Muscular response to the therapist and symptomatic improvement during biofeedback for tension headache.

The relationship between muscular response to the therapist's presence and symptomatic improvement was studied during biofeedback. Thirty-two patients suffering from tension headaches received muscular biofeedback training of six sessions plus a follow-up session two months later. Patients' electro-myographic frontal response was measured prior to treatment both with and without the therapist present. A relationship was found between symptomatic improvement at follow-up and muscular response to the therapist's presence before treatment: patients showing a decrease of at least 10% in muscular tension response to the presence of their future therapist improved more regarding headache intensity than the patients showing increase or smaller variation of their EMG. A significant correlation of .59 was found between the frontal EMG response to therapist presence during the evaluation session and headache improvement at follow-up. The results suggest that the decrease of muscular tension during the first contact with the therapist could be an indicator of good prognosis, possibly because of an immediate positive therapeutic relationship and/or favorable expectancies concerning future benefit of treatment.     

Electromyographic biofeedback training for tension headache in the elderly: A prospective study

This study evaluated the effects of a 12-session frontal electromyographic biofeedback training regimen on the headache activity of eight tension headache sufferers aged 62 and older. The biofeedback sessions were slightly modified for a geriatric population, essentially to increase comprehension and retention of rationale and instructions. Post-treatment assessment at three months revealed significant decreases in overall headache activity (50% or greater) in 50% of the subjects, and moderate improvement (35%–45%) in three of the remaining four subjects. Significant clinical and/or statistical prepost differences were also found for the number of headache-free days, peak headache activity, and medication index. This is the first prospective study of biofeedback training for tension headache in an elderly population and, unlike previous retrospective studies, suggests that such therapy may be an effective intervention in the treatment of tension headaches in the elderly.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Department of Veterans Affairs. This study was supported by a Department of Veterans Affairs MERIT-Review awarded to the first author.     

The role of absorption capacity in thermal biofeedback treatment of vascular headache

The clinical utility of Tellegen's Absorption Scale was examined using a sample of 32 chronic vascular headache patients drawn from a larger treatment study investigating the efficacy of thermal biofeedback with vascular headache. A regression analysis found that acquisition of the hand-warming response was directly related to increase in capacity for absorption. Conversely, a trend was found for absorption capacity to be inversely related to reductions in headache frequency and intensity. Reasons for these differences in process and outcome variables are discussed.This research was supported in part by a grant No. NS23440 from NINDS.     

A preliminary analysis of EMG variance as an index of change in EMG biofeedback treatment of tension-type headache

The effectiveness of EMG biofeedback training for tension headache has been well established. Previous studies evaluating changes in an average EMG activity score from pre- to posttreatment have not consistently found a relationship between a reduction in average EMG activity and headache improvement at posttreatment. The current study is a preliminary analysis of the utility of EMG variance as another possible mechanism of change. Frontalis EMG average activity and variances from 6 chronic tension-type headache sufferers who demonstrated significant improvement in headache activity at posttreatment (at least 70%) and 6 chronic tension-type headache sufferers who did not demonstrate improvement (less than 30%) were examined across 6 sessions of biofeedback treatment. The improved group demonstrated larger time-specific EMG variance in relation to mean EMG amplitudes during all treatment sessions. A dramatic decline in time-specific variance was observed during the later treatment sessions for improved participants; this pattern was not observed in the group who demonstrated little or no improvement. Results from the current study suggest that the inclusion of both average EMG activity and EMG variance may provide a more comprehensive measure to evaluate possible physiological changes responsible for improvement in headache activity following EMG biofeedback training.     

A Comparison of Tension Headache Sufferers and Nonpain Controls on the State-Trait Anger Expression Inventory: An Exploratory Study with Implications for Applied Psychophysiologists

Studies that have examined the relationship between personality characteristics and tension headache have arrived at conflicting and, for the most part, negative results. In recent years, a number of investigators have begun examining the relationship between anger and psychophysiological disorders, focusing mostly on anger which is suppressed or held in rather than expressed behaviorally. The present study explored the relationship between anger in 59 tension headache subjects and compared their results to 33 nonpain controls. Materials consisted of the revised research edition of the Spielberger State-Trait Anger Expression Inventory. As predicted, tension headache sufferers were found to have significantly more anger held inward than nonpain controls. Implications for applied psychophysiology treatment and future research directions are discussed.     

Evaluation of home-based thermal biofeedback treatment of pediatric migraine headache

Sixteen children and adolescents with migraine headache were treated with thermal biofeedback. Seven were seen individually in the clinic while the other nine participated in a limited-contact, partly home-based regimen. Evaluation of headache diary data from 4-week monitoring periods before and after treatment showed significant (p<.01) reduction in headaches, with no significant difference in efficacy between the two conditions.This research was supported in part by grants from NIMH, MH-41341, and NINCDS, NS-23440.     

