BIOFEEDBACK USE OF BIOFEEDBACK IN PAIN AND STRESS MANAGEMENT, TECHNIQUES AND EVIDENCE BASED PRACTICE Guided by –vidhushi mam PRESENTED BY –NISHA CHAUHAN Amity university A138141620003 Introduction Father of Biofeedback: John Basmajian Biofeedback is a technique which enables the individual to readily determine the activity levels of a particular physiological process, and with appropriate training, learn to manipulate the same process. Professional biofeedback organizations, gave a definition for biofeedback in 2008 1. 2. 3. Association of Applied Psychophysiology & Biofeedback(AAPB) Biofeedback Certification International Alliance (BCIA) The International Society for Neurofeedback and Research (ISNR), “Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately 'feed back' information to the user. The presentation of this information often in - conjunction with changes in thinking, emotions, and behaviour supports desired physiological changes. Over time, these changes can endure without continued use of an instrument.” Association for Applied Psychophysiology and Biofeedback.2008-05-18 Neuro Rehabilitation 3 types of biofeedback used 1. EMG biofeedback 2. Position biofeedback 3. Force biofeedback EMG Biofeedback -Weak & poorly controlled muscles -Training relaxation of overactive muscles -Determine patients potential Position Biofeedback -Train regulation of movement Force Feedback -Gives information regarding force being transmitted through specific body segments USE OF BIOFEEDBACK During a biofeedback session, electrodes are attached to skin. Finger sensors can also be used. These electrodes/sensors send signals to a monitor, which displays a sound, flash of light, or image that represents heart and breathing rate, blood pressure, skin temperature, sweating, or muscle activity. When a person is under stress, the functions change. heart rate speeds up, muscles tighten, blood pressure rises, sweat, and breathing quickens. These stress responses as they happen on the monitor, and then get immediate feedback as a person try to stop them. Biofeedback sessions are typically done in a therapist's office, but there are computer programs that connect the biofeedback sensor to patients own computer. As patient slow his heart rate, lower blood pressure, and ease muscle tension, he'll get instant feedback on the screen. Eventually, he'll learn how to control these functions on its own, without the biofeedback equipment. Several different relaxation exercises are used in biofeedback therapy, including: • Deep breathing • Progressive muscle relaxation -- alternately tightening and then relaxing different muscle groups • Guided imagery -- concentrating on a specific image (such as the color and texture of an orange) to focus mind and make patient feel more relaxed • Mindfulness meditation -- focusing thoughts and letting go of negative emotions Biofeedback Uses Biofeedback can help many different conditions. Chronic pain.-By helping patient to identify tight muscles and then learn to relax those muscles, biofeedback may help relieve the discomfort of conditions like low back pain, abdominal pain, temporomandibular joint disorders (TMJ), and fibromyalgia. For pain relief, biofeedback can benefit people of all ages, from children to older adults. Headaches-Headaches are one of the best-studied biofeedback uses. Muscle tension and stress can trigger migraines and other types of headaches, and can make headache symptoms worse. There is good evidence that biofeedback therapy can relax muscles and ease stress to reduce both the frequency and severity of headaches. Biofeedback seems to be especially beneficial for headaches when it's combined with medications. Anxiety. Anxiety relief is one of the most common uses of biofeedback. Biofeedback lets patient become more aware of his body's responses when patients are stressed and anxious. Then patient can learn how to control those responses. Urinary Incontinence. Biofeedback therapy can help people who have trouble controlling the urge to use the bathroom. Biofeedback can help women find and strengthen the pelvic floor muscles that control bladder emptying. After several sessions of biofeedback, women with incontinence may be able to reduce their urgent need to urinate and the number of accidents they have. Biofeedback can also help children who wet the bed, as well as people with fecal incontinence (the inability to control bowel movements). Unlike drugs used to treat incontinence, biofeedback doesn't tend to cause side effects. High Blood Pressure. Evidence on the use of biofeedback for high blood pressure has been mixed. Although the technique does seem to lower blood pressure slightly, biofeedback isn't as effective as medication for blood pressure control. Other biofeedback uses include:- Attention deficit hyperactivity disorder (ADHD) Chronic obstructive pulmonary disease (COPD) High blood pressure Raynaud's disease Injury Asthma Constipation Epilepsy Rheumatoid arthritis Types of Biofeedback Electromyography Feedback thermometer Feedback goniometer Electrodermograph Electroencephalography Photoplethysmography Electrocardiogram Pneumography Capnometer Rheoencephalography Hemoencephalography Feedback Thermometer -Detects skin temperature with a thermistor (a temperature-sensitive resistor) usually attached to a finger or toe. -Raynaud’s disease, chronic pain, oedema, essential hypertension, anxiety and stress. Feedback goniometer -This is an elastic structure that gives a feedback to the patient when the joint has reached a predefined joint angle. -Also monitoring joints that do not have a stable rotation axis, such as the thoracic scapula because, unlike other joint Electroencephalography -An electroencephalograph (EEG) measures the electrical activation of the brain from scalp sites located over the human cortex. -Attention deficit hyperactivity disorder (ADHD), learning disability, anxiety disorders, depression, migraine, and generalized seizures. Photoplethysmography -Measures the relative blood flow through a digit -Treating chronic