Combined Heart Rate Variability and Pulse Oximetry Biofeedback for Chronic Obstructive Pulmonary Disease: Preliminary Findings

The purpose of this study was to examine the feasibility of an intervention that included heart rate variability (HRV) biofeedback and walking with pulse oximetry feedback to improve functioning and quality of life for patients with chronic obstructive pulmonary disease (COPD). Twenty patients with COPD participated in 5 weekly sessions of HRV biofeedback and 4 weekly sessions of walking practice with oximetry feedback, with instructions for daily home practice. Primary outcomes measures were the distance walked in 6 min (6MWD) and overall quality of life, as measured by the St. George's Respiratory Questionnaire (SGRQ). Secondary outcomes included measures of self-efficacy, self-reported disability, anxiety, depression, dyspnea before and after the 6MWD, and HRV at the frequency of respiration during spontaneous and paced breathing. After 10 weeks of training, participants showed statistically and clinically significant improvements in 6MWD and quality of life. Significant changes were also seen in self-efficacy, disability, dyspnea before and after the 6MWD, and HRV amplitude during spontaneous breathing. We conclude that our intervention is feasible for patients with COPD and that further research using a randomized controlled design is warranted.     

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.     

Respiratory Sinus Arrhythmia Biofeedback Therapy for Asthma: A Report of 20 Unmedicated Pediatric Cases Using the Smetankin Method

This multiple case study describes pulmonary function changes in 20 asthmatic children from 30 consecutive cases undergoing biofeedback training for increasing the amplitude of respiratory sinus arrhythmia (RSA). The Smetankin protocol was used, which, in addition to RSA biofeedback, includes instructions in relaxed abdominal pursed-lips breathing. Ten individuals were excluded, including 6 who had been taking asthma medication, 2 who developed viral infections during the treatment period, and 2 who dropped out prior to completing treatment. Patients each received 13 to 15 sessions of training. Asthma tended to be mild, with mean spirometric values close to normal levels. Nevertheless, significant improvements were noted in 2 spirometry measures taken during forced expiratory maneuvers from maximum vital capacity: FEV₁ and FEF50. These preliminary uncontrolled data suggest that the Smetankin protocol warrants further evaluation as a nonpharmacological psychophysiological treatment for this condition, although these data could not definitively prove that the method is effective.     

The Effects of Respiratory Sinus Arrhythmia Biofeedback on Heart Rate Variability and Posttraumatic Stress Disorder Symptoms: A Pilot Study

Recent studies have found a significant association between PTSD and low heart rate variability (HRV), a biomarker of autonomic dysregulation. Research indicates that respiratory sinus arrhythmia (RSA) biofeedback increases HRV while reducing related pathological symptoms. This controlled pilot study compared RSA biofeedback to progressive muscle relaxation (PMR) as adjunctive interventions for 38 persons with PTSD symptoms in a residential treatment facility for a substance use disorder. Both groups were assessed at pre-intervention and 4-week post-intervention. Group × time interactions revealed significantly greater reductions in depressive symptoms and increases in HRV indices for the RSA group. Both groups significantly reduced PTSD and insomnia symptoms and a statistical trend was observed for reduced substance craving for the RSA group. Increases in HRV were significantly associated with PTSD symptom reduction. Overall, these results provide preliminary support for the efficacy of RSA biofeedback in improving physiological and psychological health for individuals with PTSD.     

Emotionally Triggered Asthma: A Review of Research Literature and Some Hypotheses for Self-Regulation Therapies

Asthma is a common disease whose morbidity and mortality are rapidly increasing. Panic disorder is common in asthma. Panic, other negative emotions, and a passive coping orientation may affect asthma by producing hyperventilation, increased general autonomic lability, a specific pattern of autonomic arousal that may cause bronchoconstriction, and/or detrimental effects on health care behaviors. Generalized panic is a risk factor for increased asthma morbidity. A repressive coping style also appears to be a risk factor for asthma morbidity because it is accompanied by an impaired ability to perceive symptoms, a necessary prerequisite for taking appropriate remediation. Several self-regulation strategies are hypothesized to be useful adjuncts to asthma treatment. Preliminary research has been done on relaxation therapy, EMG biofeedback, biofeedback for improved sensitivity in perceiving respiratory sensations, and biofeedback training for increasing respiratory sinus arrhythmia. It is hypothesized that finger temperature biofeedback also may be a promising treatment method, and that relaxation-oriented methods will have their greatest effect among asthmatics who experience panic symptoms, while improved perceptual sensitivity will be helpful both for patients who panic and those with repressive coping styles.     

