development The kickoff meeting of the AWH Business Advisory Council occurred in September 2002 in San Diego , where over 14,000 AARP members from across the US had gathered for their Life @ 50 member event American WholeHealth is the nations largest complementary health and wellness network company, dedicated to serving over 35 million lives through relationships with health plans, associations and employer groups, and to strengthening partnerships with over 25,000 practitioners across the county American WholeHealth supports the education of health care consumers via its award-winning site, WholeHealthMDcom American WholeHealth also supports its network participants through WholeHealthProcom, a professional web site that helps practitioners better serve their patients and improve their professional practice We are pleased that the AWH network recognizes our members in
their specialty credentialing and their consumer directories We are excited about the opportunity this represents for increasing public awareness of our biofeedback services and for our members to have a new option for marketing their services to the public said Francine Butler
Attention: APA Members
Remember to take your 25 discount on your APA renewal of dues See line 3 on the renewal page The explanation is on page 6 of the APA renewal package This benefit comes to you because you are a member of AAPB and AAPB belongs to the Federation of Behavioral, Psychological and Cognitive Sciences
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Since the genesis of the field 40 years ago, clinicians, researchers and patients have been waiting for a comprehensive textbook that would give a voice to the vast, emerging knowledge and information available in neurofeedback and biofeedback
TheNeurofeedback Book
The wait is over
An Introduction to Basic Concepts in Applied Psychophysiology
By Michael Thompson Lynda
Thompson
This is the book the field has been waiting for M Barry Sterman, PhD, Professor Emeritus, UCLA
Debuting this fall Advanced orders being taken now
Drs Michael and Lynda Thompson have made this book accessible for all levels of knowledge and experience ranging from the client just beginning to learn about his/her options to clinicians conducting advanced quantitative research The Neurofeedback Book provides a wealth of clinical information and procedures It is also a valuable resource toward which clinicians can direct patients who are seeking more information
Highlights include:
An easily understandable explanation of the science behind biofeedback and neurofeedback Clear, easy-to-understand and specifically helpful Order Form illustrations In-depth information about procedures and cutShip to: ________________________________________________________ ting-edge methodologies Insightful research and statistics to help you better Name:
_________________________________________________________ evaluate results Basic and detailed terminology germane to all Address: _______________________________________________________ EEG literature Material specifically written to prepare you for cer- City, State, Zip: _________________________________________________ tification, including a special section corresponding to the BCIA blueprint areas for EEG biofeedback Phone: ________________________________________________________
Look what experts are already saying:
This comprehensive textbook will make the remarkable but largely unknown field of neurofeedback accessible to family physicians, pediatricians and psychiatrists André Coté, MD, SDPQ Psych, DABFE; Former Medical Director, Royal Ottawa Hospital Regional Childrens Centre and Executive Director of Northern Ontario Francophone Psychiatric Programme If you are in the field of neurofeedback and/or biofeedback at any level, you simply MUST have this book It will save you
years of continuing education, speed up your learning curve, and give you techniques and information that you simply cant get anywhere else Lynda Kirk, MA, LPC, BCIA-C, QEEGT; President, Association for Applied Psychophysiology and Biofeedback and Past President, International Society for Neuronal Regulation [The Thompsons] are master teachers This book will be of great value to clinicians Tom Budzynski, PhD; Affiliate Professor of Psychology, University of Washington
Email: _________________________________________________________ Visa American Express Mastercard Card Number: ________________________________Exp Date: _________ Name on Card: __________________________________________________ The Neurofeedback Book by Michael Thompson and Lynda Thompson Prepublication Published non-members: 8900 9900 AAPB members: 6900 7900 Postage and Handling: first book: 800 each additional book: 300 Quantity Ordered: Postage/Handling: ________ ________
Whether you are using neurofeedback to
optimize performance or as a symptom management tool, this book will quickly become the first place to which you turn for answers Keep ahead of the knowledge curve by ordering your copy from the publisher today
Total: ________ Published by: Association for Applied Psychophysiology and Biofeedback 10200 West 44th Avenue, Suite 304, Wheat Ridge, CO 80033 Phone: 303-422-8436 Fax: 303-422-8894 Email: info@aapborg web site: http://wwwaapborg
AAPBs popular workshops are back dont miss these two new opportunities to get cutting-edge information from the most innovative and well-known experts in the field
Biofeed back
patients with ADHD Specify an empirically-based intervention program for treating the causes and resulting impairments of ADHD Review the essentials needed to provide effective educational support for students with ADHD Document the key components needed for providing a parenting program for caregivers Dr Monastra is nationally recognized for his ground-breaking research
on the use of QEEG techniques in the assessment and treatment of patients with ADHD His most recently published research examined the effects of a multi-modal treatment approach that integrates medication and parent training, as well as, neurophysiological, educational and nutritional interventions The lessons learned from his clinical research and practice will be published in the book, Parenting Children with ADHD: Lessons That Medicine Cannot Teach, due to be released in 2004
The Bestof
AAPB Winter Workshops 2003 Philadelphia, PA
Unlocking the Potential of Patients with AttentionDeficit/Hyperactivity Disorder: A Comprehensive, NeuroBehavioral Treatment Approach
Friday, December 5, 2003 9 am 5 pm Presenter: Vincent Monastra, PhD Clinical Director of the FPI Attention Disorders Clinic in Endicott, NY Attention-Deficit/Hyperactivity Disorder ADHD is the most commonly diagnosed, yet hotly debated, psychiatric disorder of childhood and adolescence Although this condition is