pain, edema, essential hypertension, Raynaud’s disease, anxiety, and stress. Electrocardiogram -Activity of the heart and measures the inter beat interval. -Biofeedback therapists use heart rate variability (HRV) biofeedback when treating asthma, COPD, depression, fibromyalgia, heart disease. Pneumography -Dysfunctional breathing patterns include clavicular breathing, reverse breathing behaviours which include apnoea, gasping, sighing, and wheezing. -Provide feedback about the relative expansion/contraction of the chest and abdomen, and can measure respiration rate Capnometer -A capnometer or capnograph uses an infrared detector to measure end-tidal CO2 -Anxiety disorders, asthma, chronic pulmonary obstructive disorder (COPD), essential hypertension, panic attacks, and stress. Electromyography(EMG) Electromyography (EMG) is the study of muscle function through analysis of the electrical signals emanated during muscle contraction. Electromyogram records the motor unit action potentials (MUAP’s) produced as a result of recruitment of the motor units following muscle contraction EVIDENCE BASED PRACTISE Biofeedback: Information for Pain Management Biofeedback is an integrative techniques that can be used to help patients cope with pain. By David Cosio, PhD, ABPP and Erica H. Lin, PharmD, BCACP There are 3 stages that occur during the biofeedback training. During the first stage, the patient gains awareness of his/her problematic physical response. Individuals identify how their bodies respond to a variety of stressors and determine their ability to overcome the undesired physical reactions. During the second stage, the patient uses the signals from the biofeedback to control his/her physical responses. The individual is coached by the therapist to reach certain goals related to managing a specific physical response. At the final stage, the patient transfers control from the biofeedback equipment to themselves. Individuals learn through trial and error to identify triggers that alert them to implement the self-regulation skills they learned. At the conclusion of treatment, patients are typically encouraged to practice the mental exercises daily. There are some contraindications for biofeedback that one must keep in mind. Certain cases are discouraged to pursue biofeedback therapy, including people with severe psychosis or neurosis, individuals with a pacemaker or other implantable electrical device, debilitated patients, and patients with psychopathic personalities. Biofeedback should only be used as an adjunct to, not a replacement treatment for, pharmacologic treatment of depression, diabetes, and other endocrine disorders. Biofeedback is considered to be a safe, non-drug intervention that does not appear to have any negative side effects. A positive side effect of biofeedback is that patients can use self-regulation skills to help manage other life stressors. Patients can use these skills anywhere at any time, independent of medications or doctors. • Mindful Body Scans and Sonographic Biofeedback as Preparatory Activities to Address Patient Psychological States in Hand Therapy: A Pilot Study DAVID S BLACK,CHERYL VIGEN, MARK E HARDISON, SHAWN C ROLL Introduction: This pilot study aimed to determine potential benefits of including a mindful body scan or sonographic biofeedback at the outset of a hand therapy session on key psychological states. Methods: A randomized, repeated-measures, cross-over design was used to evaluate a mindful body scan and sonographic biofeedback at the outset of a hand therapy session. Measures of pain, anxiety, and stress (i.e., salivary cortisol) were obtained from 21 hand therapy patients at the start, after 20 minutes, and at the end of each of three 60-minute treatments. Trends were examined, and mixed-effects regression compared effects across time within and across the sessions for each of the outcome measures. Results: For all intervention types, anxiety and stress decreased across the treatment session (p<0.001); no statistically significant changes were noted in pain. Using either mind-body intervention before standard care resulted in a meaningful decrease and statistical trend toward improvement in stress. The use of a mindful body scan produced an immediate, statistically significant reduction in anxiety (β = -0.14, p = 0.03), a lowered level that was maintained throughout the therapy session. • Mobile Neurofeedback for Pain Management in Veterans with TBI and PTSD Elbogen EB, Alsobrooks A, Battles S, Molloy K, Dennis PA, Beckham JC, McLean SA, Keith JR, Russoniello C. Abstract Objective: Chronic pain is common in military veterans with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Neurofeedback, or electroencephalograph (EEG) biofeedback, has been associated with lower pain but requires frequent travel to a clinic. The current study examined feasibility and explored effectiveness of neurofeedback delivered with a portable EEG headset linked to an application on a mobile device. Design: Open-label, single-arm clinical trial. Setting: Home, outside of clinic. Subjects: N = 41 veterans with chronic pain, TBI, and PTSD. Method: Veterans were instructed to perform "mobile neurofeedback" on their own for three months. Clinical research staff conducted two home visits and two phone calls to provide technical assistance and troubleshoot difficulties. Results: N = 36 veterans returned for follow-up at three months (88% retention). During this time, subjects completed a mean of 33.09 neurofeedback sessions (10 minutes each). Analyses revealed that veterans reported lower pain intensity, pain interference, depression, PTSD symptoms, anger, sleep disturbance, and suicidal ideation after the three-month intervention compared with baseline. Comparing pain ratings before and after individual neurofeedback sessions, veterans reported reduced pain intensity 67% of the time immediately following mobile neurofeedback. There were no serious adverse events reported. Conclusions: This preliminary study found that veterans with chronic pain, TBI, and PTSD