Tim Brunson DCH

Welcome to The International Hypnosis Research Institute Web site. Our intention is to support and promote the further worldwide integration of comprehensive evidence-based research and clinical hypnotherapy with mainstream mental health, medicine, and coaching. We do so by disseminating, supporting, and conducting research, providing professional level education, advocating increased level of practitioner competency, and supporting the viability and success of clinical practitioners. Although currently over 80% of our membership is comprised of mental health practitioners, we fully recognize the role, support, involvement, and needs of those in the medical and coaching fields. This site is not intended as a source of medical or psychological advice. -- Tim Brunson, PhD

Behavioral therapy for chronic migraine.



Chronic migraine is a disabling condition which affects a considerable proportion of patients. Several risk factors and lifestyle habits contribute to the transformation of migraine into a chronic form. Behavioral treatments, including relaxation, biofeedback, and cognitive behavioral therapy reduce the risk of episodic into chronic migraine transformation, thus restraining the headache-related disability. The rationale of behavioral therapies is that a medical problem should be recognized and thoroughly examined by the patient to be successfully managed. Being aware of factors which precipitate or aggravate migraine allows patients to progressively modulate the frequency and duration of their attacks. Similarly, the acquisition of healthy habits improves the quality of life and the subjective well-being of patients and contributes to breaking the vicious cycle that leads to migraine chronification. The highest level of care is achieved when behavioral therapies are integrated with other treatments, including physical and pharmacological interventions.

Curr Pain Headache Rep. 2013 Jan;17(1):304. doi: 10.1007/s11916-012-0304-9. Pistoia F, Sacco S, Carolei A. Department of Neurology, University of L'Aquila, Piazzale Salvatore Tommasi 1, 67100, L'Aquila, Italy, francesca.pistoia@univaq.it.

Behavioural treatments for Tourette syndrome: An evidence-based review.



Tourette syndrome (TS) is a disorder characterised by multiple motor and vocal tics and is frequently associated with behavioural problems. Tics are known to be affected by internal factors such as inner tension and external factors such as the surrounding environment. A number of behavioural treatments have been suggested to treat the symptoms of TS, in addition to pharmacotherapy and surgery for the most severe cases. This review compiled all the studies investigating behavioural therapies for TS, briefly describing each technique and assessing the evidence in order to determine which of these appear to be effective. Different behavioural therapies that were used included habit reversal training (HRT), massed negative practice, supportive psychotherapy, exposure with response prevention, self-monitoring, cognitive-behavioural therapy, relaxation therapy, assertiveness training, contingency management, ahan controls). Statistically significant differences in RMU time between groups were seen post intervention (-7% at T1 and +15% at T2 for the intervention group). Fifty-five percent of the intervention group was willing to continue using the mouse. It appears feasible to perform an RCT for this type of intervention in a workplace setting. Further study including more participants is suggested. Practitioner Summary: The study findings support the feasibility of conducting randomised control trials in office settings to evaluate ergonomics interventions. The intervention resulted in reduced pain and discomfort in the shoulder. The intervention could be a relevant tool in the reduction of upper extremity musculoskeletal disorder. Further research will better explain the study's preliminary findings.

Behav Neurol. 2012 Nov 27. Frank M, Cavanna AE. The Michael Trimble Neuropsychiatry Research Group, Department of Neuropsychiatry, University of Birmingham and BSMHFT, Birmingham, UK College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.

Psychological issues in the evaluation and treatment of tension-type headache.



Tension-type headache is the most common headache disorder, affecting approximately 40 % of Americans within a one-year span. Although the most common form, episodic tension-type headache, is rarely impairing, more frequent tension-type headache can occur with significant disability and psychological comorbidity. Appreciating the psychological impact, assessing the associated biopsychosocial issues, and understanding patients' coping styles are important in forming an appropriate treatment plan and maximizing treatment outcomes. A range of psychological therapies including relaxation training, cognitive behavioral therapy, biofeedback and mindfulness have demonstrated utility in treating chronic pain conditions and reducing the associated disability. This may be particularly applicable to special populations, including pediatric patients, pregnant patients and geriatric. Psychological assessment and treatment may be done conjointly with medication management and expands treatment options. There is great need to continue researching the effects of psychological treatments, standardizing interventions and making them available to the wider population.

Curr Pain Headache Rep. 2012 Dec;16(6):545-53. doi: 10.1007/s11916-012-0301-z. Rosen NL. Hofstra North Shore LIJ Medical Center, 611 Northern Boulevard, Suite 150, Great Neck, NY, 11021, USA, noheadaches@gmail.com.

Heart rate variability biofeedback reduces food cravings in high food cravers.



Heart rate variability (HRV) biofeedback has been reported to increase HRV while decreasing symptoms in patients with mental disorders. In addition, associations between low HRV and lowered self-regulation were found in non-clinical samples, e.g., in individuals with strong chocolate cravings or unsuccessful dieting. The current study aimed at decreasing food cravings with HRV-biofeedback in individuals frequently experiencing such cravings. Participants (N = 56) with strong or low food cravings associated with a lack of control over eating were selected from the local community. Half of the participants with strong cravings (craving-biofeedback; n = 14) performed 12 sessions of HRV-biofeedback while the other half (craving-control; n = 14) and a group with low cravings (non-craving-control; n = 28) received no intervention. Subjective food cravings related to a lack of control over eating decreased from pre- to post-measurement in the craving-biofeedback group, but remained constant in the control groups. Moreover, only the craving-biofeedback group showed a decrease in eating and weight concerns. Although HRV-biofeedback was successful in reducing food cravings, this change was not accompanied by an increase in HRV. Instead, HRV decreased in the craving-control group. This study provides preliminary evidence that HRV-biofeedback could be beneficial for attenuating dysfunctional eating behavior although specific mechanisms remain to be elucidated.

Appl Psychophysiol Biofeedback. 2012 Dec;37(4):241-51. doi: 10.1007/s10484-012-9197-y. Meule A, Freund R, Skirde AK, Vögele C, Kübler A. Department of Psychology I, University of Würzburg, Marcusstrasse 9-11, Würzburg, Germany. adrian.meule@uni-wuerzburg.de

A multi-modal approach to intervention for one adolescent's frontal lisp.



An adolescent with a persistent frontal lisp participated in a two-part 11-session intervention case study. The first phase used ultrasound imagery and acoustic, phonetic and voice education to provide information about articulatory setting (AS) and general awareness of the speech production process. The second phase used traditional articulation therapy, online visual-acoustic biofeedback and fluency strategies to target the frontal lisp directly (specifically /s/, /z/, /?/ and /?/). Trained listener evaluations of pre-intervention, post-phase 1 and post-phase 2 assessments showed no improvement after phase 1, but notable improvement in all treatment targets immediately after phase 2. These improvements were substantially maintained at assessment 4 months post-intervention. The outcomes suggest that direct training was more effective than the AS approach; however, the client's ability to self-monitor in phase 2, rapid acquisition of the targets and maintenance at 4 months post-intervention possibly reflected the knowledge gained in phase 1 about AS.

Clin Linguist Phon. 2013 Jan;27(1):1-17. doi: 10.3109/02699206.2012.734366. Lipetz HM, Bernhardt BM. School of Audiology and Speech Sciences , University of British Columbia, Vancouver, BC , Canada V6T 1Z3.

Bio-inspired adaptive feedback error learning architecture for motor control.



This study proposes an adaptive control architecture based on an accurate regression method called Locally Weighted Projection Regression (LWPR) and on a bio-inspired module, such as a cerebellar-like engine. This hybrid architecture takes full advantage of the machine learning module (LWPR kernel) to abstract an optimized representation of the sensorimotor space while the cerebellar component integrates this to generate corrective terms in the framework of a control task. Furthermore, we illustrate how the use of a simple adaptive error feedback term allows to use the proposed architecture even in the absence of an accurate analytic reference model. The presented approach achieves an accurate control with low gain corrective terms (for compliant control schemes). We evaluate the contribution of the different components of the proposed scheme comparing the obtained performance with alternative approaches. Then, we show that the presented architecture can be used for accurate manipulation of different objects when their physical properties are not directly known by the controller. We evaluate how the scheme scales for simulated plants of high Degrees of Freedom (7-DOFs).

