Behavioral strategies for the reduction of pain and anxiety associated with orthopedic trauma

This study examined the efficacy of behavioral strategies in alleviating pain and anxiety associated with severe orthopedic trauma. Sixty-four patients with multiple fractures were divided into four groups: (1) control, (2) attention only, (3) EMG biofeedback-assisted relaxation, and (4) audiotaped relaxation training. All were measured over at least six sessions, or as long as hospital stay permitted. Significant between group differences were found on the following: systolic blood pressure, peripheral temperature, subjective units of discomfort, state anxiety, with a trend for use of sleep medications. No differences were found on other vital signs, EMG recordings, or other medications. EMG-biofeedback relaxation and relaxation training were relatively equivalent for all measures, and little or no change was observed for those patients who received attention only or served as controls.     

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.We would like to express our appreciation for the contributions the following people made to this project: Drs. Barry Smith, Robert Steele, Agnes Hartfield, Jeffrey Barth, Althea Wagman, and the late Harold Weiner; Earl Downs and the participating staff at Springfield State Hospital Center; and Robert Kline and Michael Kelley, who performed the data analyses. This research was supported in part by a grant from the Computer Science Center at the University of Maryland.     

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.     

Effects of Relaxation Training on Glucose Tolerance and Diabetic Control in Type II Diabetes

The present study examined the effects of progressive relaxation training and EMG biofeedback on acute glucose disposal in diabetic subjects, as measured by glucose tolerance and three other measures of diabetic metabolic control. Twenty subjects with non-insulin-using Type II diabetes took part in progressive relaxation training and EMG biofeedback in a pre-post treatment versus wait-list experimental design. Treatment effects were assessed on glucose tolerance along with three measures of diabetic control: fasting blood glucose, two-hour postprandial blood glucose, and fructosamine. Stress reduction and relaxation was assessed with two physiological measures and two subjective questionnaires. The training program produced significant reductions in stress, as measured by State Anxiety, and significant changes in physiological measures of muscle activity and skin conductance compared to the control condition. However, no changes were found in glucose tolerance (while practicing relaxation) nor in any of the three measures of general diabetic metabolic control. The major implication of this study is that relaxation training does not appear to directly improve diabetic control in mildly stressed non-insulin-using Type II diabetic patients.     

Biofeedback-based stress management training with a population of business managers

A biofeedback-based stress management training program was experimentally evaluated using populations of middle-level managers from a large corporation. The training program, once-weekly 1-hour sessions for 6 weeks, combined frontal and other site EMG biofeedback, progressive relaxation and breathing exercises, cognitive stress management, and generalization techniques. Control groups participated in either the assessment procedures only or the assessment procedures and six once-weekly discussions of stress and the job on both an individual(two sessions) and group(four sessions) basis. Significant effects were found in self-report measures, state and trait anxiety, experience of stress; in physiological measures, basal frontal EMG and frontal EMG during recovery from stress, and finger temperature; and in ratings of overall job performance. However, no consistent advantage for the training group or either control group was found. Several possible explanations for the failure of the biofeedback-based stress management training condition to achieve a consistent advantage over the control conditions are presented.     

Live and taped relaxation instructions: effects of procedural variables

Two experiments were designed to assess the effects of relaxation training, therapist presence or absence, live versus taped voice, and response-contingent versus noncontingent instructional progress on measures of subjective relaxation and frontal EMG. In the first experiment, it was found that subjects receiving taped instructions showed greater within-session subjective relaxation and lowering of within-session frontal EMG than subjects in a control condition. No differential training effects of therapist presence or absence was noted. In a second experiment, no significant differences in relaxation measures were found between subjects receiving live, response-contingent instructions and subjects receiving live, noncontingent instructions. Moreover, no meaningful differences in relaxation measures were found between subjects receiving live and taped instructions.     

Self-instructed relaxation: a therapeutic alternative

A self-instructed relaxation program was compared with therapist-instructed relaxation and waiting list controls. Self-report anxiety measures ( IPAT and STAI ) and a psychophysiological stress profile (frontal EMG, GSR, heart rate, finger temperature monitored under relaxation and stressor conditions) were utilized pre- and posttreatment to determine efficacy. Self-monitored heart rate, respiration rate, and finger temperature were used to monitor home practice sessions. Subjects reported increased ability to relax and control stress; however, frontal EMG measured under stressor conditions was the only dependent measure to confirm this perception. No between-group differences on any other dependent measures were observed. Reliable changes on all self-monitored home practice measures were observed, suggesting that this procedure is a useful gauge of home practice.     