Heart rate variability biofeedback as a method for assessing baroreflex function: a preliminary study of resonance in the cardiovascular system

This study describes the use of a biofeedback method for the noninvasive study of baroreflex mechanisms. Five previously untrained healthy male participants learned to control oscillations in heart rate using biofeedback training to modify their heart rate variability at specific frequencies. They were instructed to match computer-generated sinusoidal oscillations with oscillations in heart rate at seven frequencies within the range of 0.01–0.14 Hz. All participants successfully produced high-amplitude target-frequency oscillations in both heart rate and blood pressure. Stable and predictable transfer functions between heart rate and blood pressure were obtained in all participants. The highest oscillation amplitudes were produced in the range of 0.055–0.11 Hz for heart rate and 0.02–0.055 Hz for blood pressure. Transfer functions were calculated among sinusoidal oscillations in the target stimuli, heart rate, blood pressure, and respiration for frequencies at which subjects received training. High and low target-frequency oscillation amplitudes at specific frequencies could be explained by resonance among various oscillatory processes in the cardiovascular system. The exact resonant frequencies differed among individuals. Changes in heart rate oscillations could not be completely explained by changes in breathing. The biofeedback method also allowed us to quantity characteristics of inertia, delay, and speed sensitivity in baroreflex system. We discuss the implications of these findings for using heart rate variability biofeedback as an aid in diagnosing various autonomic and cardiovascular system disorders and as a method for treating these disorders.     

A Scoring System for Capnogram Biofeedback: Preliminary Findings

Labored breathing and irregularities in the breathing pattern may be assessed by capnography; and, an abnormal capnogram wave form may often be rectified with the help of capnogram biofeedback. Clinical experience suggests this may relieve dyspnea but to what degree, for how long and for what conditions have not been determined; the issue is complex and much remains to be discovered. The more that can be learned about the various capnogram irregularities, the more effectively such information will guide us in therapy and research. To this end a 15-category capnogram disordered breathing scale (Landis CDBS) was developed to provide a measure of disordered breathing. The CDBS score is the ratio of the total number of abnormal capnogram forms to the total number of capnogram configurations in the test sample, expressed as a percentage. The total score as well as an accounting of each abnormal scoring category was tabulated for each subject. In this retrospective and preliminary study, findings of a normal comparison group were compared with capnogram data for 3 clinical groups: asthma, anxiety/panic attacks, and patients with diverse stress-related somatic symptoms. Mean CDBS scores were: a low 14% for the Normal group compared with 64% for the Asthma group; 66% for the Anxiety patients; and 47% for the Somatic group. Each group was characterized by distinctive clusters of capnogram abnormalities. As there are methodological limitations to this small group study, the findings require validation. However, as an introduction to the scoring system and because of its potential clinical value we present this paper now.     

A Pilot Study on the Effects of Heart Rate Variability Biofeedback in Patients with Depression and in Healthy Subjects

Decreased vagal activity and increased sympathetic arousal have been proposed as major contributors to the increased risk of cardiovascular mortality in patients with depression. It was aim of the present study to assess the feasibility of using heart rate variability (HRV) biofeedback to treat moderate to severe depression. This was an open-label study in which 14 patients with different degrees of depression (13 f, 1 m) aged 30 years (18–47; median; range) and 12 healthy volunteers attended 6 sessions of HRV biofeedback over two weeks. Another 12 healthy subjects were observed under an active control condition. At follow up BDI was found significantly decreased (BDI 6; 2–20; median 25%–75% quartile) as compared to baseline conditions (BDI 22;15–29) in patients with depression. In addition, depressed patients had reduced anxiety, decreased heart rate and increased HRV after conduction of biofeedback (p < 0.05). By contrast, no changes were noted in healthy subjects receiving biofeedback nor in normal controls. In conclusion, HRV biofeedback appears to be a useful adjunct for the treatment of depression, associated with increases in HRV.     

