Biofeedback training: Offerings,plans, and some attitudes in graduate schools and internships

Graduate schools and APA-approved internships in North America were surveyed to determine the type and extent of biofeedback training, additional biofeedback training planned, requirements considered to be a minimum necessary before beginning clinical practice of biofeedback, when biofeedback is considered an appropriate application, and whether biofeedback is considered a passing fad in clinical practice. Questionnaires were returned by 56% of the graduate schools and 54% of the internships, and revealed training in 58% and 67% respectively. Training in biofeedback procedures appears to be growing, and most graduate schools and internships think that biofeedback is not a passing fad in clinical practice. Training emphases vary considerably across graduate schools and internships, with some schools and internships excluding theory and/or practice and/or research from their instruction. The results are discussed in relation to the question of determining which procedures to include in future instruction.     

Specific effects and biofeedback versus biofeedback-assisted self-regulation training

In any field, clear and logical conceptualizations are the basis of accurate models----correct research design----correct results----correct conclusions----advancement in the field. Faulty conceptualizations----faulty models----faulty research design----faulty results----faulty conclusions----confusion. In analyzing the conceptualizations of "biofeedback" as expressed by John Furedy (1987) in, "Specific versus Placebo Effects in Biofeedback Training: A Critical Lay Perspective," we focus on two issues: Does biofeedback have a treatment effect? Is biofeedback necessary for the training effect? In discussing issue (1) we describe the multiple meanings of "biofeedback" and raise the fundamental question: Is biofeedback a treatment? We argue that faulty conceptualizations of clinical biofeedback (1) assume that the treatment in clinical biofeedback is "biofeedback" with specific effects, (2) assume that the scientific basis of biofeedback is dependent upon demonstrations of these specific effects through double-blind design that distinguish "specific" from "placebo effects," and (3) trivialize clinical research by attempting to determine the usefulness of biofeedback information--usefulness that is already understood logically by professionals and consumers and demonstrated by clinical studies in the laboratory and in the clinic. We further argue that accurate conceptualizations of clinical biofeedback (1) identify self-regulation skills as the treatment with specific effects of physiological change and symptom reduction, and (2) describe the use of information from biofeedback instruments as scientific verification of self-regulation skills. Finally, the scientific basis of clinical biofeedback is based on (1) evidence from experimental and clinical control studies that have demonstrated the effectiveness of self-regulation skills for symptom alleviation, and (2) the use of biofeedback instruments to verify the acquisition of self-regulatory skills, thus fulfilling the scientific dictum of verifiability.     

Current advances in training orthopaedic patients to comply with partial weight-bearing instructions

Partial weight-bearing instructions are commonly given to orthopaedic patients and are an important part of post-injury and/or post-operative care. However, the ability of patients to comply with these instructions is poorly defined. Training methods for instructing these patients vary widely among institutions. Traditional methods of training include verbal instruction and use of a bathroom scale. Recent technological advances have created biofeedback devices capable of offering feedback to partial weight-bearing patients. Biofeedback devices have shown great promise in training patients to better comply with partial weight-bearing instructions. This review examines the background and significance of partial weight bearing and offers insights into current advances in training methods for partial weight-bearing patients.     

Self-regulation of response patterning

This paper develops the basic premise that learning to self-regulate a pattern of responses can have different consequences from those observed when controlling individual functions alone. It is suggested that the self-regulation of patterns of responses can be a particularly sensitive and effective procedure for(a) uncovering biological linkages and constraints between responses in the intact human,(b) investigating how multiphysiological systems combine to produce unique subjective experiences and effects on performance, and(c) enhancing the clinical effectiveness of biofeedback procedures by training patients to integrate and coordinate voluntarily specific patterns of cognitive, autonomic, and motor responses. These hypotheses are illustrated by basic research involving biofeedback training for patterns of blood pressure, heart rate and EEG activity, related experiments on the cognitive self-regulation of patterns of physiological responses using affective imagery and meditation procedures, and case studies of patients treated with biofeedback. The concept of electronic biofeedback as an unnatural act is presented with the goal of placing self-regulation within a more biobehavioral perspective emphasizing the natural patterning of physiological processes.Presidential address read at the Biofeedback Research Society meeting on February 18, 1974 at Colorado Springs, Colorado. I would like to express my gratitude to my former teachers and colleagues, whose thinking and data have helped shape the theme presented in this paper. They are, in alphabetical order: Professors Joseph Campos, Andrew Crider, Harold Johnson, Peter Lang, David Shapiro, and Bernard Tursky. I would also like to thank my graduate students, notably Terry Bergman, Richard Davidson, Paul Fair, Daniel Goleman, Jim Hassett, and Marilyn Neyers for their important contributions to the research program.A portion of the recent data reported here was supported by the Advanced Research Projects Agency of the Department of Defense and monitored by the Office of Naval Research under Contract N00011-70-C-0350 to the San Diego State University Foundation.     