Feedback delays and relaxation expectancies in EMG biofeedback

The use of noncontingent feedback controls in studies of the efficacy and process of electromyographic (EMG) biofeedback may yield results confounded by differential expectancies for relaxation. Furthermore, the role of expectancies in producing psychological and physical relaxation as well as reducing muscle activity is unclear. This study investigated the effects of feedback delays and induced relaxation expectancies on EMG activity and experienced relaxation. One hundred four non-clinical subjects participated in one auditory frontal EMG biofeedback training session. Subjects were assigned to one of four computerized feedback delay conditions (0.0037, 0.7493, 2.2481, 6.7444 s) and to one of two relaxation expectancy conditions (positive or negative). During 20 minutes of biofeedback training, all groups decreased frontal activity. Feedback delays interacted with training epochs in affecting EMG; the longest delay group reduced frontal activity more slowly than the shortest delay group during training. Positive relaxation expectancies produced greater experienced relaxation than did negative relaxation expectancies. Instrumental and expectancy factors in EMG biofeedback appear to operate independently of each other by reducing physiological activity and producing psychological relaxation respectively.     

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.     

Evaluation of a Respiratory Muscle Biofeedback Procedure–Effects on Heart Rate and Dyspnea

Patients with respiratory diseases or anxiety frequently complain about dyspnea, which may be partly related to chronic tension of respiratory muscles and/or dynamic hyperinflation. In two experiments we tested a biofeedback technique that recorded electromyographic (EMG) activity from a bipolar surface electrode placement over the right external intercostal muscles with visual signal feedback. Healthy participants were tested in their ability to alter the signal. Heart rate was measured continuously throughout training trials. In the second experiment, dyspnea was rated on a modified Borg scale after each trial. Participants were able to increase their EMG activity considerably while heart rate and dyspnea increased substantially. Changes in EMG activity were achieved mostly by manipulating accessory muscle tension and/or altering breathing pattern. Thus, the technique is capable of altering respiratory muscle tension and associated dyspnea. Further studies may test the procedure as a relaxation technique in patients with respiratory disease or anxiety.     

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.     

Effectiveness of multiple-site EMG biofeedback in the reduction of arousal

During the training phase, 36 subjects received (a) EMG biofeedback from multiple muscle sites, (b) EMG biofeedback from the frontal site, or (c) no biofeedback. Results indicated that neither biofeedback procedure reduced self-reports of anxiety, but that multiple-site biofeedback was effective in reducing several indices of autonomic arousal (pulse rate, finger pulse volume, and skin temperature) while frontal biofeedback was not. During the generalization/stress phase, all subjects were threatened with and received electric shocks and were told to apply the relaxation techniques they learned during the training phase even though no additional biofeedback would be provided. Results indicated that multiple-site biofeedback was effective in reducing self-reports of anxiety and autonomic arousal but that frontal biofeedback was not. These results confirm previous data indicating that frontal biofeedback is not an effective procedure for controlling stress, but suggest that EMG biofeedback can be effective in reducing self-reported anxiety and autonomic arousal if a multiple muscle-site feedback procedure is employed.     

Live and taped relaxation instructions: Effects of procedural variables

Two experiments were designed to assess the effects of relaxation training, therapist presence or absence, live versus taped voice, and response-contingent versus noncontingent instructional progress on measures of subjective relaxation and frontal EMG. In the first experiment, it was found that subjects receiving taped instructions showed greater within-session subjective relaxation and lowering of within-session frontal EMG than subjects in a control condition. No differential training effects of therapist presence or absence was noted. In a second experiment, no significant differences in relaxation measures were found between subjects receiving live, response-contingent instructions and subjects receiving live, noncontingent instructions. Moreover, no meaningful differences in relaxation measures were found between subjects receiving live and taped instructions.This research is based on a dissertation by the first author, under the direction of the second author. The authors thank James E. Hastings and the dissertation committee, Jeffrey M. Lohr, Dennis Bonge, and Honore M. Hughes, for their assistance and helpful comments. This research was supported by the Marie Wilson Howells Research Fund.     

Feedback delays and relaxation expectancies in EMG biofeedback

The use of noncontingent feedback controls in studies of the efficacy and process of electromyographic (EMG) biofeedback may yield results confounded by differential expectancies for relaxation. Furthermore, the role of expectancies in producing psychological and physical relaxation as well as reducing muscle activity is unclear. This study investigated the effects of feedback delays and induced relaxation expectancies on EMG activity and experienced relaxation. One hundred four non-clinical subjects participated in one auditory frontal EMG biofeedback training session. Subjects were assigned to one of four computerized feedback delay conditions (0.0037, 0.7493, 2.2481, 6.7444 s) and to one of two relaxation expectancy conditions (positive or negative). During 20 minutes of biofeedback training, all groups decreased frontal activity. Feedback delays interacted with training epochs in affecting EMG; the longest delay group reduced frontal activity more slowly than the shortest delay group during training. Positive relaxation expectancies produced greater experienced relaxation than did negative relaxation expectancies. Instrumental and expectancy factors in EMG biofeedback appear to operate independently of each other by reducing physiological activity and producing psychological relaxation respectively.This study was completed by the first author under the direction of the second author in partial fulfillment of the requirements for the Master of Arts degree. We gratefully acknowledge the computerization advice and assistance provided by Larry Wheeler, and the assistance in data collection provided by Dawn Dexter and Michael Winstanley.     