characterized by symptoms of inattention, hyperactivity, and impulsivity, the presence of other symptoms eg depression, anxiety and aggression in the majority of patients, makes the process of differential diagnosis a challenging one In addition, the severity of functional problems that occur in these patients require treatment plans that combine medical, neurophysiological, educational, nutritional, and parenting interventions This workshop will provide information about advances in the assessment and treatment of ADHD, including those derived from Quantitative Electroencephalography QEEG Emphasis will be placed on strategies for treating the typical ADHD patient, who presents with comorbid psychiatric conditions and significant functional impairments at home, school and in the community Attendees will: Describe a comprehensive process for evaluating the behavioral, neurophysiological and functional impairments of physiological response style, facilitate physiological self-regulation
to treat a variety of disorders, and as an adjunctive technique during psychotherapy Ample time will be given to the discussion of cases taken from the presenters clinical experience There also will be an opportunity to discuss your cases In addition to providing clinical applications of biofeedback, the workshop will serve as a review for those who are preparing for the BCIA General Certification Examination Attendees will: Review the basic physiology underlying sEMG, Finger Temperature, Skin Conductance Activity and Heart Rate Discuss the clinical applications of the physiological processes above in a typical mental health clinic Demonstrate applicable clinical biofeedback techniques used with clients Dr Montgomery has more that 30 years of clinical experience with biofeedback in a variety of settings As a member of the graduate faculty of Nova and Nova Southeastern University, he has taught the graduate course in Clinical Biofeedback for over 20 years In this role, he has
supervised graduate students conducting clinical outcome research, many of whom have had work published as case studies or controlled group comparisons He also maintains a part-time biofeedback practice His background includes eight years of full-time private practice in a neurosurgical clinic, where he offered direct service and supervised other biofeedback providers He has served on the boards of AAPB, BCIA and the Biofeedback Society of Florida
General Clinical Biofeedback: A Review
Saturday, December 6, 2003 9 am 5 pm Presented by Doil Montgomery, PhD Past-President AAPM, former Chair of BCIA This workshop will be a review of biofeedback and associated adjunctive techniques used in a mental health clinic It will cover clinical applications of Surface EMG, Finger Temperature, Skin Conductance Activity, and Heart Rate We will discuss how these modalities are used to assess
See reverse for registration information
Fall 2003 Biofeedback 7A
Who Should Attend
Psychologists, primary
care physicians, nurses, social workers, counselors, and others who wish to incorporate biofeedback into their clinical practice and/or wish to meet the didactic educational requirements for certification in general biofeedback by BCIA
REGISTRATION FORM Register: 1 Online: wwwaapborg The AAPB 2 Fax: 303-422-8894 Winter 2003 3 Mail: AAPB 10200 W 44th Ave Professional Suite 304, Wheat Ridge CO 80033-2840 Workshops
Last Name:___________________________First Name: _________________________________ Title: ____________________________________________________________________________ Organization: ____________________________________________________________________ Address: _________________________________________________________________________ City:____________________________State:__________________Zip: _____________________ Phone: ____ _____________________ Fax: ____ ____________________________________ E-mail:___________________________________________________________________________ Is
this an address change for the database? Yes No This information will be on your name tag Check here if you require special accommodations to fully participate Please attach a written description of your needs
Continuing Education Information for All Workshops
For Psychologists: The Association for Applied Psychophysiology and Biofeedback is approved by the American Psychological Association to offer continuing education for psychologists The APA Approved Sponsor maintains responsibility for the program For Nurses: The Association for Applied Psychophysiology and Biofeedback is approved as a provider of continuing education in nursing by the Colorado Nurses Association, which is accredited as an approver of continuing education in nursing by the American Nurses Credentialing Centers Commission on Accreditation
Join AAPB and take advantage of member rates
By Nov 19 Nov 19 NonNonMember member Member member Friday, December 5, 2003 Unlocking the Potential of Patients With 229 289
279 339 Attention-Deficit/Hyperactivity Disorder: A Comprehensive, Neuro-Behavioral Treatment Approach Saturday, December 6, 2003 General Clinical Biofeedback: A Review 229 289 279 339 Full-time students may take a 25 discount on courses check here for this option Provide ID Discount: For each additional registration from the same company, deduct 20 for each workshop For Continuing Education Purposes, Please Check: Psychologist Nurse Physician Other specify _______________________________ Workshop Fee Student Discount Multiple registration: Balance: _________ _________ __________ __________ After
Workshop Schedule
Each workshop is scheduled from 9:00 am to 5:00 pm with a one-hour lunch break Coffee will be available in the morning Registration will be available 30 minutes prior to the opening of each workshop
Meeting Location and Accommodations:
The workshops will be held at the DoubleTree Hotel in Philadelphia, PA Accommodation details will be included with your confirmation
packet
Air Travel and Car Rental
If you need assistance with travel arrangements, you may call Preferred Travel at 800 848-6864 or 303 298-7050 or fax requests to 303 298-7090 9:00 am to 6:00 pm MST Please identify yourself as an attendee of the AAPB Workshops
__________ Amount Enclosed Check made payable to AAPB Check ________ VISA Mastercard AMEX Credit Card __________________________ Exp Date ___/ Name of Cardholder:_______________________Signature: ___________________________________
Cancellation Policy
Cancellations received in writing by November 25, 2003 will be issued a refund less a 50 processing fee NO REFUNDS FOR CANCELLATIONS AFTER NOVEMBER 25, 2003 AAPB reserves the right to cancel In the unlikely event of cancellation, AAPB is not responsible for any costs, damages, or other expenses of any kind, including, without limitation, transportation, and/or hotel costs incurred by registrant Speakers subject to change without notice
8A
Biofeedback
Fall
2003
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