Relationship Between Changes in EMG and Respiratory Sinus Arrhythmia in a Study of Relaxation Therapy for Asthma

This paper reports the relationships among changes in cardiovagal activity, surface EMG, and measures of pulmonary function in a study of relaxation therapy for asthma. Changes in FEV ₁ /FVC were negatively correlated with those in cardiac interbeat interval, consistent with the hypothesis that relaxation-induced changes in airway function are mediated autonomically, with increased vagal tone and/or decreased sympathetic arousal producing bronchoconstriction. Contrary to Kotses's theory of a vagal-trigeminal reflex as mediator for relaxation-induced improvement in asthma, decreases in pulmonary function occurred during relaxation sessions, accompanied by increases in cardiovagal activity, and within-session changes in frontal EMG in the first session of training were positively associated with changes in a measure of pulmonary function (FEV1/FVC). However, consistent with this hypothesis, first-session frontalis EMG changes were positively associated with changes in respiratory sinus arrhythmia, and last-session changes in cardiac interbeat interval were positively associated with changes in FEV1/FVC. The results suggest that the immediate effects of generalized relaxation instruction can be associated with a parasympathetic rebound, which, in turn, may induce countertherapeutic changes in asthma. However, the effects of specific facial muscle relaxation remain uncelar.     

Abbreviated Resonant Frequency Training to Augment Heart Rate Variability and Enhance On-Demand Emotional Regulation in Elite Sport Support Staff

Support and management staff in elite sport experience work-related stress and emotional disturbance to a similar extent as athletes (Fletcher and Wagstaff 2009). The resonant frequency breathing technique (Lehrer et al. 2000) can inhibit autonomic changes associated with stressful situations or events and as such provides a potential emotional regulation tool. The present study utilised five practitioner-led heart rate variability (HRV) biofeedback sessions and home practice via mobile applications to train support and management staff (n = 9) in resonant frequency breathing techniques. Although baseline HRV did not change from pre to post training, participants increased total HRV (i.e., SDNN; p = .006), parasympathetic HRV (i.e., RMSSD; p = .028) and HRV reflective of baroreflex function (i.e., low frequency power; p = .018) while accurately performing resonant frequency breathing without a breath pacer. Post-intervention questionnaire data revealed an increase (p = .032) in habitual use of somatic strategies for emotional regulation, and social validation data suggested that the technique enhanced emotional regulation at home, work and during international competition. HRV biofeedback and the resonant frequency technique provided an on-demand emotional regulation technique for elite sport support and management staff.     

Cardiac sympathetic and parasympathetic activity during self-regulation of heart period

Fourteen subjects attempted to increase and 15 attempted to decrease cardiac interbeat interval (IBI) while being provided with biofeedback of IBI, T-wave vector magnitude (TWVM), or respiratory sinus arrhythmia (RSA). Subjects in both groups showed directional change in IBI relative to a tracking control task, but the three types of feedback did not differentially affect performance. Voluntary IBI increases were associated with significant increases in TWVM and RSA, and voluntary IBI decreases were associated with significant reductions in RSA and nonsignificant reductions in TWVM. This pattern of results suggests that alterations in cardiac vagal tone are involved in voluntary IBI increases and decrease tasks. The results also suggest a role for cardiac sympathetic nervous activity in voluntary IBI increase. The role of changing respiration cycle period was also investigated.This research was supported in part by a Department of Psychiatry Medical Student Research Stipend to Courtney German. The design and construction of the biofeedback apparatus used in this research fulfilled in part the requirements for a Master of Science degree in engineering from St. Mary's University by Steve Borcherding.     

Creating the Future of Applied Psychophysiology and Biofeedback: From Fantasy to Reality

AAPB and its membership are faced with a number of giant challenges, including but not limited to: (1) the cost savings efforts of third-party payors and managed care organizations; (2) the lack of public awareness of biofeedback and its usefulness; and (3) the lack of sufficient research data on both the effectiveness and efficacy of biofeedback. In spite of these challenges, there are windows of opportunity that have been or which could be created to move biofeedback further into the realm of conventional treatment. We must focus our efforts on working together to: (1) create strategic plans for creating the future of applied psychophysiology and biofeedback; (2) educate all decision makers, including the general public; (3) establish better relationships with other professionals with common interests; (4) conduct more efficacy and effectiveness research; and (5) create a demand for our services so that the public will be more willing to pay for our services out of their own pocket. In order for this to happen, we must stop fighting with each other and direct our energies to productive activities that can change fantasies into realities.     