Biol Cybern. 2012 Oct;106(8-9):507-22. Epub 2012 Aug 21. Tolu S, Vanegas M, Luque NR, Garrido JA, Ros E. CITIC-Department of Computer Architecture and Technology, ETSI Informática y de Telecomunicación, University of Granada, Granada, Spain, stolu@atc.ugr.es.

A bio-inspired glucose controller based on pancreatic ß-cell physiology.



Control algorithms for closed-loop insulin delivery in type 1 diabetes have been mainly based on control engineering or artificial intelligence techniques. These, however, are not based on the physiology of the pancreas but seek to implement engineering solutions to biology. Developments in mathematical models of the ß-cell physiology of the pancreas have described the glucose-induced insulin release from pancreatic ß cells at a molecular level. This has facilitated development of a new class of bio-inspired glucose control algorithms that replicate the functionality of the biological pancreas. However, technologies for sensing glucose levels and delivering insulin use the subcutaneous route, which is nonphysiological and introduces some challenges. In this article, a novel glucose controller is presented as part of a bio-inspired artificial pancreas. A mathematical model of ß-cell physiology was used as the core of the proposed controller. In order to deal with delays and lack of accuracy introduced by the subcutaneous route, insulin feedback and a gain scheduling strategy were employed. A United States Food and Drug Administration-accepted type 1 diabetes mellitus virtual population was used to validate the presented controller. Premeal and postmeal mean ± standard deviation blood glucose levels for the adult and adolescent populations were well within the target range set for the controller [(70, 180) mg/dl], with a percent time in range of 92.8 ± 7.3% for the adults and 83.5 ± 14% for the adolescents. This article shows for the first time very good glucose control in a virtual population with type 1 diabetes mellitus using a controller based on a subcellular ß-cell model.

J Diabetes Sci Technol. 2012 May 1;6(3):606-16. Herrero P, Georgiou P, Oliver N, Johnston DG, Toumazou C. Center for Bio-Inspired Technology, Institute of Biomedical Engineering, Imperial College London, London, United Kingdom. pherrero@imperial.ac.uk

Dynamical Behaviors of Rb-E2F Pathway Including Negative Feedback Loops Involving miR449.



MiRNAs, which are a family of small non-coding RNAs, regulate a broad array of physiological and developmental processes. However, their regulatory roles have remained largely mysterious. E2F is a positive regulator of cell cycle progression and also a potent inducer of apoptosis. Positive feedback loops in the regulation of Rb-E2F pathway are predicted and shown experimentally. Recently, it has been discovered that E2F induce a cluster of miRNAs called miR449. In turn, E2F is inhibited by miR449 through regulating different transcripts, thus forming negative feedback loops in the interaction network. Here, based on the integration of experimental evidence and quantitative data, we studied Rb-E2F pathway coupling the positive feedback loops and negative feedback loops mediated by miR449. Therefore, a mathematical model is constructed based in part on the model proposed in Yao-Lee et al. (2008) and nonlinear dynamical behaviors including the stability and bifurcations of the model are discussed. A comparison is given to reveal the implication of the fundamental differences of Rb-E2F pathway between regulation and deregulation of miR449. Coherent with the experiments it predicts that miR449 plays a critical role in regulating the cell cycle progression and provides a twofold safety mechanism to avoid excessive E2F-induced proliferation by cell cycle arrest and apoptosis. Moreover, numerical simulation and bifurcation analysis shows that the mechanisms of the negative regulation of miR449 to three different transcripts are quite distinctive which needs to be verified experimentally. This study may help us to analyze the whole cell cycle process mediated by other miRNAs more easily. A better knowledge of the dynamical behaviors of miRNAs mediated networks is also of interest for bio-engineering and artificial control.

PLoS One. 2012;7(9):e43908. doi: 10.1371/journal.pone.0043908. Epub 2012 Sep 18. Yan F, Liu H, Hao J, Liu Z. Department of Mathematics, Shanghai University, Shanghai, P. R. China ; Institute of System Biology, Shanghai University, Shanghai, P. R. China.

Tactile, gustatory, and visual biofeedback stimuli modulate neural substrates of deglutition.



It has been well established that swallowing kinematics are modified with different forms of exogenous and endogenous input, however the underlying neural substrates associated with these effects are largely unknown. Our objective was to determine whether the swallowing BOLD response is modulated with heightened sensory modalities (taste, cutaneous electrical stimulation, and visual biofeedback) compared to water ingestion (control) in healthy adults across the age span. Habituation and sensitization were also examined for each sensory condition. Our principal findings are that each sensory swallowing condition activated components of the swallowing cortical network, plus regions associated with the particular sensory modality (i.e. primarily frontal motor planning and integration areas with visual condition). Overall, the insula was most commonly active among the sensory modalities. We also discuss gradual increases and decreases in BOLD signal with repeated exposures for each condition. We conclude that both stimulus- and intention-based inputs have unique cortical swallowing networks relative to their modality. This scientific contribution advances our understanding of the mechanisms of normal swallowing cortical control and has the potential to impact clinical uses of these modalities in treatments for neurogenic dysphagia.

Neuroimage. 2011 Aug 18. Humbert IA, Joel S. Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, 98 North Broadway, Suite 403, Baltimore, MD 21231, USA.

Tongue-based biofeedback for balance in stroke: results of an 8-week pilot study.



OBJECTIVE: To assess balance recovery and quality of life after tongue-placed electrotactile biofeedback training in patients with stroke. DESIGN: Prospective multicenter research design. SETTING: Outpatient rehabilitation clinics. PARTICIPANTS: Patients (N=29) with chronic stroke. INTERVENTIONS: Patients were administered 1 week of therapy plus 7 weeks of home exercise using a novel tongue based biofeedback balance device. MAIN OUTCOME MEASURES: The Berg Balance Scale (BBS), Timed Up and Go (TUG), Activities-Specific Balance Confidence (ABC) Scale, Dynamic Gait Index (DGI), and Stroke Impact Scale (SIS) were performed before and after the intervention on all subjects. RESULTS: There were statistically and clinically significant improvements from baseline to posttest in results for the BBS, DGI, TUG, ABC Scale, and some SIS domains (Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, Social, Physical, Recovery domains). Average BBS score increased from 35.9 to 41.6 (P<.001), and DGI score, from 11.1 to 13.7 (P<.001). Time to complete the TUG decreased from 24.7 to 20.7 seconds (P=.002). Including the BBS, DGI, TUG, and ABC Scale, 27 subjects improved beyond the minimal detectable change with 95% certainty (MDC-95) or minimal clinically important difference (MCID) in at least 1 outcome and 3 subjects improved beyond the MDC-95 or MCID in all outcomes. CONCLUSIONS: Electrotactile biofeedback seems to be a promising integrative method to balance training. A future randomized controlled study is needed. Arch Phys Med Rehabil. 2011 Sep;92(9):1364-70. Badke MB, Sherman J, Boyne P, Page S, Dunning K. Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, WI, USA. mbadke5@aol.com

Virtual reality and pain management: current trends and future directions.



Virtual reality (VR) has been used to manage pain and distress associated with a wide variety of known painful medical procedures. In clinical settings and experimental studies, participants immersed in VR experience reduced levels of pain, general distress/unpleasantness and report a desire to use VR again during painful medical procedures. Investigators hypothesize that VR acts as a nonpharmacologic form of analgesia by exerting an array of emotional affective, emotion-based cognitive and attentional processes on the body's intricate pain modulation system. While the exact neurobiological mechanisms behind VR's action remain unclear, investigations are currently underway to examine the complex interplay of cortical activity associated with immersive VR. Recently, new applications, including VR, have been developed to augment evidenced-based interventions, such as hypnosis and biofeedback, for the treatment of chronic pain. This article provides a comprehensive review of the literature, exploring clinical and experimental applications of VR for acute and chronic pain management, focusing specifically on current trends and recent developments. In addition, we propose mechanistic theories highlighting VR distraction and neurobiological explanations, and conclude with new directions in VR research, implications and clinical significance.

Pain Manag. 2011 Mar;1(2):147-157. Li A, Montaño Z, Chen VJ, Gold JI. Children's Hospital Los Angeles, Departments of Anesthesiology Critical Care Medicine & Radiology, 4650 West Sunset Boulevard, MS#12, Los Angeles, CA 90027, USA.

The Mozart effect in biofeedback visual rehabilitation: a case report.



