The effectiveness of EMG biofeedback training in low back pain

Eighteen patients with chronic low back pain(lbp) of muscle tension origin were given an EMG biofeedback training. Compared to seven controls they showed a significant decrease during training in muscle tension and subsequently in pain. However, at follow-up EMG levels dropped to the initial(high) level. Pain scores of patients with high pain decrements during training showed further improvement during follow-up, which was not the case with patients showing less substantial improvement. The importance of cognitions was discussed.We wish to express our thanks to Marijke Höweler-van Dalen for supervising this investigation, to Arnold Goedhart for statistical advice, to Dr. Orlebeke for his critical remarks, and to Dr. Penders for referring the patients in Amsterdam. We are particularly indebted to the general practitioners Paul Kreutzer and Jan Huls for referring the Andijk patients. Without their support this investigation would not have been possible.     

Electromyographic biofeedback for relief of tension in the facial and throat muscles of a woodwind musician

Electromyographic(EMG) biofeedback, for the relaxation of specific throat and facial muscles, was given to a woodwind musician. The patient had a nineteen-year history of tics and high levels of tension in his throat and facial muscles. Eventually these problems progressed to a point that interfered with his ability to perform as a professional woodwind musician. Following detoxification from alcohol and Dexamyl, and after a period of psychotherapy, EMG biofeedback relaxation training was started for the muscles specifically showing chronically high tension levels. The EMG training consisted of four phases designed to help the patient progressively lower tension and generalize these newly learned techniques to his professional life. He had a total of twenty treatments of approximately 45 minutes each. This procedure resulted in dramatic reductions in tension levels of the specific throat and facial muscles along with increased proficiency as a muscician and in psychological functioning.     

Awareness during electromyographic biofeedback: Of signal or process?

During relaxation training, awareness of trial-to-trial changes in frontalis-muscle tension levels was assessed with and without auditory electromyographic(EMG) biofeedback. Immediately after each 128-sec training trial, the subject was required to guess whether muscle tension indexed by EMG activity increased(“Up”) or decreased(“Down”) relative to the immediately preceding trial. The probability of correct guessing, P(c), improved as the absolute difference in EMG increased between trials only when biofeedback was presented. For subjects not receiving biofeedback, P(c) remained low even when the absolute difference between trials was large. Subjects in each condition employed a strategy to guess “Down” more often consistent with the expectation that they were being trained to relax. The “Down” set strategy was shown to be separable from the informational basis of P(c) provided by biofeedback. This procedure can be employed to evaluate central assumptions of biofeedback relating to posttraining awareness of changes in muscle tension and the relationship between awareness and control of muscle tension.     

EMG-biofeedback reduction of tension headache

The biofeedback literature affirms the therapeutic efficacy of EMG-biofeedback-assisted relaxation for the treatment of tension headache. However, this form of therapy has failed to focus on the role of cognitive variables in the control and perception of tension headache. The present case study provides a prototype treatment combining cognitive behavior-modification procedures with EMG-biofeedback training to treat a subject with chronic tension headache. Phase I, baseline, involved collecting mean EMG and daily headache activity, emphasizing specification of environmental stressors. Phase II, cognitive skills-training, focused on:(1) identifying negative self-statements(cognitions) related to stressors, and(2) training the subject to replace negative self-statements with coping self-instructions. This treatment resulted in a 33% headache reduction over baseline, with no concomitant changes in frontalis EMG. Phase III, EMG-biofeedback training, resulted in a 38% reduction in mean EMG level and a 66% reduction in mean headache activity when compared to baseline. The results suggest the importance of attending to cognitive factors in the treatment of tension headache.This paper was presented at the 6th annual meeting of the Biofeedback Research Society, Monterey, California, 1975.     

The relative effectiveness of three techniques to induce the trophotropic response

The purpose of this study was to examine the relative effectiveness of electromyographic biofeedback training(EMG BFT), remeditation, and progressive muscle relaxation(PMR) in eliciting a relaxation or trophotropic response as measured by frontalis muscle tension, heart rate, electrodermal response, respiration rate, and skin temperature. Fifty-four college students were randomly assigned to one of five groups:(1) control,(2) placebo control,(3) EMG BFT,(4) meditation,(5) PMR. After baseline measures were obtained subjects were trained in 10 30-minute training sessions and posttested. Comparisons by ANOVAs indicated there was a significant decrease in muscle tension in the EMG BFT and meditation groups and significant decreases in respiration rate in the meditation and PMR groups. No other changes were attributed to treatment.     