THE PLACE AND TRAINING OF THE GENERAL PRACTITIONER

Training for the medical student whose goal is general practice should aim at equipping him to maintain the close personal relationship with the patient which is considered the ideal basis for the treatment and prevention of disease. Preparation for general practice should anticipate graduate experience on a par with that which is currently considered necessary for the various specialties. Internship should be such as to fit the general practitioner to the peculiarities of the kind of community in which he will practice. Ability to recognize his own limitations and situations in which special consultation or referral are indicated should be developed in the student.The University of Colorado School of Medicine has adopted a course of training, from pre-medical education through internship, designed for the student who is to specialize in general practice.     

Interpersonal stress and style as predictors of biofeedback/relaxation training outcome: Preliminary findings

Although the data base describing clinical outcome following biofeedback/relaxation training is accumulating, there have been relatively few attempts to predict short-term outcome, and even fewer for long-term outcome. Significant short-term outcome predictors have been identified, and they often allude to the level of psychological distress as a major factor affecting outcome. To investigate further the role of psychological variables in outcome prediction, this project presents preliminary findings that demonstrate the relationship involving interpersonal psychological stress, interpersonal style of behavior, and outcome. With a very heterogenous group of patients (N=39), measures of interpersonal style of behavior were used to discriminate correctly 80% of cases by outcome at the 3-month postadmission evaluation. With a more homogeneous group having somatic disorders alone (headache, Raynaud's, etc.), the accuracy of prediction at 3 months was 90%. No measures were capable of predicting long-term outcome with accuracies even moderately greater than chance. The results indicate that style of interpersonal behavior (e.g., managerial, dependent) and, to a lesser extent, interpersonal stress is predictive of short-term outcome following biofeedback/relaxation training. Individuals who tend to like responsibility and who are more executive and independent generally benefited more than doubtful, obedient, and depressed individuals. While the resulting prediction rates were only slightly more accurate than MMPI D and Pt subscales alone, the procedures provide additional information regarding the personality characteristics of successful and unsuccessful biofeedback clients, and may also provide the clinician with information regarding treatment choice if biofeedback is provided as an adjunct to psychotherapy.     

Biofeedback,relaxation training,and music: Homeostasis for coping with stress

This study compared the efficacy of five relaxation training procedures, four of which employed EMG auditory feedback: (1) biofeedback only (BF), (2) autogenic training phrases (ATP), (3) music (MU), (4) autogenic training phrases and music (ATP & MU), and (5) a control group, in developing self-regulation of a cultivated low arousal state as a countermeasure to tensed muscular reaction to stressful imagery. Twenty subjects established a pre- and posttraining frontalis region EMG biofeedback baseline measurement. Sixteen subjects were assigned at random to the 25-minute taped relaxation training procedure. After eight training sessions (4 weeks), MU and ATP & MU groups achieved highly significant differences when compared with the control group. The ATP & MU group attained the lowest postbaseline arousal level measured by the EMG. EMG as a physiological measure for transfer of training functioned well in detecting the psychophysiological affect of stressful imagery.This report is based on a thesis submitted in partial fulfillment of the requirements for the Master of Arts in Psychology degree by the author. The author extends his gratitude to Dr. Theodore Steiner, Dr. Paul Eskildsen, and Dr. Frank Hovell, who served on the committee, and to Rosemary Kolentus, for her help with this article.     

