A long-term,single-group follow-up study of biofeedback therapy with chronic medical and psychiatric patients

In a long-term follow-up study, 524 (93%) of 563 consecutive medical and psychiatric patients, who received an average of 8 sesisons of biofeedback and relaxation training, provided follow-up evaluations of treatment outcome. Seventy-five percent reported maximum, significant, or moderate improvement. There was a significant positive association between the percent of patients improved and the number of treatment sessions up to 10 sessions, but not thereafter. Symptom frequency decreased by 54% and symptom severity by 30%. About 54% of the medicated patients reported a decrease in medication. No differential therapist effects were found. About twice as many patients rated relaxation training as most helpful compared with the audio/visual signals from biofeedback instruments.This research was funded in part by the Minneapolis Clinic Medical Foundation. The author wishes to thank the biofeedback therapists for their cooperation and excellent service: Jones Adkins, Mike Schwieters, and Suzanne Kroon, especially the latter for her assistance in this program evaluation project. Vital contributions were made by secretarial staff, including Ann Hovde and Linda Bruch. Two undergraduate honors students in psychology from the University of Minnesota also provided important assistance: Steve Ristvedt and Shirley Fors. Computer and statistical consultation was provided by Terri Schultz and Dr. Sanford Weisberg of the St. Paul Computer Center.     

Effectiveness of multiple muscle-site EMG biofeedback and relaxation training in reducing the aversiveness of cancer chemotherapy

A 44-year-old female cancer patient was given progressive muscle relaxation training and multiple muscle-site EMG biofeedback to reduce the conditioned negative responses she had apparently developed to her chemotherapy treatments. Following three baseline chemotherapy sessions, the patient was given relaxation training and biofeedback during four consecutive chemotherapy treatments and was asked to practice her relaxation skills daily in the hospital or at home. After the patient felt able to relax on her own, relaxation training and biofeedback were terminated and three follow-up sessions were held. Results indicated that during the chemotherapy sessions in which the patient received relaxation training and biofeedback, she showed reductions in physiological arousal (EMG, pulse rate, systolic blood pressure, and diastolic blood pressure) and reported feeling less anxious and nauseated. Moreover, these changes were maintained during the follow-up sessions. These results suggest that relaxation training plus multiple muscle-site biofeedback may be an effective adjunctive procedure for reducing some of the adverse side effects of cancer chemotherapy.     

EMG biofeedback treatment of torticollis: a controlled outcome study.

Successful treatment of torticollis with electromyographic (EMG) biofeedback has been reported in a number of single case and single group studies. The present investigation represents the first controlled outcome study. Twelve torticollis patients were randomly assigned to EMG biofeedback or relaxation training and graded neck exercises (RGP). The procedure involved three sessions of baseline assessment, 15 sessions of EMG BF or RGP, 6 sessions of EMG BF or RGP plus home-management, 6 sessions of home-management alone, and follow-up 3 months after the end of treatment. A variety of outcome measures were used including physiological (EMG from the two sternocleidomastoid muscles, skin conductance level), behavioral (angle of head deviation, range of movement of the head), and self-report (depression, functional disability, body concept), therapist and "significant other" reports and independent observer assessment of videos. In both groups, neck muscle activity was reduced from pre- to posttreatment. This reduction was greater in the EMG biofeedback group. There was evidence of feedback-specific neck muscle relaxation in the EMG biofeedback group. Therefore, the outcome was not due to nonspecific factors and could be attributed to feedback-specific effects. Changes in skin conductance level showed that neck muscle relaxation was not simply mediated by a general reduction of "arousal." Significant improvements of extent of head deviation, and range of movement of the head, as well as reductions of depression were present, which were not different in the two groups. At the end of treatment, no patient was asymptomatic. Any therapeutic benefit was generally maintained at follow-up. The results and the procedural simplicity of RGP make the issue of cost-efficacy of EMG biofeedback a pertinent one. Further controlled outcome studies of EMG biofeedback treatment of torticollis with larger samples are required.     

Biofeedback-assisted relaxation training for the aging chronic pain patient.

