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Figure 3. EMG recordings of bilateral paraspinal muscle activity during a symmetrical activity (simulation). Both muscles should follow approximately the same pattern of tensing and relaxing during a motion and should reach about the same levels of tension. The solid line is the left paraspinal and the dotted line is the right paraspinal. The figure shows a patient attempting to tense both sets of muscles, hold the tension, and relax again. The patterns are obviously less symmetrical before than after training.
Before training After training
It is important to emphasize teaching patients to instantly shut off the paraspinal muscles after straightening up following a bend and rise cycle. If the trapezius is involved, teach patients to instantly shut them off after a shrug. Most patients with low back pain have far more tension in their paraspinals than is normal – even given the incredible range of “normal” discussed earlier. For these patients, virtually the same protocol as described for headaches can be used except that tension in both the left and right paraspinals and, as appropriate, the trapezius, is fed back. Patients are given the same tension awareness/relaxation exercise and are told to practice it the same way as are headache patients. They are taught to become very aware of when they are tensing their back muscles inappropriately at home and then in the work environment.
Typical protocol: During the first half of a typical biofeedback session have patients begin in a standing position. First they work on relaxing their muscle to normal levels using shaping techniques as necessary. Then they tense the lower back for about two seconds and then relax for about five seconds. Have the patient repeat this cycle at least ten times while we both watch the monitor and work to correct abnormalities. Remember that most patients with low back pain cannot tell how tense their muscles are so you are training them to recognize how tense they actually are at various levels of tension. This is the calibration exercise discussed earlier. For the last half of the session, have the patient bend forward 30 degrees and then stand back up slowly. The key is to get them to keep the signals of the two EMG channels within about fifteen percent of symmetrical (about the normal amount of left – right variability) and to relax quickly when they stand up.
Physical therapists with extensive experience incorporating biofeedback into back pain interventions such as Glenn Kasman (1998), Susan Middaugh (2003), Randy Neblett (2002, 2004), Steve Wolf (1998), and many others have developed detailed protocols for treating musculoskeletal back pain. The protocols usually center around (1) correcting posture – especially during work, (2) correcting incorrect motions, and (3) strengthening weak muscles. These form the basis for the authors' treatments as well. Always attempt to simulate the environment in which the back pain occurs. Thus, for people who spend a great deal of time working at computers, simulate the computer work station and do both an ergonomic and muscle tension evaluation of their position and work habits. The lack of very brief breaks during typing and similar work is very evident when watching the recording.
A crucial part of training is to incorporate the “five percent” rule into the biofeedback regime. It is based on Susan Middaugh’s philosophy that limbs kept only five degrees away from proper posture (e.g. arms slightly forward of vertical while using a keyboard), muscles kept only five percent tenser than necessary while working (e.g. shoulders tense while typing), and (from Glaros’s work) muscles kept minimally tense only five percent longer than necessary (e.g. after the task is completed) can result in severe pain which quickly becomes chronic. Thus, it is important to insure that any problems of this nature are noted. The patient is trained to become aware of these muscular problems and to correct them immediately. When dealing with people who do manual labor, the therapist should be especially careful to train them to be very aware of (1) when muscles are inappropriately tense during the task and (2) when muscles remain inappropriately tense after the task. This training virtually always requires training patients in muscle tension awareness and relaxation skills.
Correcting Concurrent Problems
Posture. Correcting postural problems is as important as correcting the static and motion problems described above so patients must be taught to be aware of and to correct any such problems which became evident during the assessment. See the appendices for exercises.
Improper Back Utilization and Weakness. Often patients use their back incorrectly at the work place, sit incorrectly, or simply have muscles too weak to perform the required tasks. Evaluation of these problems is normally performed by physical and occupational therapists trained in ergonomics. They frequently perform biofeedback interventions in the work place or work with therapists trained to perform biofeedback to correct muscle use problems. They tend to prescribe a very wide variety of muscle strengthening exercises as discussed earlier.