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.     

Electromyographic biofeedback treatment of a woman with chronic dysphagia

In this case report, a 25-year-old female with chronic dysphagia spastica(difficulty swallowing because of constriction of the throat muscles) was treated with 20 sessions of frontal electromyographic(EMG) biofeedback and home-relaxation practice. The subject monitored on a 10-point scale her difficulty swallowing during meals for 2 months prior to treatment, during treatment, and after treatment. There was a significant decrease in reported difficulty swallowing associated with frontalis EMG feedback. Improvement was maintained at a 6-month follow-up.     

Perceived control

The present investigation tested the hypothesis that perceived control reduces reported symptom incidence for individuals with stressful life events. Subjects(undergraduate psychology students from an urban university) were divided into two groups, high and low in stress, based on their life change unit scores as measured by the Schedule of Recent Events(Holmes & Rahe, 1967). Subjects participated in a study in which they attempted to reduce pulse rate(PR) and were informed of their successes(i.e., PR reductions) through bogus feedback. High and low stress subjects were assigned randomly to one of the following conditions: bogus ascending success feedback(AS), wherein successes were concentrated more in the later stage of a PR reduction period; bogus equally distributed success feedback(EDS), wherein successes were equally distributed in the early and later stages of a PR reduction period; or no feedback(NF). The study consisted of three sessions held on 3 consecutive days. Each session consisted of a 3-minute baseline(nonfeedback) period followed by a 10-minute PR reduction period. Self-reports on 13 symptom items were measured 2 weeks before the study(pretest), after the final session of the study(posttest), and 3 weeks after the study(follow-up). Results indicated that on 5 of the 13 symptom items, the AS condition produced a significant reduction in reported symptom incidence for high-stress subjects only, and this effect was maintained for 3 weeks after the experiment. Results are discussed in terms of the effect perceived control may have on perceptions of physical health. Suggestions are made regarding the use of biofeedback treatment as a method by which perceptions of symptom distress may be reduced for individuals exposed to cumulative stressful experiences.     

EEG and behavioral changes in a hyperkinetic child concurrent with training of the sensorimotor rhythm (SMR)

Reduced seizure incidence coupled with voluntary motor inhibition accompanied conditioned increases in the sensorimotor rhythm(SMR), a 12–14 Hz rhythm appearing over rolandic cortex. Although SMR biofeedback training has been successfully applied to various forms of epilepsy in humans, its potential use in decreasing hyperactivity has been limited to a few cases in which a seizure history was also a significant feature. The present study represents a first attempt to explore the technique's applicability to the problem of hyperkinesis independent of the epilepsy issue. The results of several months of EEG biofeedback training in a hyperkinetic child tend to corroborate and extend previous findings. Feedback presentations for SMR were contingent on the production of 12–14-Hz activity in the absence of 4–7-Hz slow-wave activity. A substantial increase in SMR occurred with progressive SMR training and was associated with enhanced motor inhibition, as gauged by laboratory measures of muscular tone(chin EMG) and by a global behavioral assessment in the classroom. Opposite trends in motor inhibition occurred when the training procedure was reversed and feedback presentations were contingent on the production of 4–7 Hz in the absence of 12–14-Hz activity. Although the preliminary nature of these results is stressed, the subject population has recently been increased to establish the validity and generality of the findings and will include the use of SMR biofeedback training after medication has been withdrawn.This research was a segment of the junior author's dissertation research.     

Treatment of spastic dysphonia by EMG biofeedback

Two middle-aged subjects, a male and female, with spastic dysphonia(hoarseness, stammering) were treated with both frontalis and throat muscle electromyographic(EMG) biofeedback. Both subjects reported no noticeable improvement in their voice qualities. Results of a battery of psychological tests provided some insight into the inability of EMG treatment, as well as other therapeutic approaches, to alleviate the pathology.     

Respiratory Sinus Arrhythmia Versus Neck/Trapezius EMG and Incentive Inspirometry Biofeedback for Asthma: A Pilot Study

This pilot study compared biofeedback to increase respiratory sinus arrhythmia (RSA) with EMG and incentive inspirometry biofeedback in asthmatic adults. A three-group design (Waiting List Control n = 5, RSA biofeedback n = 6, and EMG biofeedback n = 6) was used. Six sessions of training were given in each of the biofeedback groups. In each of three testing sessions, five min. of respiratory resistance and EKG were obtained before and after a 20-min biofeedback session. Additional five-min epochs of data were collected at the beginning and end of the biofeedback period (or, in the control group, self-relaxation). Decreases in respiratory impedance occurred only in the RSA biofeedback group. Traub-Hering-Mayer (THM) waves (.03-.12 Hz) in heart period increased significantly in amplitude during RSA biofeedback. Subjects did not report significantly more relaxation during EMG or RSA biofeedback than during the control condition. However, decreases in pulmonary impedance, across groups, were associated with increases in relaxation. The results are consistent with Vaschillo's theory that RSA biofeedback exercises homeostatic autonomic reflex mechanisms through increasing the amplitude of cardiac oscillations. However, deep breathing during RSA biofeedback is a possible alternate explanation.     