The older segments of the U.S. population are expanding rapidly and account for a disproportionate amount of health care, including treatment for pain-related musculoskeletal disorders. In a prospective study with objective measures and one-year follow-up, Middaugh et al. (1988) found that older patients (55-78 yr; N = 17, 76% success) treated in a multidisciplinary chronic pain rehabilitation program enjoyed a success rate equal to that of younger patients (29-48 yr, N = 20, 70% success). The current study presents additional data on these two groups of patients to compare their ability to learn the physiological self-regulation skills taught in the biofeedback/relaxation component of the multimodal program. This component included progressive muscle relaxation training, diaphragmatic breathing instruction, and EMG biofeedback. Repeated measures ANOVA showed significant increases in digital skin temperature (peripheral vasodilation) and decreases in respiration rate both within and across training sessions (p values = .04 to .0001) with no differences between age groups (p greater than .05). EMG measures for the upper trapezius ms in patients with cervical pain showed similar deficits in muscle control at evaluation and similar improvements with biofeedback training for the two age groups. These findings indicate that older pain patients responded well to the biofeedback/relaxation training component of the multimodal pain program.     

The effect of stressful life events on EMG biofeedback and relaxation training in the treatment of anxiety

The present study evaluated the effect of frontal EMG biofeedback and relaxation training on a group of 20 anxious patients experiencing stressful life events. The patients were divided into two groups, high and low in stress, based on their life change score on the Recent Life Changes Questionnaire. Patients were evaluated at pre, post, and 6-week follow-up. Treatment consisted of 10 sessions of biofeedback-assisted relaxation. Results indicated that the high stress group showed pre to post changes on anxiety, depression, symptoms, and EMG, while low stress showed no change. Post to follow-up comparisons showed maintenance of improvement for the high stress group and no change for low stress. From pre to follow-up assessment, the high stress group showed significant changes. Both groups reported internal attributions following biofeedback and relaxation training. The high stress group attributed their improvement to the belief they were in control of their minds and bodies, while the low stress group most frequently reported the effort put into the task. The results indicate support for a cognitive explanation for some of biofeedback's effects.     

Biofeedback-assisted relaxation training for the aging chronic pain patient

The older segments of the U.S. population are expanding rapidly and account for a disproportionate amount of health care, including treatment for pain-related musculoskeletal disorders. In a prospective study with objective measures and one-year follow-up, Middaugh et al. (1988) found that older patients (55–78 yr; N=17, 76% success) treated in a multidisciplinary chronic pain rehabilitation program enjoyed a success rate equal to that of younger patients (29–48 yr; N=20, 70% success). The current study presents additional data on these two groups of patients to compare their ability to learn the physiological self-regulation skills taught in the biofeedback/relaxation component of the multimodal program. This component included progressive muscle relaxation training, diaphragmatic breathing instruction, and EMG biofeedback. Repeated measures ANOVA showed significant increases in digital skin temperature (peripheral vasodilation) and decreases in respiration rate both within and across training sessions (p values=.04 to .0001) with no differences between age groups (p>.05). EMG measures for the upper trapezius ms in patients with cervical pain showed similar deficits in muscle control at evaluation and similar improvements with biofeedback training for the two age groups. These findings indicate that older pain patients responded well to the biofeedback/relaxation training component of the multimodal pain program.This research was supported in part by NIDRR grant No. H133G90085, Department of Education, DHEW, and by the Medical University of South Carolina General Clinical Research Center under NIH grant No. RR1070.     

The use of EEG theta biofeedback in the treatment of a patient with sleep-onset insomnia.

In this report, the treatment of a 42-year-old female with a complaint of chronic sleep-onset insomnia is described. Following the unsuccessful use of relaxation training, treatment consisted of 11 sessions of EEG theta rhythm (4--7 Hz) biofeedback. Theta density and five sleep indices were monitored throughout baseline, placebo, and treatment sessions. A significant increase in theta density was accompanied by reports of a decrease in sleep latency and an increase in total sleep time. This improvement was maintained after withdrawal of medication and at 3-month follow-up.     