Treatments for Piriformis Syndrome and Trigger Points. If piriformis syndrome or trigger points are present, they have to be treated either before or concurrently with the psychophysiological intervention or the odds of making real progress are minimal.
3. Non-Cardiac Chest Pain
Gevirtz and his team (DeGuire, Gevirtz, Hawkinson, & Dixon,1996; Gevirtz, 2001; Moynihan & Gevirtz, 2001) have shown that there is a solid relationship between anxiety and non-cardiac related chest pain. They have also shown that abnormal patterns of respiration, which are well known to lead to feelings of anxiety due to changes in concentration of carbon dioxide, also result in non-cardiac chest pain. Their review of the literature indicates that between 51 and 90% of non-cardiac related chest pain is associated with hyperventilation. Retraining breathing patterns results in long term (at least three years) control of stress-related cardiac pain symptoms and hyperventilation-related symptoms such as anxiety. DeGuire, et al. evaluated the long-term effects of paced diaphragmatic breathing on subjects who reported functional cardiac symptoms and who also demonstrated associated signs of hyperventilation syndrome. Subjects were a representative sample composed of 10 out of the original 41 subjects who had participated three years previously in a study designed to evaluate the short-term effects of breathing retraining on functional cardiac symptoms and respiratory parameters (respiratory rate and end-tidal carbon dioxide). The results of this follow-up study indicate that breathing retraining had lasting effects on both respiratory parameters measured. Subjects evidenced significantly higher end-tidal carbon dioxide levels and lower respiratory rates when compared to pretreatment levels measured three years earlier. Subjects also continued to report a decrease in the frequency of functional cardiac symptoms when compared to pretreatment levels. Their study shows that correction of abnormal breathing patterns relieves the chest pain or eliminates it all together without further intervention to correct an anxiety disorder. Thus, it is the sequelae of incorrect breathing which create both anxiety and chest pain for many patients – not an underlying anxiety disorder which results in incorrect breathing.
Potts, Lewin, Fox, and Johnstone (1999) used a combination of: education, relaxation, breathing training, graded exposure to activity and exercise, and challenging automatic thoughts about heart disease to treat 60 patients who had continuing chest pain despite cardiological reassurance following haemodynamically normal angiography. The treatment was delivered in six sessions over eight weeks to groups of up to six patients. The patients kept daily records of chest pain episode frequency and nitrate use. Questionnaires were used to assess anxiety, depression and disability. Exercise tolerance was tested by treadmill electrocardiography, with capnographic assessment of hyperventilation. As compared to a waiting-list control group, treatment significantly reduced the number of chest pain episodes (median pre: 6.5 per week to post 2.5 per week). In addition, anxiety and depression scores as well as perceived disability decreased, and exercise tolerance increased. These improvements were maintained at six month follow-up. Treatment reduced the prevalence of hyperventilation from 54% to 34%, but the prevalence of ECG-positive exercise tests was unaltered. Patients continuing to attribute their pain to heart disease had poorer outcomes.
There is now substantial evidence from studies by Gevirtz and others that psychophysiological approaches such as (1) respiration training (2) resonant frequency training (heart rate variability (HRV) biofeedback), and (3) autogenic training should all produce at least some success. Not enough studies have been done to estimate success rates in relation to initial severity, or to establish the duration of effectiveness. Autogenic training for treatment of angina pectoris is supported by one good controlled study with a four year follow-up (Laberke, 1952, as reviewed by Linden, 1994).