Ten-year stability of EEG biofeedback results for a hyperactive boy who failed fourth grade perceptually impaired class

Ten years ago, the first successful application of a clinical,private-practice based, EEG 14-Hz biofeedback training regimen for the treatment of learning disorders was performed by the author. After the 10-year-old boy, with presenting symptomology including a developmental reading disorder, hyperactivity, and an educational classification of perceptually impaired, continued symptom free for a period oftwo years, his case was submitted for publication. Ten years after his termination from successful treatment, his ongoingly normal social and academic functioning is noted and his EEG brainwave signature examined and compared with a population of 24 used-to-be learning disabled, one-half of which had a pretreatment state including the educational classification of perceptually impaired. This 10-year follow-up confirms the long-term stability of the results of this EEG 14-Hz biofeedback regimen. Current findings on recent medical research identifying a major cerebral locus of dysfunction for hyperkinesis and how it supports the electrode placements of this clinical office setting regimen is also discussed.     

Biofeedback training in frontalis muscle relaxation and enhancement of belief in personal control

The hypothesis that biofeedback training in frontalis muscle relaxation increases beliefs in internal (personal) locus of control was tested. Subjects were divided into two groups (internals and externals) based on Mirels' (1970) factor analyzedpersonal control subscale of Rotter's (1966) I-E Scale. Internal and external subjects were assigned randomly to one of three conditions: biofeedback (BF), false feedback (FF), or no feedback (NF). All subjects were measured on frontalis electromyographic (EMG) activity. Training consisted of three sessions spaced 1 week apart. Each session was comprised of a 5-minute baseline (nonfeedback) trial followed by a 20-minute experimental session. After each experimental session, subjects completed a questionnaire which assessed the extent to which they attributed their EMG performance to personal and environmental sources. After three sessions, subjects were posttested on the I-E Scale. Results indicated that subjects receiving BF reduced their EMG activity more than did subjects in either the FF or NF conditions, and this effect was maintained across all three sessions. Subjects who received BF shifted toward internal personal locus of control from pre- to posttesting, whereas no such change was found for either FF or NF subjects. Also, the relationship between BF training and change in personal locus of control was mediated by subjects attributing their EMG reduction more to personal effort than to properties of the task. Results are discussed in terms of the importance of contingent feedback as a determinant of cognitions of control.     

The effects of frontal EMG biofeedback and progressive relaxation upon hyperactivity and its behavioral concomitants

Hyperactive children(N=15) and nonhyperactive children(N=15) were compared. Hyperactive children were found to possess significantly higher(p < .002) muscular tension levels and, in addition, presented more behavioral problems and had lower test scores. Both electromyographic(EMG) biofeedback and progressive relaxation exercises were successful in the significant reduction of muscular tension, hyperactivity, distractability, irritability, impulsivity, explosiveness, aggressivity, and emotionality in hyperactive children. The greatest improvement was seen in the area of emotionality—aggression(irritability, explosiveness, impulsivity, low frustration tolerance, aggression). No differences were seen in the EMG improvement of drug and nondrug hyperactive children; both made progress under these self-control techniques. However, nondrug children made greater improvements in the behavioral area. Both EMG biofeedback and progressive relaxation resulted in improvements on the test scores of hyperactive subjects(Bender-Gestalt, Visual Sequential Memory, Digit Span, Coding). The therapy would appear to be improved by the inclusion of mental relaxation, concentration, meditation, and mind-blanking exercises for mental control.     