PURPOSE: To evaluate the usefulness of acoustic biofeedback by means of Mozart's Sonata for Two Pianos in D Major K. 448 to maintain and/or restore visual performance in a patient with macular pucker and glaucoma. METHODS: A 74-year-old patient with open angle glaucoma in both eyes and macular pucker in the right eye (RE) underwent visual rehabilitation with acoustic biofeedback by means of the MAIA™ Vision Training Module (Centervue, Padova, Italy) 10 minutes each eye once a week for 5 weeks. The patient was asked to move his eyes according to a sound which changed into Mozart's Sonata for Two Pianos when the patient locked the fixation target. RESULTS: Best-corrected visual acuity improved in his right eye (RE) and was stable in the left eye (LE). Fixation stability improved in both eyes, and retinal sensitivity decreased in the RE and improved in the LE. The characteristic of the macular pucker did not change during the training as demonstrated with optical coherence tomography. The patient was very satisfied with the training, as demonstrated by a 25-item questionnaire (National Eye Institute - Visual Functioning Questionnaire, NEI-VFQ-25). The patient's reading speed and the character size which he was able to read improved in his RE. CONCLUSION: Music could enhance synaptic plasticity and affect neural learning and fixation training by means of MAIA vision training. Therefore it can improve visual performance in patients with macular pucker, postpone the surgical time, and assure a better quality of life for the patient.

Clin Ophthalmol. 2011;5:1269-72. Salvatore S, Librando A, Esposito M, Vingolo EM. Department of Ophthalmology, University La Sapienza, Polo Pontino, Alfredo Fiorini Hospital, Terracina, Italy.

Efficacy of electromyographic biofeedback and electrical stimulation...



Full Title: Efficacy of electromyographic biofeedback and electrical stimulation following arthroscopic partial meniscectomy: a randomized controlled trial.

Objective: To compare the effectiveness of electromyographic biofeedback training and electrical stimulation therapy for rehabilitation following arthroscopic partial meniscectomy. Design: Randomized, prospective, controlled single-blind trial. Setting: Department of physical medicine and rehabilitation, university hospital. Subjects: Forty-five patients who had undergone surgery for arthroscopic partial meniscectomy were randomly divided into three groups with 15 patients in each group. Interventions: The control group had home exercise, the second and third groups received electromyographic biofeedback training or electrical stimulation therapy to quadriceps muscle in addition to home exercise. Main measures: The patients were evaluated for: visual analogue scale, gait velocity (m/s), time using a walking aid after surgery, Lysholm Knee Scoring Scale score, knee flexion-extension angle, maximum and average contraction powers of vastus medialis obliquus and vastus lateralis muscles on the day before the operation and two and six weeks after. Results: The time using a walking aid was 8.3 ± 8.0, 1.5 ± 2.5 and 4.5 ± 5.5 days, respectively, for the home exercise, electromyographic biofeedback training and electrical stimulation groups, and significantly shorter in the electromyographic biofeedback training than in the home exercise group (P < 0.017). While significant progress was detected in Lysholm Knee Scoring Scale score in the second and sixth postoperative weeks compared to the preoperative within-group evaluation for each of the three groups (P < 0.017), there was significant difference in Lysholm Knee Scoring Scale in the second postoperative week in favour of electromyographic biofeedback training compared to home exercise (P < 0.017). There were significant differences in vastus medialis obliquus average and vastus lateralis maximum and average contractions in favour of electromyographic biofeedback compared to home exercise and electrical stimulation in the second postoperative week (P < 0.017). Conclusions: The addition of electromyographic biofeedback training to a conventional exercise programme following arthroscopic partial meniscectomy helps to speed up the rehabilitation process.

Clin Rehabil. 2011 Oct 4. Akkaya N, Ardic F, Ozgen M, Akkaya S, Sahin F, Kilic A. Universty of Pamukkale, Medicine Faculty, Department of Physical Medicine and Rehabilitation, Denizli, Turkey.

Biofeedback in the treatment of heart disease.



Biofeedback is a method of training subjects to regulate their own physiology using feedback from physiologic sensors connected to an output display. Biofeedback-assisted stress management (BFSM) incorporates the physiologic signals with instructions on stress management. The goal of BFSM training is to give subjects the tools to control their own mental and physiologic reactions, leading to improved health and wellness. In cardiovascular disease, over activation of the sympathetic component of the autonomic nervous system and psychologic stress together negatively affect quality of life and clinical status. BFSM targets both areas. We hypothesize that this intervention can be used in cardiovascular disease to improve clinical status and quality of life, as well as interfere with disease progression. We are conducting trials of BFSM in heart failure and stable coronary artery disease. Preliminary data suggest that use of BFSM by heart failure patients may actually cause cellular and molecular remodeling of the failing heart in the direction of normal. We are comparing the effects of BFSM with usual care in patients with stable coronary artery disease, testing the hypothesis that the intervention will decrease both sympathetic hyperarousal and activation of the inflammatory cascade. Since heart rate variability is abnormal in both cardiovascular disease and depression, and since BFSM has been successfully used to change heart rate variability, we also expect this intervention to have a positive impact on the depression that often accompanies cardiovascular disease.

Cleve Clin J Med. 2011 Aug;78 Suppl 1:S20-3. Moravec CS, McKee MG. Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, NE61, Cleveland, OH 44195; moravec@ccf.org.

Neurofeedback in autism spectrum disorders.



Aim: To review current studies on the effectiveness of neurofeedback as a method of treatment of the core symptoms of autism spectrum disorders (ASD). Method Studies were selected based on searches in PubMed, Ovid MEDLINE, EMBASE, ERIC, and CINAHL using combinations of the following keywords: 'Neurofeedback' OR 'EEG Biofeedback' OR 'Neurotherapy' OR 'Mu-Rhythm' OR 'SMR' AND 'Autism' OR 'Autism Spectrum Disorder' OR 'Pervasive Developmental Disorder'. Results The existing evidence does not support the use of neurofeedback in the treatment of ASD. Studies with outcomes in favour of neurofeedback might be showing an improvement in comorbid attention-deficit-hyperactivity disorder symptoms rather than a true improvement in core ASD symptoms. Interpretation Limitations of this review are those inherent in the studies available, including small sample size, short duration, variable diagnostic criteria, and insufficient control interventions, all causing a lack of generalizability.

Dev Med Child Neurol. 2011 Jul 14. doi: 10.1111/j.1469-8749.2011.04043.x. Holtmann M, Steiner S, Hohmann S, Poustka L, Banaschewski T, Bölte S. LWL-University Hospital for Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics of the Ruhr University Bochum, Hamm, Germany Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Mannheim, Germany Department of Women's and Children's Health, Karolinska Institutet Centre of Neurodevelopmental Disorders, Karolinska Institutet, Stockholm, Sweden.

Obsessive-compulsive tendencies and undermined confidence...



Full Title: Obsessive-compulsive tendencies and undermined confidence are related to reliance on proxies for internal states in a false feedback paradigm.

BACKGROUND AND OBJECTIVES: We have previously hypothesized that obsessive-compulsive (OC) tendencies are associated with a general lack of subjective conviction regarding internal states, which leads to compensatory seeking of and reliance on more discernible substitutes (proxies) for these states (Lazarov, A., Dar, R., Oded, Y., & Liberman, N. (2010). Behaviour Research and Therapy, 48, 516-523). This article presents two studies designed to provide further support to this hypothesis by using false biofeedback as a proxy for internal states. METHODS: In Study 1 we presented high and low OC participants with pre-programmed false feedback showing either increasing or decreasing levels of muscle tension. In Study 2 we presented similar false feedback on level of relaxation to non-selected participants, half of which received instructions that undermined their confidence in their ability to assess their own level of relaxation. RESULTS: In Study 1, high OC participants were more affected by false biofeedback when judging their own level of muscle tension than were low OC participants. In Study 2, undermined confidence participants were more affected by false biofeedback when judging their own level of relaxation as compared to control participants. LIMITATIONS: Our findings are based on a non-clinical, highly functioning, largely female student sample and their generalization to OCD requires replication with a sample of OCD patients. CONCLUSIONS: These results provide converging evidence for our hypothesis by replicating and extending our previous findings. We discuss the implication of our hypothesis for the understanding and treatment of OCD and outline directions for future research.