EMG biofeedback treatment of torticollis: A controlled outcome study

Successful treatment of torticollis with electromyographic (EMG) biofeedback has been reported in a number of single case and single group studies. The present investigation represents the first controlled outcome study. Twelve torticollis patients were randomly assigned to EMG biofeedback or relaxation training and graded neck exercises (RGP). The procedure involved three sessions of baseline assessment, 15 sessions of EMG BF or RGP, 6 sessions of EMG BF or RGP plus home-management, 6 sessions of home-management alone, and follow-up 3 months after the end of treatment. A variety of outcome measures were used including physiological (EMG from the two sternocleidomastoid muscles, skin conductance level), behavioral (angle of head deviation, range of movement of the head), and self-report (depression, functional disability, body concept), therapist and significant other reports and independent observer assessment of videos. In both groups, neck muscle activity was reduced from pre- to posttreatment. This reduction was greater in the EMG biofeedback group. There was evidence of feedback-specific neck muscle relaxation in the EMG biofeedback group. Therefore, the outcome was not due to nonspecific factors and could be attributed to feedback-specific effects. Changes in skin conductance level showed that neck muscle relaxation was not simply mediated by a general reduction of arousal. Significant improvements of extent of head deviation, and range of movement of the head, as well as reductions of depression were present, which were not different in the two groups. At the end of treatment, no patient was asymptomatic. Any therapeutic benefit was generally maintained at follow-up. The results and the procedural simplicity of RGP make the issue of cost-efficacy of EMG biofeedback a pertinent one. Further controlled outcome studies of EMG biofeedback treatment of torticollis with larger samples are required.This work was funded by grants from the Medical Research Council and the Dystonia Society.     

Comparison of Biofeedback and Relaxation in the Treatment of Pediatric Headache and the Influence of Parent Involvement on Outcome

The relative efficacy of EMG-frontalis feedback and progressive relaxation was examined in children with tension-type or combined headaches (8–14 yrs. old). Furthermore, the influence of parent involvement, in the form of a three-session educational approach, on training outcome was systematically explored (2 × 2 factor design). Fifty children took part in the study, 40 were randomly assigned to the four different treatment conditions, 10 children participated in the self-monitoring control group. The training comprised 6 sessions of 1 hr each in the relaxation treatment and 12 sessions of 1/2 hr duration in the biofeedback group. Headache diaries were kept by children and parents for 4-week period prior to therapy, and for a similar length of time at post-treatment and follow-up (6 months). Multivariate analyses of variance on the headache diary data yield no significant main or interaction effects of treatment format or of parent involvement, but only a main effect of period, indicating a general efficacy of the four treatment conditions. At follow-up the reduction of headache activity is even more prominent. A different evaluative approach points to the superiority of biofeedback revealing a mean effect size for biofeedback training that reflects a good to excellent improvement rate. Correlations between headache data from children and parents are high.     

Biofeedback-assisted relaxation training for primary dysmenorrhea: A case study

Primary dysmenorrhea is a familiar complaint to medical practitioners. Recently, behavior therapy has been shown to be an effective treatment for the symptoms of dysmenorrhea. The present case study offers biofeedback-assisted relaxation treatment as an effective alternative treatment. The Menstrual Symptom Questionnaire was used to classify dysmenorrhea as spasmodic or congestive. This classification provides homogeneous groups of patients. The patient in this study had an 18-year history of primary dysmenorrhea that was resistant to hormonal and analgesic treatment. After two months of baseline observation, she was given eight sessions of skin-temperature biofeedback and autogenic training. She reported significant reduction of pain and discomfort with the use of biofeedback-assisted relaxation. Desensitization using visual imagery, an important component of previous therapies, was not used. Further examination of the efficacy of biofeedback-assisted relaxation training for the treatment of both congestive and spasmodic dysmenorrhea is suggested.     

Biofeedback-assisted relaxation training for primary dysmenorrhea: a case study.

Primary dysmenorrhea is a familiar complaint to medical practitioners. Recently, behavior therapy has been shown to be an effective treatment for the symptoms of dysmenorrhea. The present case study offers biofeedback-assisted relaxation treatment as an effective alternative treatment. The Menstrual Symptom Questionnaire was used to classify dysmenorrhea as spasmodic or congestive. This classification provides homogeneous groups of patients. The patient in this study had an 18-year history of primary dysmenorrhea that was resistant to hormonal and analgesic treatment. After two months of baseline observation, she was given eight sessions of skin-temperature biofeedback and autogenic training. She reported significant reduction of pain and discomfort with the use of biofeedback-assisted relaxation. Desensitization using visual imagery, an important component of previous therapies, was not used. Further examination of the efficacy of biofeedback-assisted relaxation training for the treatment of both congestive and spasmodic dysmenorrhea is suggested.     