Understand – then Criticize

In this article we propose a policy intended to alleviate the typical problems of student internships and improve the usefulness and relevancy of any partnership. We extend previous ideas about professional development schools or partnerships to eliminate the disconnect between K–12 schools and universities and add a component of multiple constituent mentoring necessary for effective music teacher and music teacher educator training. A partnership with multiple mentors—K–12 students, K–12 teachers, undergraduate students, graduate students, and university music education faculty—can provide the most benefits to the greatest number of people. The policy presented in this article will likely require the implementation of philosophical and curricular changes, but these efforts would be well worth the investment of time and resources.     

Specific effects and biofeedback versus biofeedback-assisted self-regulation training

In any field, clear and logical conceptualizations are the basis of accurate models → correct research design → correct results → correct conclusions → advancement in the field. Faulty conceptualizations → faulty models → faulty research design → faulty results → faulty conclusions → confusion. In analyzing the conceptualizations of “biofeedback” as expressed by John Furedy (1987) in, “Specific versus Placebo Effects in Biofeedback Training: A Critical Lay Perspective,” we focus on two issues: Does biofeedback have a treatment effect? Is biofeedback necessary for the training effect? In discussing issue (1) we describe the multiple meanings of “biofeedback” and raise the fundamental question: Is biofeedback a treatment? We argue that faulty conceptualizations of clinical biofeedback (1) assume that the treatment in clinical biofeedback is “biofeedback” with specific effects, (2) assume that the scientific basis of biofeedback is dependent upon demonstrations of these specific effects through double-blind designs that distinguish “specific” from “placebo effects,” and (3) trivialize clinical research by attempting to determine the usefulness of biofeedback information — usefulness that is already understood logically by professionals and consumers and demonstrated by clinical studies in the laboratory and in the clinic. We further argue that accurate conceptualizations of clinical biofeedback (1) identify self-regulation skills as the treatment with specific effects of physiological change and symptom reduction, and (2) describe the use of information from biofeedback instruments as scientific verification of self-regulation skills. Finally, the scientific basis of clinical biofeedback is based on (1) evidence from experimental and clinical control studies that have demonstrated the effectiveness of self-regulation skills for symptom alleviation, and (2) the use of biofeedback instruments to verify the acquisition of self-regulatory skills, thus fulfilling the scientific dictum of verifiability.     

Biofeedback in medicine: who,when, why and how?

Biofeedback is a mind-body technique in which individuals learn how to modify their physiology for the purpose of improving physical, mental, emotional and spiritual health. Much like physical therapy, biofeedback training requires active participation on the part of patients and often regular practice between training sessions. Clinical biofeedback may be used to manage disease symptoms as well as to improve overall health and wellness through stress management training. Research has shown that biofeedback interventions are efficacious in treating a variety of medical conditions, and many Americans are turning to biofeedback and other less traditional therapies for their routine healthcare.Clinical biofeedback training is growing increasingly popular in the USA, as many people are seeking out relatively new approaches to healthcare. This article provides an overview of clinical biofeedback training, outlines two models of training, details research which has established how effective biofeedback is in patients with a given disease, and describes who should be referred for biofeedback training.     

Heart Rate Variability Biofeedback Does Not Substitute for Asthma Steroid Controller Medication

Despite previous findings of therapeutic effects for heart rate variability biofeedback (HRVB) on asthma, it is not known whether HRVB can substitute either for controller or rescue medication, or whether it affects airway inflammation. Sixty-eight paid volunteer steroid naïve study participants with mild or moderate asthma were given 3 months of HRVB or a comparison condition consisting of EEG alpha biofeedback with relaxing music and relaxed paced breathing (EEG+), in a two-center trial. All participants received a month of intensive asthma education prior to randomization. Both treatment conditions produced similar significant improvements on the methacholine challenge test (MCT), asthma symptoms, and asthma quality of life (AQOL). MCT effects were of similar size to those of enhanced placebo procedures reported elsewhere, and were 65% of those of a course of a high-potency inhaled steroid budesonide given to a sub-group of participants following biofeedback training. Exhaled nitric oxide decreased significantly only in the HRVB group, 81% of the budesonide effect, but with no significant differences between groups. Participants reported becoming more relaxed during practice of both techniques. Administration of albuterol after biofeedback sessions produced a large improvement in pulmonary function test results, indicating that neither treatment normalized pulmonary function as a potent controller medication would have done. Impulse oscillometry showed increased upper airway (vocal cord) resistance during biofeedback periods in both groups. These data suggest that HRVB should not be considered an alternative to asthma controller medications (e.g., inhaled steroids), although both biofeedback conditions produced some beneficial effects, warranting further research, and suggesting potential complementary effects. Various hypotheses are presented to explain why HRVB effects on asthma appeared smaller in this study than in earlier studies. Clinical Trial Registration NCT02766374.     