J Behav Ther Exp Psychiatry. 2011 Jul 22;43(1):556-564. Lazarov A, Dar R, Liberman N, Oded Y. Department of Psychology, Tel Aviv University, Tel Aviv 69978, Israel.

Biofeedback therapy for symptoms of bowel dysfunction following surgery for colorectal cancer.



BACKGROUND: Following colorectal cancer (CRC) surgery, up to 60% of patients experience post-surgery bowel dysfunction (PSBD). This retrospective review aimed to evaluate biofeedback therapy with regard to patients' symptoms of fecal incontinence (FI) and stool frequency. METHODS: Patients with symptoms including frequency, urgency, FI, incomplete evacuation, failure to respond to dietary, medication or standard pelvic floor exercises (= 6 months) underwent biofeedback therapy between 2003 and 2006. Patients attended 3-4 sessions 1 week apart incorporating: anorectal function assessment; Fecal Incontinence Quality of Life (FIQL) and severity questionnaires; suggested coping strategies; dietary advice; bowel, food and exercise diary training; relaxation breathing; evacuation techniques; anal and pelvic floor muscle exercises using computerized visual feedback; and were reassessed at a final session following 4 weeks of home practice. RESULTS: Nineteen CRC PSBD patients [anterior resection (3); ultra-low anterior resection (10); segmental colectomy (2); and proctocolectomy (4)], mean age: 64.1 (95% CI: 47.0-81.3) years, participated. FIQL scales improved significantly for lifestyle, coping and embarrassment but not depression. Incontinence severity and number of bowel motions significantly decreased. Satisfaction with results of therapy was high. Subjective bowel control rating improved. FIQL scores further improved 2 years later. CONCLUSION: The holistic biofeedback protocol for PSBD in CRC patients is successful in the short and medium term.

Tech Coloproctol. 2011 Sep;15(3):319-26. Bartlett L, Sloots K, Nowak M, Ho YH. Faecal Incontinence Research Group, School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, QLD, 4811, Australia. Lynne.Bartlett@my.jcu.edu.au

Change in dexterity with sensory awareness training: a randomised controlled trial.



The role of sensory awareness in movement control is receiving increasing interest in sports and clinical literature as a feed-forward and feedback mechanism. The aim of the study was to assess the feasibility and effect of training in sensory awareness on dexterity in healthy adults. 29 healthy students were randomly allocated to a single-group, sensory awareness lesson with the dominant hand, the same lesson with the nondominant hand, or to a sham control group. Dexterity measures included the Purdue Pegboard Test, a grip-lift manipulandum, and perceived changes using a questionnaire. The sensory awareness lesson with the dominant hand produced a statistically significant improvement in mean dexterity compared to the control group, but not between the other two pairs of groups. The sensory awareness training paradigm is feasible and a single session improved dexterity in healthy adults.

Percept Mot Skills. 2011 Jun;112(3):783-98. Bitter F, Hillier S, Civetta L. International Centre for Allied Health Evidence, School of Health Sciences, University of South Australia.

A biofeedback cycling training to improve locomotion...



Full Title: A biofeedback cycling training to improve locomotion: a case series study based on gait pattern classification of 153 chronic stroke patients.

BACKGROUND: The restoration of walking ability is the main goal of post-stroke lower limb rehabilitation and different studies suggest that pedaling may have a positive effect on locomotion. The aim of this study was to explore the feasibility of a biofeedback pedaling treatment and its effects on cycling and walking ability in chronic stroke patients. A case series study was designed and participants were recruited based on a gait pattern classification of a population of 153 chronic stroke patients. METHODS: In order to optimize participants selection, a k-means cluster analysis was performed to subgroup homogenous gait patterns in terms of gait speed and symmetry.The training consisted of a 2-week treatment of 6 sessions. A visual biofeedback helped the subjects in maintaining a symmetrical contribution of the two legs during pedaling. Participants were assessed before, after training and at follow-up visits (one week after treatment). Outcome measures were the unbalance during a pedaling test, and the temporal, spatial, and symmetry parameters during gait analysis. RESULTS AND DISCUSSION: Three clusters, mainly differing in terms of gait speed, were identified and participants, representative of each cluster, were selected.An intra-subject statistical analysis (ANOVA) showed that all patients significantly decreased the pedaling unbalance after treatment and maintained significant improvements with respect to baseline at follow-up. The 2-week treatment induced some modifications in the gait pattern of two patients: one, the most impaired, significantly improved mean velocity and increased gait symmetry; the other one reduced significantly the over-compensation of the healthy limb. No benefits were produced in the gait of the last subject who maintained her slow but almost symmetrical pattern. Thus, this study might suggest that the treatment can be beneficial for patients having a very asymmetrical and inefficient gait and for those that overuse the healthy leg. CONCLUSION: The results demonstrated that the treatment is feasible and it might be effective in translating progresses from pedaling to locomotion. If these results are confirmed on a larger and controlled scale, the intervention, thanks to its safety and low price, could have a significant impact as a home- rehabilitation treatment for chronic stroke patients.

J Neuroeng Rehabil. 2011 Aug 24;8:47. Ferrante S, Ambrosini E, Ravelli P, Guanziroli E, Molteni F, Ferrigno G, Pedrocchi A. NearLab, Bioengineering Department, Politecnico di Milano, Milano, Italy. simona.ferrante@polimi.it.

Effects of heart rate variability biofeedback in subjects with stress-related chronic neck pain...



Full title: Effects of heart rate variability biofeedback in subjects with stress-related chronic neck pain: a pilot study.

Recent studies focusing on autonomic nervous system (ANS) dysfunctions, together with theoretical pathophysiological models of musculoskeletal disorders, indicate the involvement of ANS regulation in development and maintenance of chronic muscle pain. Research has demonstrated the effectiveness of heart rate variability (HRV) biofeedback (BF) in increasing HRV and reducing the symptoms of different disorders characterized by ANS aberration. The study investigated the effects of resonance frequency HRV BF on autonomic regulation and perceived health, pain, stress and disability in 24 subjects with stress-related chronic neck-shoulder pain. Twelve subjects participated in 10 weekly sessions of resonant HRV BF and were compared to a control group. Subjective reports and HRV measures during relaxation and in response to a standardized stress protocol were assessed for both groups pre- and post-intervention. Group × time interactions revealed a significantly stronger increase over time in perceived health (SF-36) for the treatment group, including vitality, bodily pain and social functioning. Interactions were also seen for HRV during relaxation and reactivity to stress. The present pilot study indicates improvement in perceived health over a 10 week intervention with HRV-biofeedback in subjects with chronic neck-pain. Increased resting HRV as well as enhanced reactivity to hand grip and cold pressor tests might reflect beneficial effects on ANS regulation, and suggest that this intervention protocol is suitable for a larger controlled trial.

Appl Psychophysiol Biofeedback. 2011 Jun;36(2):71-80. Hallman DM, Olsson EM, von Schéele B, Melin L, Lyskov E. Centre for Musculoskeletal Research, University of Gävle, SE-801 76, Gävle, Sweden, david.hallman@hig.se.

Exploring the effectiveness of a computer-based heart rate variability biofeedback program...



Full title: Exploring the effectiveness of a computer-based heart rate variability biofeedback program in reducing anxiety in college students.

Given the pervasiveness of stress and anxiety in our culture it is important to develop and implement interventions that can be easily utilized by large numbers of people that are readily available, inexpensive and have minimal side effects. Two studies explored the effectiveness of a computer-based heart rate variability biofeedback program on reducing anxiety and negative mood in college students. A pilot project (n = 9) of highly anxious students revealed sizable decreases in anxiety and negative mood following utilizing the program for 4 weeks. A second study (n = 35) employing an immediate versus delayed treatment design replicated the results, although the magnitude of the impact was not quite as strong. Despite observing decreases in anxiety, the expected changes in psychophysiological coherence were not observed.

Appl Psychophysiol Biofeedback. 2011 Jun;36(2):101-12. Henriques G, Keffer S, Abrahamson C, Jeanne Horst S. Graduate Psychology, James Madison University, Harrisonburg, VA, USA, henriqgx@jmu.edu.

Predictors of outcome of anorectal biofeedback therapy in patients with constipation.