Treatment of posttraumatic stress disorder with relaxation and biofeedback training

This study investigated the use of biofeedback and relaxation training on six patients with posttraumatic stress disorder (PTSD) referred routinely for biofeedback treatment in a VA medical center. Subjects received between 8 and 14 sessions of training overall, as well as concurrent individual and group therapy. Measures used to assess treatment outcome include pre- and posttreatment MMPI, State-Trait Anxiety Inventory, Beck Depression Inventory, and Multidimensional Health Locus of Control scores, as well as electromyographic and subjective measures of tension within each session. Additionally, an overall posttreatment clinical rating of change and 1- to 2-year follow-up data were obtained for each subject. Slight to marked improvements were demonstrated for each subject, as evidenced by improvements on the State Anxiety Inventory Scale and the Beck Depression Inventory, a decrease in overall MMPI scores, and lowered EMG and subjective tension ratings for all participants. Possible alternative explanations for improvement (situational demand characteristics, regression toward the mean, lack of independent subject evaluation) are described, along with other study limitations. This preliminary investigation suggests that the use of relaxation training and biofeedback may be a particularly useful component within a comprehensive treatment program for this disorder.     

Treatment of posttraumatic stress disorder with relaxation and biofeedback training

This study investigated the use of biofeedback and relaxation training on six patients with posttraumatic stress disorder (PTSD) referred routinely for biofeedback treatment in a VA medical center. Subjects received between 8 and 14 sessions of training overall, as well as concurrent individual and group therapy. Measures used to assess treatment outcome include pre- and posttreatment MMPI, State-Trait Anxiety Inventory, Beck Depression Inventory, and Multidimensional Health Locus of Control scores, as well as electromyographic and subjective measures of tension within each session. Additionally, an overall posttreatment clinical rating of change and 1- to 2-year follow-up data were obtained for each subject. Slight to marked improvements were demonstrated for each subject, as evidenced by improvements on the State Anxiety Inventory Scale and the Beck Depression Inventory, a decrease in overall MMPI scores, and lowered EMG and subjective tension ratings for all participants. Possible alternative explanations for improvement (situational demand characteristics, regression toward the mean, lack of independent subject evaluation) are described, along with other study limitations. This preliminary investigation suggests that the use of relaxation training and biofeedback may be a particularly useful component within a comprehensive treatment program for this disorder.     

The treatment of cluster headache with relaxation and thermal biofeedback

Eleven patients with episodic cluster headache were assessed and offered a treatment program consisting of 8 weeks of training in abbreviated progressive relaxation followed by 12 sessions of thermal biofeedback. Four dropped out before treatment began. Of the seven who completed the full treatment regimen, three (27% of initial sample) reported some degree of improvement when their next cluster bout occurred. In no one was the disorder eliminated.This research was supported by a grant from the National Institute of Neurological and Communicative Disorders and Stroke, NS-15235.     

Biofeedback treatment of Raynaud's disease and phenomenon

Six Raynaud's disease and four Raynaud's phenomenon patients were treated with 12 sessions of finger temperature biofeedback. The mean frequency of vasospastic attacks was reduced to 7.5% of that reported during the pretreatment baseline and was maintained for a 1 year follow-up period. Significant control of digital temperature was demonstrated during laboratory training sessions. Raynaud's phenomenon patients showed significantly greater temperature increases during feedback periods than Raynaud's disease patients. Correlations between finger temperature and other physiological measures suggested that results could not be attributed to general physical relaxation. The role of imagery in self-control of digital temperature is considered.Portions of this paper were presented at the annual meeting of the Biofeedback Society of America, Albuquerque, March 1978.     

Change Mechanisms Associated with Combined Relaxation/EMG Biofeedback Training for Chronic Tension Headache

Therapeutic mechanisms hypothesized to underlie improvements in tension headache activity achieved with combined relaxation and eleclromyographic (EMG) biofeedback therapy were examined. These therapeutic mechanisms included (1) changes in EMG activity in frontal and trapezii muscles, (2) changes in central pain modulation as indexed by the duration of the second exteroceptive silent period (ES2), and (3) changes in headache locus of control and self-efficacy. Forty-four young adults with chronic tension-type headaches were assigned either to six sessions of relaxation and EMG biofeedback training (N = 30) or to an assessment only control group (N = 14) that required three assessment sessions. Measures of self-efficacy and locus of control were collected at pre- and posttreatment, and ES2 was evaluated at the beginning and end of the first, third, and lost session. EMG was monitored before, during, and following training trials. Relaxation/EMG biofeedback training effectively reduced headache activity: 51.7% of subjects who received relaxation/biofeedback therapy recorded at least a 50% reduction in headache activity following treatment, while controls failed to improve on any measure. Improvements in headache activity in treated subjects were correlated with increases in self-efficacy induced by biofeedback training but not with changes in EMG activity or in ES2 durations. These results provide additional support for the hypothesis that cognitive changes underlie the effectiveness of relaxation and biofeedback therapies, at least in young adult tension-type headache sufferers.     