Del Pozo, Gevirtz, Scher, and Guarneri (2004) demonstrated that cardiorespiratory (heart rate variability) biofeedback effectively increased heart rate variability in patients with documented coronary artery disease (CAD). They used patients with established CAD (n = 63; mean age 67 years) who were randomly assigned to conventional therapy or to 6 biofeedback sessions consisting of abdominal breathing training, heart and respiratory physiologic feedback, and daily breathing practice. HRV was measured by the standard deviation of normal-to-normal QRS complexes (SDNN) at week 1 (pretreatment), week 6 (after treatment), and week 18 (follow-up). Baseline characteristics were similar for the treatment and control groups. The SDNN for the biofeedback and control groups did not differ at baseline or at week 6 but were significantly different at week 18. The biofeedback group, but not the control subjects showed a significant increase in SDNN from baseline to week 6 and to week 18.
It is concluded that psychophysiological techniques can be applied with confidence to the amelioration of non-cardiac chest pain.
4. Pelvic Floor Pain Disorders Amenable To Psychophysiological Interventions
There is moderate evidence supporting the effectiveness of psychophysiological interventions for pelvic floor related pain disorders including chronic pelvic pain of unknown origin, prementruals symdrome (PMS), Dysmenorrhea, Vulvar vestibulitis, and Constipation related pain
Virtually all of the articles identified in a recent literature search are relatively small clinical studies and have short follow‑up periods so little is known about the long term impact of biofeedback on work related deficits related to either PMS or dysmenorrhea. Dietvorst and Osborne (as quoted in Sherman, 2004) published a case study in 1978 in which they used temperature biofeedback and autogenic relaxation training to successfully treat a woman with chronic primary dysmenorrhea. Breckenridge, Gates, Hall and Evans (1983) gave 12 weekly EMG feedback sessions to eight young women with primary dysmenorrhea. They showed a significant decrease in severity of dysmenorrhea symptom scores on the Menstrual Symptom Questionnaire. Balick, Elfner, May, and Moore (1982) did a similar study with the addition of temperature feedback given to nine dysmenorrheic women (aged 20 ‑ 33) and found similar results upon six month follow‑up. Bennink, Hulst, and Benthem (1982) did a controlled study in which subjects who received only relaxation training or a no treatment control did not change while those receiving biofeedback did. Hart, Mathisen, and Prater (1981) used a self‑controlled design in which two month baseline and follow‑up periods were compared for eleven subjects with primary dysmenorrhea. They used both skin conductance and EMG feedback and found a significant reduction in symptoms upon follow‑up. Mathew, Claghorn, Largen and Dobbins (1979) treated twelve women with PMS with temperature biofeedback and found changes on the Menstrual Distress Questionnaire. The author’s team (Hamblen, Sherman & Powell, 1996) completed an open study in which thirty female soldiers with mixed PMS and dysmenorrhea were treated with a combination of progressive muscle relaxation exercises, frontal EMG biofeedback, and fingertip temperature biofeedback. Each kept a one month log of symptom severity and work impact before and after the standardized eight week treatment. Reports to the therapist indicated that most showed dramatic improvements but (a) only five subjects actually handed in a fully completed post treatment long and (b) the long term follow-up was not funded so it is not known whether the effects were maintained.
The use of psychophysiological interventions for amelioration of pelvic floor muscle related pain has become a staple of clinical practice. Studies such as that by Hetrick et al. (2006) clearly support the ability of SEMG evaluations to differentiate between men with chronic pelvic pain syndrome and pain free controls. Similar studies of women with vulvar vestibulitis show that muscle functioning is different among women with and without the problem (Reissing, Brown, Lord, Binik & Khalife, 2005). Clinical studies show that muscle tension biofeedback is an effective intervention for pelvic floor pain of unknown etiology for adults (Nadler, 2002) and children (Hoebeke et al., 2004). The technique is clearly effective for men with chronic pelvic pain syndrome (Clemens, Nadler, Schaeffer, Belani, Albaugh & Bushman, 2000, Cornel, van Haarst, Schaarsberg & Geels, 2005). However, there are no controlled studies of biofeedback for pelvic pain which compare the effectiveness of biofeedback with other techniques or placebos. This lack of evidence is not to be confused with the reasonably strong evidence supporting the use of biofeedback for strengthening and reducing both spasms and instability in the pelvic floor as part of treatments for incontinence. The key elements in any of the treatment approaches are: (a) perform a surface EMG evaluation to determine whether the muscles are inappropriately tense or relaxed and whether accessory muscles (such as those in the abdomen) are tensing at the wrong time, (b) teach subjects to recognize when they are inappropriately tense or relaxed, and (c) teach the subjects to tense or relax appropriately. This obviously can not be done without a very solid understanding of what the muscles are supposed to be doing and how tense they are supposed to be, at each point in the sequence leading to urination. Tries and Eisman's review (1995) provides the best information for this area.