Aliment Pharmacol Ther 2011; 33: 1245-1251 SUMMARY: Background Anorectal biofeedback therapy (BFT) is a safe and effective treatment in patients with constipation. Given the high prevalence of constipation and therefore high demand for BFT, there is a need to prioritise patients. Aims To explore clinical features and anorectal physiology which predict success or failure of BFT and to derive a statistical model which helps to predict the success of BFT. Methods A total of 102 patients with constipation referred for BFT were evaluated. All patients underwent comprehensive clinical and anorectal function assessment, including balloon expulsion testing. The BFT protocol consisted of a comprehensive 6-weekly visit programme comprising instruction on toilet behaviour and abdominal breathing, achieving adequate rectal pressure and anal relaxation, and balloon expulsion and rectal sensory retraining. Success of BFT was based on an improvement in global bowel satisfaction. Results Harder stool consistency (P = 0.009), greater willingness to participate (P < 0.001), higher resting anal sphincter pressure (P = 0.04) and prolonged balloon expulsion time (P = 0.02) correlated with an improvement in bowel satisfaction score. A longer duration of laxative use (P = 0.049) correlated with no improvement in bowel satisfaction score. Harder stools, shorter duration of laxative use, higher straining rectal pressure and prolonged balloon expulsion independently predicted successful BFT. A model (, where ß represents a regression coefficient, X is a given predictive variable and S(i) is the weighted index score for each individual) incorporating these four variables enabled prediction of successful BFT, with sensitivity and specificity of 0.79 and 0.81, respectively. Conclusions Important clinical and anorectal physiological features were found to be associated with outcome of anorectal biofeedback therapy in patients with constipation. This information and the predictive model will assist clinicians to prioritise patients for anorectal biofeedback therapy.

Aliment Pharmacol Ther. 2011 Jun;33(11):1245-51. doi: 10.1111/j.1365-2036.2011.04653.x. Epub 2011 Apr 6. Shim LS, Jones M, Prott GM, Morris LI, Kellow JE, Malcolm A. Gastrointestinal Investigation Unit, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia. Department of Psychology, Macquarie University, North Ryde, NSW, Australia.

Biofeedback-Assisted Cardiovascular Control in Hypertensives Exposed to Emotional Stress



The study was aimed at examining the effect of a short Heart Rate-Biofeedback(HR-BF) protocol on systolic (SBP) and diastolic (DBP) blood pressure levels and BP emotional reactivity. Twenty-four unmedicated outpatients with pre- and stage 1 hypertension, were randomly assigned to active treatment (BF-Training) or control (BP-Monitoring) group. Subjects in BF-Training Group underwent four BF sessions. Guided imagery of stressful events was introduced during sessions 3 and 4. Control participants self-monitored their BP at home for 4 weeks. Subjects in both groups performed an emotional Speech Test before and after the training (or monitoring) period. SBP and mean arterial pressure responses to the emotional Speech Test were significantly smaller after the BF-training than the BP-monitoring. Moreover, clinic SBP and DBP were significantly reduced by about 10 mmHg in BF-Training Group, whereas they remained unchanged in control group. Self-monitored BP decreased significantly in the active treatment group and not in control group. A short BF-training, including guided imagery of stressful events, was effective in reducing BP reactions to a psychosocial stressor. BP measured in the clinic, and self-monitored at home were also significantly reduced in the BF-Training Group. HR-BF appears to be a suitable intervention for hypertensive patients, mostly when BP increase is associated with emotional activation.

Appl Psychophysiol Biofeedback. 2011 Jun 9. Palomba D, Ghisi M, Scozzari S, Sarlo M, Bonso E, Dorigatti F, Palatini P. Department of General Psychology, University of Padova, Via Venezia, 8, 35131, Padua, Italy, daniela.palomba@unipd.it.

Resonances in the cardiovascular system caused by rhythmical muscle tension.



Paced 0.1 Hz breathing causes high-amplitude HR oscillation, triggering resonance in the cardiovascular system (CVS). This oscillation is considered to be a primary therapeutic factor in HRV biofeedback treatments. This study examined whether rhythmical skeletal muscle tension (RSMT) can also cause 0.1 Hz resonance in the CVS, and compared oscillatory reactivity in CVS functions caused by RSMT and paced breathing (PB). Sixteen young healthy participants completed five tasks: baseline, three RSMT tasks at frequencies of 0.05, 0.1, and 0.2 Hz, and a 0.1 Hz PB task. ECG, respiration, finger pulse, and skin conductance data were collected. Results showed that 0.1 Hz RSMT as well as 0.1 Hz PB triggered resonance in the CVS and caused equivalent oscillations in all measured CVS functions, although in women, RSMT compared to PB caused lower HR oscillation. Clinical application of 0.1 Hz RSMT is discussed.

Psychophysiology. 2011 Jul;48(7):927-36. doi: 10.1111/j.1469-8986.2010.01156.x. Epub 2010 Dec 10. Vaschillo EG, Vaschillo B, Pandina RJ, Bates ME. Center of Alcohol Studies, Rutgers-The State University of New Jersey, Piscataway, New Jersey, USA.

Resonances in the cardiovascular system caused by rhythmical muscle tension.



Paced 0.1 Hz breathing causes high-amplitude HR oscillation, triggering resonance in the cardiovascular system (CVS). This oscillation is considered to be a primary therapeutic factor in HRV biofeedback treatments. This study examined whether rhythmical skeletal muscle tension (RSMT) can also cause 0.1 Hz resonance in the CVS, and compared oscillatory reactivity in CVS functions caused by RSMT and paced breathing (PB). Sixteen young healthy participants completed five tasks: baseline, three RSMT tasks at frequencies of 0.05, 0.1, and 0.2 Hz, and a 0.1 Hz PB task. ECG, respiration, finger pulse, and skin conductance data were collected. Results showed that 0.1 Hz RSMT as well as 0.1 Hz PB triggered resonance in the CVS and caused equivalent oscillations in all measured CVS functions, although in women, RSMT compared to PB caused lower HR oscillation. Clinical application of 0.1 Hz RSMT is discussed.

Psychophysiology. 2011 Jul;48(7):927-36. doi: 10.1111/j.1469-8986.2010.01156.x. Epub 2010 Dec 10. Vaschillo EG, Vaschillo B, Pandina RJ, Bates ME. Center of Alcohol Studies, Rutgers-The State University of New Jersey, Piscataway, New Jersey, USA.

Biofeedback for fecal incontinence: a randomized study comparing exercise regimens.



BACKGROUND: : Fecal incontinence affects up to 11% of Australian community-dwelling adults and 72% of nursing home residents. Biofeedback is a recommended conservative therapy when medication and pelvic floor exercises have failed to improve patient outcomes. OBJECTIVE: : This study aimed to investigate the impact of a new exercise regimen on the severity of fecal incontinence and the quality of life of participants. DESIGN: : This was a randomized clinical study. SETTINGS: : This study was conducted at the Anorectal Physiology Clinic, Townsville Hospital, Queensland, Australia. PATIENTS: : Seventy-two participants (19 male), with a mean age of 62.1 years, attended 5 clinic sessions: 4 weekly sessions followed by 4 weeks of home practice and a follow-up assessment session. A postal survey was conducted 2 years later. INTERVENTION: : Thirty-seven patients (12 male) were randomly assigned to the standard clinical protocol (sustained submaximal anal and pelvic floor exercises) and 35 patients (7 male) were randomly assigned to the alternative group (rapid squeeze plus sustained submaximal exercises). MAIN OUTCOME MEASURES: : The main outcomes were measured by use of the Cleveland Clinic Florida Fecal Incontinence score and the Fecal Incontinence Quality of Life Scale survey tool. RESULTS: : No significant differences were found between the 2 exercise groups at the beginning or at the end of the study or as a result of treatment in objective, quality-of-life, or fecal incontinence severity measures. Sixty-nine participants completed treatment. The severity of fecal incontinence decreased significantly (11.5/20 to 5.0/20, P < .001). Eighty-six percent (59/69) of participants reported improved continence. Quality of life significantly improved for all participants (P < .001). Results were sustained 2 years later. Patients who practiced at least the prescribed number of exercises had better outcomes than those who practiced fewer exercises. LIMITATIONS: : This study was limited because it involved a heterogeneous sample, it was based on subjective reporting of exercise performance, and loss to follow-up occurred because of the highly mobile population. CONCLUSIONS: : Patients attending this biofeedback program attained significant improvement in the severity of their fecal incontinence and in their quality of life. Although introduction of rapid muscle squeezes had little impact on fecal incontinence severity or patient quality of life, patient exercise compliance at prescribed or greater levels did.