The response of manual motor functioning in Parkinsonians to frontal EMG biofeedback and progressive relaxation

The purpose of the current investigation was to determine the effects of frontal EMG biofeedback and progressive relaxation training on manual motor functioning in Parkinsonians. Twenty patients were matched and randomly assigned to two groups. All subjects were administered a brief manual motor assessment. The experimental group then underwent weekly sessions of frontal EMG and relaxation training for a period of 15 weeks. At the conclusion of the training period, both experimental and control groups were again administered the manual motor tasks. The results indicated that Parkinsonian patients are capable of significantly lowering frontal EMG activity levels. The motor task results, however, yielded no statistically significant differences between the two groups as a result of the biofeedback training.     

The use and utility of EMG biofeedback with chronic schizophrenic patients

This study examined the efficacy of muscle relaxation training via electromyographic (EMG) biofeedback from the frontalis and forearm extensor muscles of schizophrenic inpatients. Thirty chronically hospitalized patients were randomly assigned to one of three conditions: EMG biofeedback from the forearm extensor and frontalis muscles, progressive relaxation, and a control group. Treatment consisted of one session of orientation and baseline, and six sessions of training. The results indicated that the schizophrenic patients receiving EMG training had significantly lower EMG recordings than the progressive relaxation group, which, in turn, was significantly lower than the control group. Analyses of covariance on the Tension-Anxiety scale from the Profile of Mood States revealed no significant effects, while finger-tapping rates were significantly improved only for the arm receiving feedback training in the EMG group. On the Nurses Observation Scale for Inpatient Evaluation the biofeedback group significantly improved on the Social Competence and Social Interest factors.     

Long-term maintenance of improvements achieved with (abortive) pharmacological and nonpharmacological treatments for migraine: preliminary findings

This report presents the first prospective comparison of the long-term maintenance of reductions in recurrent migraine headaches achieved with (abortive) pharmacological and nonpharmacological (combined relaxation training and thermal biofeedback training) treatments. Nineteen of 21 (90%) successfully treated patients (50% or greater reduction in headache activity) were contacted for follow-up evaluation 3 years later. Migraine sufferers who had been treated with ergotamine were less likely to still be relying on the treatment they had received and more likely to have additional medical treatment for their headaches and to be using prophylactic or narcotic medication than were migraine sufferers who had been treated with relaxation/biofeedback training. However, daily headache recordings revealed that patients in both treatment groups continued to show lower headache activity at 3-year follow-up than prior to treatment. Although preliminary, these findings raise the possibility that improvements achieved with nonpharmacological treatment are more likely to be maintained without additional treatment than are similar improvements achieved with abortive pharmacological treatment.     

Effects of group relaxation training and thermal biofeedback on blood pressure and related physiological and psychological variables in essential hypertension

One hundred and one patients, 70 experimental and 31 controls, with a diagnosis of essential hypertension, were examined for the effects of group relaxation training and thermal biofeedback on blood pressure and on other psychophysiologic measures: heart rate, forehead muscle tension, finger temperature, depression, anxiety, plasma aldosterone, plasma renin activity, and plasma and urinary cortisol. Eighty percent of the participants were medicated. Treatment yielded a short-term success rate, defined as a decrease in mean arterial pressure of 5 mm Hg, of 49% in the experimental group. Other significant short-term changes included a reduction of forehead muscle tension, state anxiety, plasma aldosterone, and increased finger temperature. Follow-up measurements were made approximately 10 months after treatment in 36 patients, 51% of the treatment completers. Twenty of the 36 were short-term treatment failures, while 16 were treatment succeeders. Thirty-seven percent of the short-term succeeders continued to meet blood pressure criterion at follow-up. In short-term succeeders, continued practice of relaxation may influence long-term maintenance of decreased blood pressure. It is suggested that group relaxation training can be beneficial for short-term and long-term adjunctive treatment of essential hypertension in selected individuals.I greatly appreciate the assistance of Minda Sogocio, Judy Stewart, and Kay Gerstenmaier from the Toledo Health Department, and Ilona Jurek, Carrie Wakai, and Robert Spain from the Medical College of Ohio at Toledo. This research was supported by a grant to A. McGrady through the Hypertension Control Program of the City of Toledo Health Department, from the Ohio Department of Health.