Biofeedback in the treatment of headache and other childhood pain

Since the first biofeedback (BFB) studies on pediatric pain were published in the early 1980s, most of the studies have focused on the treatment of pediatric migraine. More recently, BFB has also been evaluated in the treatment of tension headache in children. Not surprisingly, most of what we know about the efficacy and mechanisms of BFB in the treatment of children's pain problems concerns the treatment of childhood headache (HA). In this review, we provide a detailed summary of studies that have evaluated BFB in the treatment of childhood HAs with an emphasis on treatment outcome and maintenance of treatment success. Moreover, findings and hypotheses with regard to the mechanisms that may mediate the treatment effects of BFB are addressed. Finally, we discuss specific issues relating to the treatment of pain in children with BFB and outline future directions of research.     

Behavioral management of recurrent headache: three decades of experience and empiricism

In the past three decades, behavioral interventions (chiefly relaxation, biofeedback, and stress-management) have become standard components of the armamentarium for management of migraine and tension-type headaches. Meta-analytic literature reviews of these behavioral interventions have consistently identified clinically significant reductions in recurrent headache. Across studies, behavioral interventions have yielded approximately 35–50% reduction in migraine and tension-type headache activity. Although we have only recently begun to directly compare standard drug and nondrug treatments for headache, the available evidence suggests that the level of headache improvement with behavioral interventions may rival those obtained with widely used pharmacologic therapies in representative patient samples. In recent years, some attempts have been made to increase the availability and cost effectiveness of behavioral interventions through alternative delivery formats and mass communications. Recent developments within diagnosis and classification are summarized, pointing out implications for behavioral researchers. Select future directions are discussed, which include impact of the triptans, cost and cost effectiveness, and integration of behavioral treatments into primary care settings, the place where the great majority of headache sufferers receive treatment.     

Electromyographic biofeedback training for tension headache in the elderly: a prospective study.

This study evaluated the effects of a 12-session frontal electromyographic biofeedback training regimen on the headache activity of eight tension headache sufferers aged 62 and older. The biofeedback sessions were slightly modified for a geriatric population, essentially to increase comprehension and retention of rationale and instructions. Post-treatment assessment at three months revealed significant decreases in overall headache activity (50% or greater) in 50% of the subjects, and moderate improvement (35%-45%) in three of the remaining four subjects. Significant clinical and/or statistical pre-post differences were also found for the number of headache-free days, peak headache activity, and medication index. This is the first prospective study of biofeedback training for tension headache in an elderly population and, unlike previous retrospective studies, suggests that such therapy may be an effective intervention in the treatment of tension headaches in the elderly.     

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.     

Game-based biofeedback for paediatric anxiety and depression

Twenty-four children and adolescents aged 9-17 who were referred for treatment for anxiety were assigned to either a game-based biofeedback group or a waiting list comparison group. The eight-session biofeedback intervention included psychoeducation, identification of triggers and signs of anxiety, and in vivo practice. The intervention used computer-based gaming technology to teach and practise relaxation. Analyses using ANCOVA revealed significant differences in post-test scores of anxiety and depression measures between the two groups. The intervention group reduced anxiety and depression scores on standardised tests. Findings suggest that biofeedback-assisted relaxation training can be useful in decreasing anxiety and depressive symptoms in anxious youths.     

The relationship between capacity for absorption and chronic headache patients' response to relaxation and biofeedback treatment

A sample of 49 chronic headache patients (35 vascular and 14 tension) was separated according to capacity for absorption (as measured by Tellegen & Atkinson's 1974 scale) into groups high in absorption and groups low in absorption, with patients in the middle range being excluded. Absorption capacity was found to affect response to treatment in complex ways. Vascular headache patients high in absorption were significantly improved following relaxation training, but not after biofeedback training. Vascular headache patients low in absorption were significantly improved after biofeedback training. Tension headache patients low in absorption did not respond significantly to either form of treatment, while those high in absorption responded significantly to biofeedback training. Reasons for these differences in response to treatment were discussed.This research was supported by a grant from the National Institute of Neurological and Communicative Disorders and Stroke, NS-15235.     

The Effect of the Definition of Menstrually-Related Headache on the Response to Biofeedback Treatment

Twelve women with either pure migraine headache (HA) or a combination of migraine and tension-type HA monitored HA activity over two menstrual cycles while noting onset of menstruation and onset of ovulation. They then received 12 sessions of thermal biofeedback (TBF) with adjunctive autogenic training. Six women with only tension-type HA participated in similar monitoring before receiving 9 sessions of progressive relaxation training.Results for those with vascular HA showed a significant reduction in HA activity and a reduction in medication taken for HAs. Those with tension-type HA did not respond significantly to the relaxation training. Depending upon how one defined menstrually-related HAs among those with vascular HA, there either was, or was not, a differential effect of TBF on menstrual-cycle-related HA.     