The Influence of Voice Volume, Pitch, and Speech Rate on Progressive Relaxation Training: Application of Methods from Speech Pathology and Audiology

Vocal characteristics of therapists, including voice volume, pitch and timbre of speech, and rate of speech have been hypothesized to facilitate the therapeutic process, particularly during procedures like progressive relaxation training (PRT). Very little empirical work, however, has examined the relation between vocal characteristics and treatment process or outcome. The purpose of this study was to examine the role of vocal characteristics during a single session of PRT applying technological innovations devised for speech pathology and audiology settings for evaluating therapist's vocal characteristics. Forty-eight high anxious young adult women were randomly assigned to one of four conditions for training: PRT with the recommended therapist voice (RV) that decreased in tone, volume, and rate across the session, PRT with conversational therapist voice during the session (CV), a credible treatment control called systematic self-relaxation (SR), or no treatment control (NT). All subjects participated in a single PRT session during which heart rate, EMG, self-report measures of tension (SRT) and anxiety, and treatment credibility ratings were obtained. Results revealed significant reductions in SRT, self-reported anxiety, and heart rate for participants in all groups. Only the RV group displayed significant reductions in EMG when compared with the other three groups. Participants in the RV group also rated the therapist's voice as “more facilitating” of relaxation when compared to the CV group. These results suggest that methods employed for evaluating the quality of vocal characteristics in speech and audiology clinics may be useful for evaluating the quality of therapist's voice when conducting PRT.     

Self-instructed relaxation: A therapeutic alternative

A self-instructed relaxation program was compared with therapist-instructed relaxation and waiting list controls. Self-report anxiety measures (IPAT and STAI) and a psychophysiological stress profile (frontal EMG, GSR, heart rate, finger temperature monitored under relaxation and stressor conditions) were utilized pre- and posttreatment to determine efficacy. Self-monitored heart rate, respiration rate, and finger temperature were used to monitor home practice sessions. Subjects reported increased ability to relax and control stress; however, frontal EMG measured under stressor conditions was the only dependent measure to confirm this perception. No between-group differences on any other dependent measures were observed. Reliable changes on all self-monitored home practice measures were observed, suggesting that this procedure is a useful gauge of home practice.This study was made possible by grants from the Programs of Distinction Research Fund, Simon Fraser University, and from the Federal Health Promotion Directorate, Grant No. 1216-9-167.     

Effects of noncontingent feedback on EMG training, EMG responses, and subjective experience

Various types of noncontingent feedback have been used as control procedures in EMG training; however, their effects on such training have received little attention. Experiment 1 in the present study examined the effects of noncontingent feedback on EMG training, and Experiment 2 assessed the effects of feedback characteristics on EMG responses. In Experiment 1, three noncontingent feedback groups (yoked control, randomly fluctuating tones, and decreasing tones) and one contingent group underwent 20 minutes of training for frontal EMG decreases. Procedures in Experiment 2 were identical to those in Experiment 1 except that subjects were instructed merely to listen to the feedback tones. Results of Experiment 1 indicated that contingent and noncontingent fluctuating feedback groups achieved significantly lower EMG levels than noncontingent decreasing and yoked control groups. In Experiment 2, however, no differences in EMG activity were found among groups. In both experiments, groups did not differ in terms of subjective variables such as frustration, suspiciousness about the tone, or length of time attending to the tone. Results of these two experiments suggest that differences in EMG responses to various types of noncontingent feedback result from interactions between characteristics of the feedback stimulus and instructions to decrease the stimulus.     

EMG stability as a biofeedback control

Factors that may confound comparisons between electromyographic (EMG) biofeedback training and its control conditions include feedback quality and experience of success. We investigated the usefulness of a control procedure designed to overcome these potential sources of confounding. The procedure consisted of training muscle tension stability. We used it as a control for frontal EMG relaxation training in children with asthma. To equate the groups for feedback quality and experience of success, we gave each child in the control condition audio feedback decreasing in pitch when muscle tension was at or near baseline levels, and feedback increasing in pitch when muscle tension was either substantially above or below baseline levels. Children in both groups were instructed to decrease the pitch of the tone. In comparison to children in the relaxation condition, the children in the control condition exhibited stable levels of muscle tension throughout eight training sessions. We concluded that feedback for stable muscle tension may be a useful control procedure for EMG biofeedback training whenever experimental and control procedures differ in either feedback quality of degree to which they permit subjects to experience success.This research was supported by NIH-Grant HL 27402. We are grateful to Paul Schnitter who constructed the EMG stability feedback device.     

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.