The production and generalization of large-magnitude heart rate deceleration by contingently faded biofeedback

Eight subjects were taught to decrease their heart rates via biofeedback training. Four of these received contingently faded, beat-by-beat analogue feedback and contingent reinforcement each time their performance met a specified and adjusting criterion. The other four received continuous, beat-by-beat analogue feedback, but not the contingent reinforcement. Subjects in the two groups were yoked to ensure equal densities of reinforcement. Subjects in the first group were asked to decrease heart rates 15% from baseline and were then trained using only 75%, 50% and 25% of beat-by-beat feedback. It was hypothesized that the immediate reinforcement of appropriate behavior and the contingent fading(following mastery) of feedback would aid in the generalization of the response. Following completion of all criterion steps or 10 training sessions, whichever came first, all subjects were tested with no feedback and no contingent reinforcement. The group receiving contingently faded feedback training showed a significantly greater heart rate decrease in the training sessions and also the test session. These results were interpreted as indicating that biofeedback can be conceptualized as an operant conditioning paradigm, and that the use of operant techniques may help subjects produce clinically significant changes.This research was supported in part by a grant to Robert J. Gatchel from the National Heart, Lung, and Blood Institute (Grant No. NIH HL 21426-01).     

Effect of slide projections and tape-recorded suggestions on thermal biofeedback training

A previous experiment(Herzfeld & Taub, 1977) demonstrated that slide projections and explicit suggestions relating to thermal experiences can significantly augment temperature self-regulations training(.5° F,p<.05). However, the experimental design was thought to result in an underestimate of the magnitude of the effect, since each subject served as his own control and could therefore make use on nonsuggestion training days of material provided on training days. In this experiment, separate groups of subjects either were given feedback combined with the suggestion procedure on each of 8 training days or were given feedback alone. The mean temperature self-regulation of the suggestion group(2.01° F) was significantly better than the self-regulation(.73) of the nonsuggestion group(t test,p<.01).a difference of 1.28° F.     

Biofeedback and progressive relaxation treatment of sleep-onset insomnia

Previous research suggests that self-defined insomniacs are distinguished from normals by high levels of anxiety and physiological arousal, which might be mitigated by muscle relaxation. This study assessed the relative effects of frontal EMG biofeedback, progressive relaxation, and a placebo set of relaxation exercises on the sleep of 18 onset insomniacs. Each subject was trained in one of these three methods for six half-hour sessions and slept in the laboratory for two consecutive nights before and after training. The experimental groups demonstrated significant decreases in physiological activity during training while changes in the control group were minimal. Reductions in sleep-onset time were: biofeedback group, 29.66 minutes; progressive relaxation group, 22.92 minutes; control group, 2.79 minutes. The experimental groups improved significantly(p<.05) more than the control group, but did not differ from each other. No significant relationships between physiological levels and sleep-onset time were found, which suggests that muscle relaxation alone was not responsible for subjects' improvements. Since 20 minutes of daily practice were required to achieve an approximate 30-minute decrease in sleep-onset time, the practical utility of the methods is questioned.Portions of this paper were presented at the 15th Annual Meeting of the Association for the Psychophysiological Study of Sleep, Edinburgh, July, 1975, and at the 6th Annual Meeting, Biofeedback Research Society, Monterey, California, February, 1975.     

A Mixed Model for Binary Data: The Modified X2-test

In this paper, a statistical model for clinical trials is presented for the special situation that a varying and unstructered number of binary responses is obtained from each subject. The assumptions of the model are the following: 1.) For each subject there is a (constant) individual Bernoulli parameter determining the distribution of the binary responses of this subject. 2.) The Bernoulli parameters associated with the subjects are realizations of independent random variables with distributions P_g in treatment group g(g = 1, 2, …, G). 3.) Given the value of the Bernoulli parameter, the observations are stochastically independent within each subject. Under these assumptions, a test statistic is derived to test the hypothesis H₀:E(P₁) = E(P₂) = … = E(P_G). It is proven and demonstrated by simulations, that the test statistic asymptotically (i.e. for a large number of subjects) follows the X²-distribution.     

The role of EMG awareness in EMG biofeedback learning

Underlying most research on biofeedback learning is a theoretical model of the processes involved. The current study tested a prediction from the Awareness Model: High initial EMG awareness should facilitate response control during EMG biofeedback training. Seventy-two undergraduates were assessed for forehead EMG awareness by asking them to produce target responses from 1.0 to 5.0 µV every 15 s for 16 trials. Based on this assessment, two groups (high and low awareness) were trained for 64 trials to produce these target levels with either EMG biofeedback, practice (no feedback), or noncontingent EMG feedback. A transfer task was identical to the initial assessment. During training, the biofeedback group deviated less from target than the practice and noncontingent groups. The biofeedback group was the only group to improve from initial EMG awareness activity. During transfer, only the low awareness biofeedback group remained below initial EMG awareness level. These findings can be interpreted in terms of the Two-Process Model.     

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.