Glazer, Rodke, Swencionis, Hertz, and Young (1995) studied 33 women having pain due to vulvar vestibulitis syndrome in which they gave SEMG biofeedback and relaxation training from the pelvic floor twice per week for 16 weeks to correct muscular instability, irritability, and weakness. After training, pelvic floor muscle contractions increased by 95.4%, resting tension levels decreased by 68%, and instability at rest decreased by 62%. Of great importance, pain decreased by 83% from baseline levels. McKay et al (2001) found that 20 of 29 women treated with biofeedback were able to become sexually active and to control their vulvar vestibulitis related pain after SEMG biofeedback.
Turnbull and Ritvo (1992) used biofeedback and relaxation exercises to treat painful constipation among five women. Pain decreased significantly along with the other symptoms. Palsson, Heymen and Whitehead (2004) found three studies on the use of biofeedback to relieve anorectal pain which showed that the technique was efficacious.
Glazer’s approach to treatment includes biofeedback assisted exercises to stabilize the pelvic floor. He has patients perform 60 cycles of contracting the floor muscles and holding for 10 seconds then relaxing for ten seconds. The session takes about 20 minutes. Reducing fatigue is accomplished by holding tension for 10 seconds while reducing variability. This permits reduction of resting tension to 0.5 to 1 microvolt. The difference between normal readings and those made from a patient with vestibulitis is illustrated in Figure 4. White, Jantos and Glazer (1997) have found similar patterns and published good illustrations of what can be expected before and after therapy.
Figure 4. Differences between normal pelvic floor muscle tension recordings and those typical of patients with vestibulitis. Simulation based on a compilation of our data and reading White et al.’s (1997) work.
Normal baseline and pattern
Elevated, unstable baseline and of tensing in effective, spasmodic pattern of tensing shown by patients with vulvar vestibulitis
EFFICACY RATINGS FOR PSYCHOPHYSIOLOGICAL ASSESSMENT AND BIOFEEDBACK OF CHRONIC PAIN PROBLEMS
The Association for Applied Psychophysiology has developed the following criteria for setting the level of evidence for efficacy (Moss & Gunkelman, 2002, LaVaque et al., 2002):
Level 1: Not empirically supported: Supported only by anecdotal reports and/or case studies in non-peer reviewed venues.
Level 2: Possibly Efficacious: At least one study of sufficient statistical power with well identified outcome measures, but lacking randomized assignment to a control condition internal to the study.
Level 3: Probably Efficacious: Multiple observational studies, clinical studies, wait list controlled studies, and within subject and intersubject replication studies that demonstrate efficacy.
Level 4: Efficacious:
- In a comparison with a no-treatment control group, alternative treatment group, or sham (placebo) control utilizing randomized assignment, the investigational treatment is shown to be statistically significantly superior to the control condition or the investigational treatment is equivalent to a treatment of established efficacy in a study with sufficient power to detect moderate differences, and
- The studies have been conducted with a population treated for a specific problem, for whom inclusion criteria are delineated in a reliable, operationally defined manner, and
- The study used valid and clearly specified outcome measures related to the problem being treated and
- The data are subjected to appropriate data analysis, and
- The diagnostic and treatment variables and procedures are clearly defined in a manner that permits replication of the study by independent researchers, and
- The superiority or equivalence of the investigational treatment have been shown in at least two independent research settings.