Discourse on the development of EEG diagnostics and biofeedback for attention-deficit/hyperactivity disorders

This article presents a review of work that my colleagues and I have been doing during the past 15 years developing a rationale for the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and treatment of ADHD employing EEG biofeedback techniques. The article first briefly reviews the history of research and theory for understanding ADHD and then deals with the development of EEG and event-related potential (ERP) assessment paradigms and treatment protocols for this disorder, including our work and that of others who have replicated our results. Illustrative material from our current research and child case studies is included. Suggestions for future experimental and clinical work in this area are presented and theoretical issues involving the understanding of the neurophysiological and neurological basis of ADHD are discussed.Over the years, many people have been involved both in my laboratory and at Southeastern Biofeedback Institute working with me in developing this area; I wish to acknowledge some of them. They are specifically Dr. Margaret Shouse and Dr. Chris Mann, who have been involved in the initial and recent stages of my research; Ms. Jennifer Samples, who has worked with us in the Institute for many years and has helped us in training many of the children that have benefited from EEG biofeedback. I would especially wish to acknowledge the skill and dedication of Judith O. Lubar, of Southeastern Biofeedback Institute, who has worked with me clinically in terms of developing treatment protocols for ADHD biofeedback and who has trained many of the children who have successfully completed EEG Biofeedback. I would like to acknowledge the generous help of the Lexicor Corporation of Boulder, Colorado who have provided support and instrumentation for recent studies in this area. Mr. Rod Bunn and Mr. Robert Muenchen, who have provided computer support, programming, and statistical assistance in evaluating data in various studies, are gratefully acknowledged. Some of this research was supported by a grant under the ESEA Title IV-C Program for the handicapped. I also gratefully acknowledge Children's Hospital of Knoxville, TN, who have provided essential contract support for our laboratory at the University of Tennessee.     

Muscle tension and physiologic hyperarousal,performance, and state affectivity: assessing the independence of effects in frequent headache and depression

Anxiety, depression, and frequent headache are closely associated. The comorbidity may be due to selection bias (such as inherent in treatment seeking), shared environmental or genetic factors, or a common underlying process. In this study, comorbidity is considered an alternative explanation for correlates of frequent headache found in earlier work. This study addressed whether EMG, peripheral temperature, performance measures, and measures of affect were independently attributable to depression or headache proneness, after control of trait anxiety. Headache state was evaluated in parallel analysis. Seventy-two participants, comprising four groups, were tested: depressedt/ptheadache-prone, depressed/headache-resistant, not depressed/headache-prone, and not depressed/headache-resistant. Participants completed a performance task that allowed assessment of ambition and performance accuracy while measures of affect, headache state, EMG, and peripheral temperature were obtained. Headache proneness, independently of depression and trait anxiety, was related to heightened EMG. Depression was related to EMG, ambition, and performance accuracy independently of headache proneness and trait anxiety. Headache state was associated only with negative affect, independently of depression and anxiety. These results suggest that headache states during assessment, as well as comorbid depression and anxiety, are not primarily responsible for the heightened EMG found in headache-prone individuals. Negative affect often reported in the headache prone, however, may be due to concommitant anxiety. Other analyses address a variety of issues surrounding distinctions among these variables raised in previous research.     

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 and behavioral treatment of persistent pain in the older adult: a review and a study

Persistent pain is a common health problem for older adults, age 60+, with a prevalence twice that in younger adults. Yet, older adults with chronic pain and headache are underrepresented in behaviorally oriented clinical programs that have proven effective for younger adults. A review of the literature indicates that older adults develop multiple pain-related problems that are similar to those of younger individuals. When offered the opportunity, older pain patients accept and benefit from multidisciplinary pain programs, cognitive–behavioral therapies and biofeedback training. A study comparing 58 older and 59 younger adults in a multidisciplinary pain program indicates that older pain patients readily acquire the physiological self-regulation skills taught in biofeedback-assisted relaxation training, and achieve comparable decreases in pain for the pain program as a whole.     

Scientific and clinical biofeedback in the USSR

This paper describes the history of biofeedback research and application in the USSR. The approach of USSR scientists to the study of basic mechanisms of biofeedback and the status of clinical applications of biofeedback in the Soviet Union are described. Trends in the publication of biofeedback-related papers in Russian are presented, and the present state of the art described. Promising prospects for biofeedback research and application are discussed.     

From tibialis anterior to Tai Chi: biofeedback and beyond

This keynote presentation highlights events that have contributed to scientific explorations of one research clinician. Steve Wolf traces his scientific roots to early studies in single motor unit control under the guidance of his primary mentor, John Basmajian, MD. This work led to subsequent studies on the role of EMG feedback in predicting successful outcomes in upper extremity use and in ambulatory capabilities among patients with chronic stroke. These findings are contrasted to further efforts to condition entire reflexes rather than individual muscles through use of operant-conditioning paradigms. The findings from applications of EMG biofeedback to stroke patients became the basis for minimal motor criteria in the treatment of the impaired upper extremities of patients with chronic stroke, using forced use or constraint-induced movement therapy. Last, investigations into center of pressure feedback using computerized balance machines resulted in a series of experiments that ultimately led to the finding that Tai Chi as an exercise form for older adults can have a substantially favorable effect in delaying the onset of fall events.