Dis Colon Rectum. 2011 Jul;54(7):846-56. Bartlett L, Sloots K, Nowak M, Ho YH. 1School of Public Health, Tropical Medicine & Rehabilitation Science, North Queensland Centre for Cancer Research, James Cook University, Townsville, Australia 2Clinical Measurements Unit, The Townsville Hospital, Townsville, Australia 3School of Medicine and the Australian Institute of Tropical Medicine, North Queensland Centre for Cancer Research, James Cook University, Townsville, Australia.

Measurement properties of the pressure biofeedback unit in the evaluation of transversus abdominis..



Full title: Measurement properties of the pressure biofeedback unit in the evaluation of transversus abdominis muscle activity: a systematic review.

BACKGROUND: Measurements from pressure biofeedback units (PBUs) can be used to evaluate the activity of the transversus abdominis (TrA) muscle indirectly. These measurements can classify patients or monitor the progress of treatment programmes for people with low back pain. OBJECTIVE: To systematically review studies on the measurement properties of PBUs for the assessment of TrA activity. DATA SOURCES: Eligible studies were identified through searches of PUBMED, CINAHL and BIREME (1990 to 2009). In addition, hand searches of journals and citation tracking were performed. STUDY SELECTION: Full-text studies involving any type of clinimetric tests of PBU measurement for the assessment of TrA activity were selected. DATA EXTRACTION: Two independent reviewers selected the studies, extracted the data and assessed methodological quality. DATA SYNTHESIS: Due to the heterogeneity of study designs and statistical analysis, it was not possible to pool the data for a meta-analysis. RESULTS: Six studies met the inclusion criteria. These studies were typically of low quality and recruited healthy subjects rather than patients with low back pain. The studies found moderate to good reproducibility (intra-class correlation coefficients from 0.47 to 0.82) and acceptable construct validity (intra-class correlation coefficients from 0.48 to 0.90). CONCLUSIONS: The current evidence about the measurement properties of PBUs for the assessment of TrA activity is mainly based on studies with suboptimal designs, and the findings from these studies are likely to be overly optimistic. The most important clinical questions about the measurement properties of PBUs for the assessment of TrA activity are yet to be answered.

Physiotherapy. 2011 Jun;97(2):100-6. Epub 2010 Oct 23. de Paula Lima PO, de Oliveira RR, Costa LO, Laurentino GE. Masters Programme in Physical Therapy, Universidade Federal de Pernambuco, Brazil. pedrofisioterapia@hotmail.com

Increased EMG response following electromyographic biofeedback treatment of rectus femoris muscle...



Full title: Increased EMG response following electromyographic biofeedback treatment of rectus femoris muscle after spinal cord injury.

OBJECTIVE: To study increases in electromyographic (EMG) response from the right and left rectus femoris muscles of individuals with long-term cervical spinal cord injuries after EMG biofeedback treatment. DESIGN: Repeated measure trials compared EMG responses before and after biofeedback treatment in patients with spinal cord injuries. MAIN OUTCOME MEASURES: The Neuroeducator was used to analyse and provide feedback of the EMG signal and to measure EMG response. SETTING: Department of Traumatic Orthopaedics, School of Medicine, University of São Paulo, Brazil. PARTICIPANTS: Twenty subjects (three men and 17 women), between 21 and 49 years of age, with incomplete spinal cord injury at level C6 or higher (range C2 to C6). Of these subjects, 10 received their spinal cord injuries from motor vehicle accidents, one from a gunshot, five from diving, three from falls and one from spinal disc herniation. RESULTS: Significant differences were found in the EMG response of the right rectus femoris muscle between pre-initial (T1), post-initial (T2) and additional (T3) biofeedback treatment with the subjects in a sitting position [mean (standard deviation) T1: 26µV (29); T2: 67µV (50); T3: 77µV (62)]. The mean differences and 95% confidence intervals for these comparisons were as follows: T1 to T2, -40.7 (-53.1 to -29.4); T2 to T3, -9.6 (-26.1 to 2.3). Similar differences were found for the left leg in a sitting position and for both legs in the sit-to-stand condition. CONCLUSIONS: The EMG responses obtained in this study showed that treatment involving EMG biofeedback significantly increased voluntary EMG responses from right and left rectus femoris muscles in individuals with spinal cord injuries.

Physiotherapy. 2011 Jun;97(2):175-9. Epub 2010 Aug 4. De Biase ME, Politti F, Palomari ET, Barros-Filho TE, De Camargo OP. Institute of Orthopaedics and Traumatology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil.

Athletes Are Different: Factors That Differentiate Biofeedback/Neurofeedback for Sport Versus...



Full Title: Athletes Are Different: Factors That Differentiate Biofeedback/Neurofeedback for Sport Versus Clinical Practice

by Vietta Wilson, PhD, and Erik Peper, PhD

Biofeedback and neurofeedback training procedures are often different for athletes than for clinical patients. Athletes come to improve performance whereas patients come to reduce symptoms. This article outlines factors that distinguish work with athletes from work with clinical patients. The differences in training include the purpose of training, the nature of the participant in training, session design, and covert factors underlying the training. Unlike clients, athletes often do intensive transfer of learning training, between 2 and 6 hours of daily sport practice across days, weeks, and months. Although biofeedback and neurofeedback are important factors for enhancing peak performance, there are many covert and overt factors producing performance success such as motivation, intensity of training, ''A-ha'' experiences, experimental expectancy, behavioral consequences, and mastery learning. The training process with athletes is illustrated through a case example of a young tennis player who mastered control of his anger.

Full article.

Short-term memory effects of an auditory biofeedback on isometric force control...



Full title: Short-term memory effects of an auditory biofeedback on isometric force control: Is there a differential effect as a function of transition trials?

The aim of the present study was to investigate memory effects, force accuracy, and variability during constant isometric force at different force levels, using auditory biofeedback. Two types of transition trials were used: a biofeedback-no biofeedback transition trial and a no biofeedback-biofeedback transition trial. The auditory biofeedback produced a low- or high-pitched sound when participants produced an isometric force lower or higher than required, respectively. To achieve this goal, 16 participants were asked to produce and maintain two different isometric forces (30±5% and 90N±5%) during 25s. Constant error and standard deviation of the isometric force were calculated. While accuracy and variability of the isometric force varied according to the transition trial, a drift of the force appeared in the no biofeedback condition. This result suggested that the degradation of information about force output in the no biofeedback condition was provided by a leaky memory buffer which was mainly dependent on the sense of effort. Because this drift remained constant whatever the transition used, this memory buffer seemed to be independent of short-term memory processes.

Hum Mov Sci. 2011 Jun;30(3):436-45. Epub 2011 Apr 1. Cuisinier R, Olivier I, Troccaz J, Vuillerme N, Nougier V. UJF-Grenoble 1/CNRS/TIMC-IMAG UMR 5525, Grenoble, F-38041, France.

Comparing biofeedback with active exercise and passive treatment...



Full title: Comparing biofeedback with active exercise and passive treatment for the management of work-related neck and shoulder pain: a randomized controlled trial.

Comparing biofeedback with active exercise and passive treatment for the management of work-related neck and shoulder pain: a randomized controlled trial.OBJECTIVES: To compare the effects of biofeedback with those of active exercise and passive treatment in treating work-related neck and shoulder pain. DESIGN: A randomized controlled trial with 3 intervention groups and a control group. SETTING: Participants were recruited from outpatient physiotherapy clinics and a local hospital. PARTICIPANTS: All participants reported consistent neck and shoulder pain related to computer use for more than 3 months in the past year and no severe trauma or serious pathology. A total of 72 potential participants were recruited initially, of whom a smaller group of individuals (n=60) completed the randomized controlled trial. INTERVENTIONS: The 3 interventions were applied for 6 weeks. In the biofeedback group, participants were instructed to use a biofeedback machine on the bilateral upper trapezius (UT) muscles daily while performing computer work. Participants in the exercise group performed a standardized exercise program daily on their own. In the passive treatment group, interferential therapy and hot packs were applied to the participants' necks and shoulders. The control group was given an education booklet on office ergonomics. MAIN OUTCOME MEASURES: Pain (visual analog scale), neck disability index (NDI), and surface electromyography were assessed preintervention and postintervention. Pain and NDI were reassessed after 6 months. RESULTS: Postintervention, average pain and NDI scores were reduced significantly more in the biofeedback group than in the other 3 groups, and this was maintained at 6 months. Cervical erector spinae muscle activity showed significant reductions postintervention in the biofeedback group, and there were consistent trends of reductions in the UT muscle activity. CONCLUSIONS: Six weeks of biofeedback training produced more favorable outcomes in reducing pain and improving muscle activation of neck muscles in patients with work-related neck and shoulder pain.