were able to use neurofeedback with mobile devices independently after modest training and support. While a double-blind randomized controlled trial is needed for confirmation, the results show promise of a portable, technology-based neuromodulatory approach for pain management with minimal side effects. • Heart Rate Variability Biofeedback to Treat Fibromyalgia: An Integrative Literature Review Reneau M. Objectives: Fibromyalgia (FM) is associated with debilitating pain and a reduced heart rate variability (HRV), reflecting decreased emotional adaptability and resistance to stress. Common pharmacological treatments are ineffective, and opioids are highly addictive and cause an estimated 15,000 overdose deaths per year. Effective recommendations include patient-centered interventions like physical activity, cognitive behavioral therapy, and biofeedback. Heart rate variability biofeedback (HRVB) may be effective in improving HRV, thus increasing stress resistance and emotional adaptability and reducing pain. Design: This integrative literature review was conducted to examine the relationship between HRVB and FM-related chronic pain using the Theory of Symptom Self-Management and to identify available HRVB technology. Data sources: PubMed, EBSCOhost, and Google Scholar electronic databases for relevant publications. Manuscripts were selected using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses strategy, and study quality was assessed using the Critical Appraisal Skills Programme guidelines. The relationship between HRVB and FM was analyzed and evaluated based on the methodological framework proposed by Whittemore and Knafl. Review/analysis methods: Reviewed 22 articles and included six in this review. Five reported HRVB as a treatment for chronic pain, and one for FM pain. Results: Overall, the articles in this review support the claim that HRVB is related to decreased pain. The researchers evaluated five HRVB programs, three on handheld devices and two on desktop computers. Conclusions: The reviewed studies had methodological flaws. However, HRVB is a promising treatment for chronic pain. Larger, randomized controlled studies are needed to thoroughly evaluate the relationship between HRVB and FM pain. • Biofeedback an evidence based approach in clinical practice Erik Peper, Richard Harvey, Naoki TAKEBAYASHI Clinical biofeedback procedures are highly effective ameliorating a variety of symptoms that range from urinary incontinence to hypertension as well as assess a person's somatic awareness by making the invisible visible. The paper reviews the biofeedback process and some psychosomatic applications. Psychosomatic patients often demand more skills than just attaching them to the equipment. Successful treatment includes a) assessing physiology as a diagnostic strategy, b) explaining the illness processes and healing strategies that are congruent with patients' perspective, c) reframing the patients' illness beliefs, and d) psychophysiological training with homework practices to generalize the skills. This process is illustrated through the description of a single session with a patient who experienced severe gastrointestinal distress and insomnia. • Biofeedback in rehabilitation Oonagh M Giggins, Ulrik McCarthy Persson & Brian Caulfield This paper reviews the literature relating to the biofeedback used in physical rehabilitation. The biofeedback methods used in rehabilitation are based on biomechanical measurements and measurements of the physiological systems of the body. Neuromuscular biofeedback methods include electromyography (EMG) biofeedback and realtime ultrasound imaging (RTUS) biofeedback. EMG biofeedback is the most widely investigated method of biofeedback and appears to be effective in the treatment of many musculoskeletal conditions and in post cardiovascular accident (CVA) rehabilitation. RTUS biofeedback has been demonstrated effective in the treatment of low back pain (LBP) and pelvic floor muscle dysfunction. Cardiovascular biofeedback methods have been shown to be effective in the treatment of a number of health conditions such as hypertension, heart failure, asthma, fibromyalgia and even psychological disorders however a systematic review in this field has yet to be conducted. Similarly, the number of large scale studies examining the use of respiratory biofeedback in rehabilitation is limited. Measurements of movement, postural control and force output can be made using a number of different devices and used to deliver biomechanical biofeedback . Inertial based sensing biofeedback is the most widely researched biomechanical biofeedback method, with a number of studies showing it to be effective in improving measures of balance in a number of populations. Other types of biomechanical biofeedback include force plate systems, electrogoniometry, pressure biofeedback and camera based systems however the evidence for these is limited. While a number of studies in this area have been conducted, further large scale studies and reviews investigating different biofeedback applications in different clinical populations are required. Recent developments in biofeedback for neuromotor rehabilitation The original use of biofeedback to train single muscle activity in static positions or movement unrelated to function did not correlate well to motor function improvements in patients with central nervous system injuries. -He Huang1, Steven L The concept of task-oriented repetitive training Wolf2 and Jiping He*1,3 suggests that biofeedback therapy should be delivered during functionally related dynamic -Published: 21 June movement to optimize motor function 2006 Journal of improvement. NeuroEngineering and Rehabilitation 2006, 3 Current, advanced technologies facilitate the design of novel biofeedback systems that possess diverse parameters, advanced cue display, and sophisticated control systems for use in task-oriented biofeedback. References Biofeedback-principles & practice for clinicians.-Basmajian. Physical rehabilitation- Susan o Sullivan PUBMED THANKYOU