Biofeedback treatment of dysmenorrhea

Nine dysmenorrheic women were run in EMG and thermal biofeedback procedures with concurrent autogenic relaxation practice. Significant reductions in subjective estimates of symptomology associated with dysmenorrhea were noted in all subjects. EMG levels correlated positively with the reductions in symptoms. Thermal levels did not correlate with EMG. In fact no consistent patterns in thermal measures were noted. However, thermal biofeedback cannot be ruled out as an effective treatment for dysmenorrhea since reductions in symptoms occurred during thermal biofeedback training. Another significant aspect of the present study is the effectiveness of long treatment procedures. A six month period was employed and significant reductions in symptoms were noted following two months of biofeedback treatment. Finally, the importance of beginning biofeedback treatment prior to onset of menstrual symptoms is indicated.     

The Class of 1989 and physician supply in Canada

BACKGROUND: "The Class of 1989" is a study of 1722 people who were awarded an MD degree by a Canadian university in 1989. This paper reports on migration, specialty choices and patterns of post-MD training in order to assess the contribution of the graduating cohort to the physician workforce of Canada. METHODS: A longitudinal study was conducted over 7 years after graduation to trace the current location, the post-MD training history and the professional activity of the graduating cohort. Several medical professional and educational associations in Canada and the United States provided year-by-year information on field and location of post-MD training, certification achieved, whether in practice and location of practice through to spring 1996. Information from all sources was linked to a list of 1989 medical school graduates. RESULTS: From entry to medical school through to 7 years after graduation the cohort was diminished by about 16%. The main reason for loss was migration to other countries: 193 graduates (11.2%) were outside Canada in 1995-96. Internal migration was extensive also; for example, by 1995-96 relatively few of the graduates were located in Newfoundland or Saskatchewan. Of the 1516 graduates active in Canada in 1995-96, 878 (57.9%) were in general practice/family medicine, and only 638 (42.1%) were practising or training in a specialty. INTERPRETATION: The "yield" of the Class of 1989 for Canada''s physician workforce is insufficient to meet annual physician inflows from Canadian sources to serve population growth and to replace retiring or emigrating physicians. As output from Canada''s medical schools drops even further, the gap between requirements and supply will grow even wider.     

Versatility in computer automation for biofeedback: the behavioral assessment and rehabilitative training system (BARTS)

User versatility in a system for computer-automated biofeedback training is the degree to which the assessment and training parameters may be altered by the user's employing English language or other simple code, that is, without altering the system's applications software. The Behavioral Assessment and Rehabilitative Training System (BARTS) includes a design and control program that allows for the specification of assessment and training protocols by persons who are entirely lacking in computer programming skills. This paper describes the logic for data acquisition and training that is incorporated in the BARTS, describes the parameters that must be specified in constituting unique assessment or training protocols, and illustrates the system's application in a research-oriented biofeedback clinic.     

Self-directed EMG training for the control of pain and spasticity in paraplegia: a case study

A 25-year-old paraplegic woman was able to gain control of her debilitating leg and bladder spasms and abdominal pain using self-directed EMG biofeedback. The case is significant in that she previously had only cursory exposure to biofeedback as an undergraduate student and received only minimal support and direction from an instructor. She proceeded through daily home practice using a borrowed EMG unit and audiotapes from Lester Fehmi's Open Focus series. Records were kept of the frequency and intensity of her pain and spasms, as well as the frequency and procedures of her home practice. She also maintained a record of specific psychosocial events in her life, which, over time, showed a strong, consistent pattern of influence on the recurrence and severity of her symptoms. The woman's physician declared her medical progress remarkable and encouraged her biofeedback work. At 2-year follow-up, she remains virtually symptom- and medication-free. Her successful biofeedback training program provides support for the value of client-directed biofeedback in selected cases.     