Deletion of MLIP (Muscle-enriched A-type Lamin-interacting Protein) Leads to Cardiac Hyperactivation of Akt/Mammalian Target of Rapamycin (mTOR) and Impaired Cardiac Adaptation

Aging and diseases generally result from tissue inability to maintain homeostasis through adaptation. The adult heart is particularly vulnerable to disequilibrium in homeostasis because its regenerative abilities are limited. Here, we report that MLIP (muscle enriched A-type lamin-interacting protein), a unique protein of unknown function, is required for proper cardiac adaptation. Mlip^−/− mice exhibited normal cardiac function despite myocardial metabolic abnormalities and cardiac-specific overactivation of Akt/mTOR pathways. Cardiac-specific MLIP overexpression led to an inhibition of Akt/mTOR, providing evidence of a direct impact of MLIP on these key signaling pathways. Mlip^−/− hearts showed an impaired capacity to adapt to stress (isoproterenol-induced hypertrophy), likely because of deregulated Akt/mTOR activity. Genome-wide association studies showed a genetic association between Mlip and early response to cardiac stress, supporting the role of MLIP in cardiac adaptation. Together, these results revealed that MLIP is required for normal myocardial adaptation to stress through integrated regulation of the Akt/mTOR pathways.     

Frequency characteristics of signals and instrumentation: Implication for EMG biofeedback studies

Signals can be analyzed in either the time or frequency domain. In the time domain, the analysis consists of manipulating and measuring one or more characteristics of the signal that may vary with time. One can, for instance, rectify a signal, filter it, calculate its mean value, display the histogram of its amplitude, and so forth. Frequency analysis is less well understood because it requires a lengthy mathematical treatment most easily done by computer. However, it gives exclusive information on a signal. For instance, when the frequency content of a signal is known, it is easy to specify which characteristics an amplifier must have in order to amplify the signal without distortion, or to set the cutoff frequencies of filters to eliminate noise. Also, in many circumstances, frequency spectra are more easily interpreted than the original raw data. Such is the case with the EMG where the random aspect of the signal makes some form of processing (i.e., rectification, filtering, etc.) necessary, but not always as meaningful as we would like. Thus we present here the principal characteristics of frequency analysis, and discuss its usefulness in analyzing EMG signals and its application to biofeedback, clinical practice, and research.The authors acknowledge the technical assistance of F. Kemp, M. Goyette, and C. Goulet. T. Milner kindly reviewed the final version of the text. The preparation of this paper was supported through funds from Health and Welfare Canada (NHRDP) and the Centre de recherche, Institut de réadaptation de Montréal.     

Fractal Analysis and Hurst Parameter for Intrapartum Fetal Heart Rate Variability Analysis: A Versatile Alternative to Frequency Bands and LF/HF Ratio

Background

The fetal heart rate (FHR) is commonly monitored during labor to detect early fetal acidosis. FHR variability is traditionally investigated using Fourier transform, often with adult predefined frequency band powers and the corresponding LF/HF ratio. However, fetal conditions differ from adults and modify spectrum repartition along frequencies.

Aims

This study questions the arbitrariness definition and relevance of the frequency band splitting procedure, and thus of the calculation of the underlying LF/HF ratio, as efficient tools for characterizing intrapartum FHR variability.

Study Design

The last 30 minutes before delivery of the intrapartum FHR were analyzed.

Subjects

Case-control study. A total of 45 singletons divided into two groups based on umbilical cord arterial pH: the Index group with pH ≤ 7.05 (n = 15) and Control group with pH > 7.05 (n = 30).

Outcome Measures

Frequency band-based LF/HF ratio and Hurst parameter.

Results

This study shows that the intrapartum FHR is characterized by fractal temporal dynamics and promotes the Hurst parameter as a potential marker of fetal acidosis. This parameter preserves the intuition of a power frequency balance, while avoiding the frequency band splitting procedure and thus the arbitrary choice of a frequency separating bands. The study also shows that extending the frequency range covered by the adult-based bands to higher and lower frequencies permits the Hurst parameter to achieve better performance for identifying fetal acidosis.

Conclusions

The Hurst parameter provides a robust and versatile tool for quantifying FHR variability, yields better acidosis detection performance compared to the LF/HF ratio, and avoids arbitrariness in spectral band splitting and definitions.     

Dermatoscopy and High Frequency Sonography: Two Useful Non-Invasive Methods to Increase Preoperative Diagnostic Accuracy in Pigmented Skin Lesions