Arch Phys Med Rehabil. 2011 Jun;92(6):849-58. Ma C, Szeto GP, Yan T, Wu S, Lin C, Li L. Department of Rehabilitation Medicine, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China; Department of Rehabilitation Sciences, Hong Kong Polytechnic University, Hong Kong (SAR), China.

Biofeedback treatment for epilepsy



Anti-epileptic drugs are the mainstay in the management of epilepsy. However, approximately 30% of patients continue to have seizures despite optimal drug therapy. Behavioural interventions that include biofeedback have become increasingly popular over the last 3 decades, and the results have mostly been encouraging. Biofeedback is a non-invasive behavioural treatment that enables a patient to gain volitional control over a physiological process. In epilepsy, targeted parameters for biofeedback include electroencephalographic (EEG) measures of cortical activity, such as different EEG frequencies or cortical potentials (i.e., neurofeedback), and peripheral autonomic activity, such as Galvanic Skin Response (GSR). In this review, biofeedback using Sensory Motor Rhythm (SMR), Slow Cortical Potentials (SCP), and GSR are discussed. SMR biofeedback was established in the 1970s and is the most prominent methodology for biofeedback treatment of epilepsy in published literature. The technique is now regaining its popularity. SCP biofeedback was introduced in the 1990s. In contrast to SMR biofeedback, which modulates the frequency components of EEG, SCP biofeedback focuses on the regulation of potential changes (amplitude of DC shift). The clinical trials conducted using SCP biofeedback were larger than those conducted using SMR biofeedback, and their overall outcomes were promising. GSR biofeedback is a relatively new methodology in its application to epilepsy and focuses on the modulation of electrodermal measures of sympathetic activity. Compared to the neurofeedback approach, GSR biofeedback is much easier to implement, and evidence suggests that its clinical benefits can be achieved more rapidly. Although the biofeedback treatment may never achieve the status of an alternative to pharmacotherapy for epilepsy, current research findings strongly suggest that biofeedback has the potential to become a potent adjunctive non-pharmacological approach to reduce seizure frequency in patient with drug-resistant epilepsy. Further research, especially a well-controlled large clinical trial, is necessary and anticipated.

Brain Nerve. 2011 Apr;63(4):385-92. Nagai Y, Matsuura M. Brighton and Sussex Medical School, Clinical Imaging Sciences Centre.

The use of a respiratory rate biofeedback device to reduce dental anxiety...



Full title: The use of a respiratory rate biofeedback device to reduce dental anxiety: an exploratory investigation.

Anxiety experienced by individuals visiting the dental office to receive treatment is common. Evidence has shown biofeedback to be a useful modality of treatment for numerous maladies associated with anxiety. The purpose of the current pilot study was to investigate the use of a novel biofeedback device (RESPeRATE™) to reduce patients' pre-operative general anxiety levels and consequently reduce the pain associated with dental injections. Eighty-one subjects participated in this study, forty in the experimental group and forty-one in the control group. Subjects in the experimental group used the biofeedback technique, while those in the control group were not exposed to any biofeedback. All subjects filled out a pre-injection anxiety survey, then received an inferior alveolar injection of local anesthetic. Post-injection, both groups were given an anxiety survey and asked to respond to four questions regarding the injection experience using a Visual Analog Scale (VAS). With the use of the respiratory rate biofeedback device, there was a significant reduction of negative feelings regarding the overall injection experience, as measured by a VAS. Our findings demonstrate that this novel biofeedback technique may be helpful in the amelioration of dental anxiety, and may help produce a more pleasant overall experience for the patient.

Appl Psychophysiol Biofeedback. 2011 Jun;36(2):63-70. Morarend QA, Spector ML, Dawson DV, Clark SH, Holmes DC. Private Practice Limited to Periodontics, Cedar Rapids, IA, USA.

Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation...



Full title: Behavioral therapy with or without biofeedback and pelvic floor electrical stimulation for persistent postprostatectomy incontinence: a randomized controlled trial.

CONTEXT: Although behavioral therapy has been shown to improve postoperative recovery of continence, there have been no controlled trials of behavioral therapy for postprostatectomy incontinence persisting more than 1 year.

OBJECTIVE: To evaluate the effectiveness of behavioral therapy for reducing persistent postprostatectomy incontinence and to determine whether the technologies of biofeedback and pelvic floor electrical stimulation enhance the effectiveness of behavioral therapy.

DESIGN, SETTING, AND PARTICIPANTS: A prospective randomized controlled trial involving 208 community-dwelling men aged 51 through 84 years with incontinence persisting 1 to 17 years after radical prostatectomy was conducted at a university and 2 Veterans Affairs continence clinics (2003-2008) and included a 1-year follow-up after active treatment. Twenty-four percent of the men were African American; 75%, white.

INTERVENTIONS: After stratification by type and frequency of incontinence, participants were randomized to 1 of 3 groups: 8 weeks of behavioral therapy (pelvic floor muscle training and bladder control strategies); behavioral therapy plus in-office, dual-channel electromyograph biofeedback and daily home pelvic floor electrical stimulation at 20 Hz, current up to 100 mA (behavior plus); or delayed treatment, which served as the control group.

MAIN OUTCOME MEASURE: Percentage reduction in mean number of incontinence episodes after 8 weeks of treatment as documented in 7-day bladder diaries. RESULTS: Mean incontinence episodes decreased from 28 to 13 per week (55% reduction; 95% confidence interval [CI], 44%-66%) after behavioral therapy and from 26 to 12 (51% reduction; 95% CI, 37%-65%) after behavior plus therapy. Both reductions were significantly greater than the reduction from 25 to 21 (24% reduction; 95% CI, 10%-39%) observed among controls (P = .001 for both treatment groups). However, there was no significant difference in incontinence reduction between the treatment groups (P = .69). Improvements were durable to 12 months in the active treatment groups: 50% reduction (95% CI, 39.8%-61.1%; 13.5 episodes per week) in the behavioral group and 59% reduction (95% CI, 45.0%-73.1%; 9.1 episodes per week) in the behavior plus group (P = .32).

CONCLUSIONS: Among patients with postprostatectomy incontinence for at least 1 year, 8 weeks of behavioral therapy, compared with a delayed-treatment control, resulted in fewer incontinence episodes. The addition of biofeedback and pelvic floor electrical stimulation did not result in greater effectiveness.

TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00212264.

JAMA. 2011 Jan 12;305(2):151-9. Goode PS, Burgio KL, Johnson TM 2nd, Clay OJ, Roth DL, Markland AD, Burkhardt JH, Issa MM, Lloyd LK. Department of Veterans Affairs, Birmingham–Atlanta Geriatric Research, Education, and Clinical Center, Atlanta, Georgia, USA. pgoode@uab.edu

Neurofeedback intervention in fibromyalgia syndrome...



FULL TITLE: Neurofeedback intervention in fibromyalgia syndrome; a randomized, controlled, rater blind clinical trial.

We designed a randomized, rater blind study to assess the efficacy of EEG Biofeedback (Neurofeedback-NFB) in patients with fibromyalgia syndrome (FMS). Eighteen patients received twenty sessions of NFB-sensory motor rhythm (SMR) treatment (NFB group) during 4 weeks, and eighteen patients were given 10 mg per day escitalopram treatment (control group) for 8 weeks. Visual Analog Scales for pain and fatigue, Hamilton and Beck Depression and Anxiety Inventory Scales, Fibromyalgia Impact Questionnaire and Short Form 36 were used as outcome measures which were applied at baseline and 2nd, 4th, 8th, 16th, 24th weeks. Mean amplitudes of EEG rhythms (delta, theta, alpha, SMR, beta1 and beta2) and theta/SMR ratio were also measured in NFB group. All post-treatment measurements showed significant improvements in both of the groups (for all parameters p < 0.05). NFB group displayed greater benefits than controls (for all parameters p < 0.05). Therapeutic efficacy of NFB was found to begin at 2nd week and reached to a maximum effect at 4th week. On the other hand, the improvements in SSRI treatment were also detected to begin at 2nd week but reached to a maximum effect at 8th week. No statistically significant changes were noted regarding mean amplitudes of EEG rhythms (p > 0.05 for all). However, theta/SMR ratio showed a significant decrease at 4th week compared to baseline in the NFB group (p < 0.05). These data support the efficacy of NFB as a treatment for pain, psychological symptoms and impaired quality of life associated with fibromyalgia.