Level 5: Efficacious and specific: The investigational treatment has been shown to be statistically superior to credible sham therapy, pill, or alternative bona fide treatment in at least two independent research settings.
Ratings of the efficacy of biofeedback based interventions for disorders whose main symptom of interest is chronic pain:
Chronic pain includes too broad a range of disorders to assign a single efficacy rating. Table 1 contains ratings for each chronic pain disorder along with citations to studies supporting the rating.
Table 1. Efficacy Ratings of Chronic Pain Disorders
Efficacious and specific (Fifth level):
(a) Migraine headache in adults and children (Review by Blanchard 1992, Yucha and Gilbert 2004)
(b) Tension headache in both adults and children (Review by Blanchard 1992)
Efficacious (Fourth Level):
(a) Muscle related orofacial pain (reviews by Glaros & Lausten, 2002, Crider, Glaros & Gevirtz 2005). (b)) Irritable bowel syndrome (differing reviews, by Blanchard, 1993, and by Humphries & Gevirtz, 2000) (c) Anxiety related to incorrect breathing patterns causing non-cardiac chest pain (Reviews by Gevirtz, 2001, DeGuire, Gevirtz, Hawkinson, & Dixon, 1996)
(d) Posture related pain problems such as forward head thrust (Review by Middaugh, 1994)
Probably efficacious (Third level):
(a) Muscle related low back pain (Reviews by Flor & Birbaumer, 1994; Morley, Eccleston & Williams, 1999; van Tulder et al., 2006) (b) Cramping and burning phantom limb pain (Belleggia & Birbaumer, 2001, Harden et al., 2005, Reviews by Sherman, Devore, Jones, Katz, & Marbach, 1996, Flor, 2002b) (c) PMS and Dysmenorrhea (Breckenridge, 1983) (d) Pain from spastic muscles and muscle spasms (Kasman, 1998) e) Magnification of pain by stress & anxiety (Yucha & Gilbert, 2004) (f) Pelvic floor pain syndromes (Tries & Eisman, 1995, Glazer, Rodke, Swencionis, Hertz, &Young, 1995, Yucha & Gilbert, 2004) (g) Subluxation of the Patella and patelofemoral pain (Ingersoll & Knight, 1991, Crossley, Bennell, Green, Cowan & McConnell, 2002, Dursun, Dursun & Kilic, 2001)
Possibly Efficacious (Second level):
(a) Pain from carpel tunnel syndromes related to upper arm and neck muscle tension (reviews by Donaldson, Nelson, Skubick, & Clasby, 1998; Skubick, Clasby, Donaldson, & Marshall, 1993) (b) Myofascial pain syndrome / trigger point related pain (reviews by Headley, 1991; Gevirtz, 1995) (c) Raynaud's syndrome (Review by Freedman, 1991)
(d) Repetitive strain injury (Moore & Weisner, 1996)
(e) Fibromyalgia (Buckelew, Conway, Parker et al 1998, Drexler, Mur & Gunther, 2002; Ferraccioli et al., 1987; Ferraccioli et al., 1987 Mueller, Donaldson, Nelson & Layman, 2001; van Stanten et al., 2002)
Not empirically supported (First level of evidence):
(a) Pain and spasticity due to not taking microbreaks among sign language translators, musicians, factory workers, computer workers, etc.
(b) Biofeedback for complex regional pain syndrome (reflex sympathetic dystrophy).
Psychophysiological assessments and biofeedback based interventions for disorders whose main symptom of interest is chronic pain can be highly efficacious for selected disorders. There is a dearth of controlled studies in this area so the supporting evidence is not as strong as it might be. However, the evidence from formal studies shows that efficacy ranges from efficacious (e.g., treatment of migraine and tension headaches) to possibly efficacious and not empirically supported. There can be little doubt that psychophysiological measurements form a valuable part of the assessment process and that biofeedback based interventions should be given a trial for most chronic pain disorders.