Dermatoscopy and high frequency sonography have recently been combined to increase diagnostic preoperative accuracy in the treatment of pigmented skin lesions. In this monocentric study 80 patients with pigmented skin lesions were evaluated clinically, by dermatoscopy, and 20 MHz-sonography followed by dermatohistopathological evaluation; 39 malignant melanomas, 37 common nevi, 3 dysplastic nevi, and 1 nevus Spitz were diagnosed histologically. In 72 of the 80 cases (91.3%) dermatoscopical diagnoses were confirmed by histopathology, compared to only 79% correct clinical diagnoses. For the mere clinical diagnosis of melanoma sensitivity was 79%, specificity was 78% and diagnostic accuracy was 65%. All diagnostic values increased by dermatoscopy: sensitivity reached 90%, specificity was 93%, and diagnostic accuracy was 83%. In order to determine tumor thickness preoperatively tumor thickness was measured by 20 MHz sonography. The correlation of tumor thickness between histometric and sonographic results was determined for nevi (r = 0.93) and melanoma (r = 0.95); 74.3% of melanomas were diagnosed correctly within an 0.2 mm range. Regarding the clinical important limit of 1 mm tumor thickness, 87.2% were diagnosed in accordance with histometric evaluation. An increase of 18% in diagnostic accuracy by dermatoscopy and 87.2% of correctly diagnosed cases of tumor thickness of malignant melanoma by high frequency sonography clearly demonstrate that these methods should be considered standard procedures in the diagnosis of pigmented skin lesions and will facilitate the decision on necessary surgical treatment.     

Variability in Growth Characteristics of Different E. coli O157:H7 Isolates, and its Implications for Predictive Microbiology

In growth experiments 75 clinical isolates of Escherichia coli O157:H7 were studied for the variability in seven growth characteristics: minimum, optimum and maximum growth temperature, minimum and optimum pH, minimum water activity and optimum specific growth rate. With these characteristics, growth can be predicted for any given set of conditions (temperature, acidity and water activity), when the gamma model is used as predictive microbiology model. The optimum specific growth rate of the 75 strains, as conceptually defined by the model, had a mean value of 4.71 (ln[emsp4 ](count)/h), with a standard deviation of 0.39. It could not be shown that the mean optimum specific growth rate differs significantly per strain, so the variability found will predominantly be the result of other sources of variation. In contrast, the experimental results suggest that the differences in minimum temperature of growth may be partially strain specific. As variability in growth is crucial for quantitative risk assessment, the results were implemented in the gamma model. Predictions at three sets of growth conditions were compared with predictions of the Pathogen Modeling Program (PMP) (USDA) and some published experimental results. This comparison showed that growth rates higher than those published and outside the 95% confidence interval predicted by the PMP are feasible. Although it needs further development and additional tests, our approach offers a promising strategy to predict the variability in growth.     

Rapid Increase of Pneumococcal Resistance to β-Lactam and Other Antibiotics in Isolates from the Respiratory Tract (Nagasaki,Japan: 1975–1994)

The susceptibility of 101 pneumococcal isolates from the respiratory tract during 1991–1994 was examined and compared with the susceptibility of isolates over the period of 1975–1990. A rapid increase of resistance was seen not only to penicillin but also other antimicrobial agents. During 1991–1994, 38% of all the isolates were resistant to penicillin. The rates of resistance during this period were 16–23% for three newer cephalosporins, 18% for imipenem, 69% for tetracycline, 31% for erythromycin, 20% for chloramphenicol and 9% for clindamycin. The use of antibiotics within one month prior to pneumococcal isolation was correlated with penicillin resistance (P < 0.05). Serotyping of the isolates by antiserum revealed differences in predominant types between penicillin-resistant (19F, 23F, 4) and -susceptible isolates (15, 4, 11A). Our data suggests that anti-pneumococcal antibiotics should be carefully chosen on the basis of susceptibility tests.     

Inosine and hypoxanthine as novel biomarkers for cardiac ischemia: From bench to point-of-care

Cardiac ischemia associated with acute coronary syndrome and myocardial infarction is a leading cause of mortality and morbidity in the world. A rapid detection of the ischemic events is critically important for achieving timely diagnosis, treatment and improving the patient''s survival and functional recovery. This minireview provides an overview on the current biomarker research for detection of acute cardiac ischemia. We primarily focus on inosine and hypoxanthine, two by-products of ATP catabolism. Based on our published findings of elevated plasma concentrations of inosine/hypoxanthine in animal laboratory and clinical settings, since 2006 we have originally proposed that these two purine molecules can be used as rapid and sensitive biomarkers for acute cardiac ischemia at its very early onset (within 15 min), hours prior to the release of heart tissue necrosis biomarkers such as cardiac troponins. We further developed a chemiluminescence technology, one of the most affordable and sensitive analytical techniques, and we were able to reproducibly quantify and differentiate total hypoxanthine concentrations in the plasma samples from healthy individuals versus patients suffering from ischemic heart disease. Additional rigorous clinical studies are needed to validate the plasma inosine/hypoxanthine concentrations, in conjunction with other current cardiac biomarkers, for a better revelation of their diagnostic potentials for early detection of acute cardiac ischemia.