Appl Psychophysiol Biofeedback. 2010 Dec;35(4):293-302. Kayiran S, Dursun E, Dursun N, Ermutlu N, Karamürsel S. Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Kocaeli University, Umuttepe Campus, Old Istanbul Road 10, 41380 Kocaeli, Turkey.

Heart Rate Variability (HRV) and Posttraumatic Stress Disorder (PTSD)...



FULL TITLE: Heart Rate Variability (HRV) and Posttraumatic Stress Disorder (PTSD): A Pilot Study.

Exposure to combat experiences is associated with increased risk of developing Post Traumatic Stress Disorder. Prolonged exposure therapy and cognitive processing therapy have garnered a significant amount of empirical support for PTSD treatment; however, they are not universally effective with some patients continuing to struggle with residual PTSD symptoms. Heart rate variability (HRV) is a measure of the autonomic nervous system functioning and reflects an individual's ability to adaptively cope with stress. A pilot study was undertaken to determine if veterans with PTSD (as measured by the Clinician-Administered PTSD Scale and the PTSD Checklist) would show significantly different HRV prior to an intervention at baseline compared to controls; specifically, to determine whether the HRV among veterans with PTSD is more depressed than that among veterans without PTSD. The study also aimed at assessing the feasibility, acceptability, and potential efficacy of providing HRV biofeedback as a treatment for PTSD. The findings suggest that implementing an HRV biofeedback as a treatment for PTSD is effective, feasible, and acceptable for veterans. Veterans with combat-related PTSD displayed significantly depressed HRV as compared to subjects without PTSD. When the veterans with PTSD were randomly assigned to receive either HRV biofeedback plus treatment as usual (TAU) or just TAU, the results indicated that HRV biofeedback significantly increased the HRV while reducing symptoms of PTSD. However, the TAU had no significant effect on either HRV or symptom reduction. A larger randomized control trial to validate these findings appears warranted.

Appl Psychophysiol Biofeedback. 2010 Aug 3. Tan G, Dao TK, Farmer L, Sutherland RJ, Gevirtz R. Michael E. DeBakey Veterans Affair Medical Center, Houston, TX, USA.

A multi-module case-based biofeedback system for stress treatment.



OBJECTIVE: Biofeedback is today a recognized treatment method for a number of physical and psychological problems. Experienced clinicians often achieve good results in these areas and their success largely builds on many years of experience and often thousands of treated patients. Unfortunately many of the areas where biofeedback is used are very complex, e.g. diagnosis and treatment of stress. Less experienced clinicians may even have difficulties to initially classify the patient correctly. Often there are only a few experts available to assist less experienced clinicians. To reduce this problem we propose a computer-assisted biofeedback system helping in classification, parameter setting and biofeedback training. METHODS: The decision support system (DSS) analysis finger temperature in time series signal where the derivative of temperature in time is calculated to extract the features. The case-based reasoning (CBR) is used in three modules to classify a patient, estimate parameters and biofeedback. In each and every module the CBR approach retrieves most similar cases by comparing a new finger temperature measurement with previously solved measurements. Three different methods are used to calculate similarity between features, they are: modified distance function, similarity matrix and fuzzy similarity. RESULTS AND CONCLUSION: We explore how such a DSS can be designed and validated the approach in the area of stress where the system assists in the classification, parameter setting and finally in the training. In this case study we show that the case based biofeedback system outperforms trainee clinicians based on a case library of cases authorized by an expert.

Artif Intell Med. 2010 Oct 14. Ahmed MU, Begum S, Funk P, Xiong N, von Scheele B. School of Innovation, Design and Engineering, Mälardalen University, P.O. Box 883, SE-721 23, Västerås, Sweden.

Treatment of symptomatic abnormal skin scars with electrical stimulation.



OBJECTIVE: To evaluate the effect of non-invasive biofeedback electrical stimulation on symptomatic abnormal skin scars. METHOD: Thirty patients with over 140 scars with long-term pain and itch were recruited into the study. Patients monitored the intensity of symptoms (pain and itching) on a numerical rating scale. In addition, a modified Manchester scar scale was used to objectively assess digital photographs of each scar in terms of colour, contour, distortion and texture, while a non-invasive spectrophotometric intracutaneous analysis was used to monitor the scars' physical characteristics. RESULTS: The electrical stimulation device resulted in a clinically and statistically significant (p < 0.05) reduction of symptoms and scar scores. Pain and itch scores were both reduced to a median score of 0 by 2 months, from a baseline of 7 and 6 respectively. Scar scores were reduced from a baseline of 14 to a median score of 11 by 2 months. CONCLUSION: These results give a preliminary indication of the potential role of non-invasive biofeedback electrical stimulation in the management of chronic scar pain and itch. However, further large scale controlled studies are warranted to elucidate its overall efficacy and mechanistic action. CONFLICT OF INTEREST: Funding was provided from Fenzian Ltd for this study.

J Wound Care. 2010 Oct;19(10):447-53. Perry D, Colthurst J, Giddings P, McGrouther DA, Morris J, Bayat A. School of Translational Medicine, University of Manchester, UK.

Complementary and Alternative Medicine for Pain: An Evidence-based Review.



Pain is one of the most prevalent conditions for which patients seek medical attention. Additionally, the number of patients who utilize complementary and alternative medicine as a treatment of pain either in lieu of, or concurrent with, standard conventional treatments continues to grow. While research into the mechanisms, side effect profiles, and efficacies of these alternative therapies has increased in recent years, much more remains unknown and untested. Herein, we review the literature on complementary and alternative medicine for pain, with particular emphasis on evidence-based assessments pertinent to the most common alternative therapies, including acupuncture, herbal therapy, massage therapy, hypnosis, tai chi, and biofeedback.

Curr Pain Headache Rep. 2010 Nov 10. Dhanani NM, Caruso TJ, Carinci AJ. Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 15 Parkman Street, Boston, MA, 02114, USA.

Nonpharmacologic Treatments for Migraine and Tension-Type Headache...



FULL TITLE: Nonpharmacologic Treatments for Migraine and Tension-Type Headache: How to Choose and When to Use.

OPINION STATEMENT: There are a variety of nonpharmacologic treatments for headache. Educating patients about headache and its management, identifying and managing triggers (via diaries), modifying lifestyles, and understanding the importance of adopting and adhering to interventions (either pharmacologic or nonpharmacologic) are relevant to all persons with headache. In addition, specific nonpharmacologic treatments can be used either alone or in conjunction with ongoing pharmacologic intervention. Strong candidates for nonpharmacologic treatment include individuals with significant headache-related disability, comorbid mood or anxiety disorders, difficulty managing stress or other triggers, medication overuse, and patients who prefer a specific treatment. Behavioral treatments (relaxation, biofeedback, and cognitive-behavioral therapy) possess the most evidence for successful headache management. They have a long history of randomized trials showing efficacy and are considered first-line preventive options. Among complementary and alternative treatments, recent positive findings from randomized trials using acupuncture provide evidence of its potential as a first-line intervention. Other complementary and alternative techniques do not have a consistent base of research to recommend them for headache prevention, but they may be used if the patient prefers this approach or when other first-line interventions (nonpharmacologic or pharmacologic) have not provided adequate results. Among "natural" treatments, both butterbur extract and vitamin B2 have shown efficacy in more than one randomized trial and are thus potentially useful first-line preventive interventions.

Curr Treat Options Neurol. 2010 Nov 16. Nicholson RA, Buse DC, Andrasik F, Lipton RB. Department of Neurology & Psychiatry, Saint Louis University School of Medicine, 1402 S. Grand Blvd. Monteleone Hall, St. Louis, MO, 63104, USA, nicholra@slu.edu.

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