Institutional and IACUC responsibilities for animal care and use education and training programs

Training and instruction of personnel are important components of animal care and use programs because they help to ensure the health and welfare of the animals and the integrity of the research or testing results. Training also helps to promote the consideration of alternatives, recognition of animal pain and distress, appropriate use of pain-relieving agents, aseptic technique, pre- and post-procedural care, and personnel health and safety. While individuals who provide the care for or conduct research or testing in laboratory animals should take personal responsibility for ensuring that they have the skills to perform their duties, the institution is ultimately responsible for ensuring their competency. The institution is also responsible for providing the training or instruction that is required by federal legislation, regulations, and policies. The institutional animal care and use committee (IACUC) is responsible for ensuring, as part of their review of research activities, that the personnel are capable of performing the procedures described. The IACUC must also assess the institution's training program as part of their semiannual animal care and use program review and make recommendations regarding training to the institutional official. This article provides a comprehensive overview of the US regulatory mandates for training and personnel qualification.     

Self-directed EMG training for the control of pain and spasticity in paraplegia: A case study

A 25-year-old paraplegic woman was able to gain control of her debilitating leg and bladder spasms and abdominal pain using self-directed EMG biofeedback. The case is significant in that she previously had only cursory exposure to biofeedback as an undergraduate student and received only minimal support and direction from an instructor. She proceeded through daily home practice using a borrowed EMG unit and audiotapes from Lester Fehmi'sOpen Focus series. Records were kept of the frequency and intensity of her pain and spasms, as well as the frequency and procedures of her home practice. She also maintained a record of specific psychosocial events in her life, which, over time, showed a strong, consistent pattern of influence on the recurrence and severity of her symptoms. The woman's physician declared her medical progress remarkable and encouraged her biofeedback work. At 2-year follow-up, she remains virtually symptom- and medication-free. Her successful biofeedback training program provides support for the value of client-directed biofeedback in selected cases.     

Control of cardiac response under aversive stimulation

The relative heart rate effects of biofeedback training, deep muscle relaxation, and a no-feedback/music procedure were compared during two criterion situations. The first consisted of a 25-min training period during which subjects received the assigned treatments. The second consisted of the pre- to posttraining reductions in heart rate reactivity to a series of aversive tone-shock trials. On the first criterion, the heart rate decreases of the feedback and no-feedback/music groups were not clearly distinguishable; however, both groups fell significantly below the muscle-relaxation group. By contrast, on the second criterion, the three groups were clearly distinguishable, with feedback subjects evidencing the most heart rate control, followed by the muscle-relaxation and no-feedback/music groups, respectively. On the segment of the posttraining aversive trials conducted in the absence of the feedback signal, transfer of heart rate control was incomplete for feedback subjects, but still remained below the level of the other two groups. Training effects were more pronounced on tonic than on phasic heart rate changes. The difference between the two criterion situations suggests the possible need for and feasibility of employing a situational arousal methodology in evaluating the extent and limitation of physiological training procedures.     

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.     

Postgraduate clinical education — the Canadian experience

To obtain a quantitative measure of the extent to which graduate education and qualification for specialty practice have become an integral part of the total educational experience, samples of the graduating classes of 1960, 1964, 1968 and 1970 of Canadian medical schools were tracked through postgraduate educational training and into specialty certification. From the 1960 cohort 65% chose a career recognized by special certifying exams in Canada and/or the United States, entered a residency, completed it and achieved certification of special competence. From the 1970 cohort, by the end of 1972 approximately 50% had entered a recognized specialty training program leading to certification. The diminishing trend toward specialty practice is demonstrated by reviewing the comparative figures in the 1964 and 1968 cohorts. Evidence garnered in this study indicates a continuing strong motivation for specialty practice although family medicine and/or general practice appear increasingly attractive as career choices. Strong provincial educational forces as well as social and other forces will probably continue to modify career selection and may lead an increasing number of Canadian medical graduates into family practice.