Template for developing guidelines for the evaluation of the clinical efficacy of psychophysiological interventions

An essential function of both the Association for Applied Psychophysiology and Biofeedback (AAPB) and the Society for Neuronal Regulation (SNR) is the systematic evaluation of psychophysiological interventions that have been developed for the treatment of medical and psychiatric disorders. In order to address scientific concerns regarding the efficacy of specific clinical applications of biofeedback, these two societies formed and Efficacy Task Force. The process to be used in the assessment of treatment efficacy, specificity and clinical utility is presented in the form of a template that will serve as the foundation for a series of scientific reviews and practice guidlines to be published by both societies.     

Thermal Biofeedback for Primary Raynaud’s Phenomenon: A Review of the Literature

The clinical presentation of primary Raynaud’s phenomenon (RP) derives from various pathogenic triggers. The use of thermal biofeedback (TBF) may be of benefit in reducing the severity and frequency of attacks. This article summarizes the relevant research regarding the pathophysiology of primary RP and mechanism of TBF for RP. Systematic reviews of the efficacy of TBF for RP and treatment guidelines for clinicians are provided. The panel concludes that the level of evidence for TBF efficacy is categorized as Level IV: efficacious. The rationale, based on three randomized controlled trials conducted in independent laboratories, demonstrated “superiority or equivalence” of treatments that include TBF. However, randomly controlled trials (RCT) with positive clinical outcomes tended to be small. A large RCT with negative results did not effectively teach handwarming skills. Procedures for reviewing and rating of the levels of evidence of efficacy of studies was based on the Template for Developing Guidelines for the Evaluation of the Clinical Efficacy of Psychophysiological Interventions developed by the joint task force of the AAPB and the Society for Neuronal Regulation (SNR).     

Efficacy of Biofeedback-Based Treatments for Temporomandibular Disorders

Bibliographic searches identified 14 controlled and uncontrolled outcome evaluations of biofeedback-based treatments for temporomandibular disorders published since 1978. This literature includes two randomized controlled trials (RCTs) of each of three types of biofeedback treatment: (1) surface electromyographic (SEMG) training of the masticatory muscles, (2) SEMG training combined with adjunctive cognitive-behavioral therapy (CBT) techniques, and (3) biofeedback-assisted relaxation training (BART). A detailed review of these six RCTs, supplemented with information from non-RCT findings, was conducted to determine the extent to which each type of intervention met treatment efficacy criteria promulgated by the Association for Applied Psychophysiology and Biofeedback (AAPB). We conclude that SEMG training with adjunctive CBT is an efficacious treatment for temporomandibular disorders and that both SEMG training as the sole intervention and BART are probably efficacious treatments. We discuss guidelines for designing and reporting research in this area and suggest possible directions for future studies.     

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.     

Electroencephalographic Biofeedback in the Treatment of Attention-Deficit/Hyperactivity Disorder

Historically, pharmacological treatments for attention-deficit/hyperactivity disorder (ADHD) have been considered to be the only type of interventions effective for reducing the core symptoms of this condition. However, during the past three decades, a series of case and controlled group studies examining the effects of EEG biofeedback have reported improved attention and behavioral control, increased cortical activation on quantitative electroencephalographic examination, and gains on tests of intelligence and academic achievement in response to this type of treatment. This review paper critically examines the empirical evidence, applying the efficacy guidelines jointly established by the Association for Applied Psychophysiology and Biofeedback (AAPB) and the International Society for Neuronal Regulation (ISNR). On the basis of these scientific principles, EEG biofeedback was determined to be “probably efficacious” for the treatment of ADHD. Although significant clinical improvement was reported in approximately 75% of the patients in each of the published research studies, additional randomized, controlled group studies are needed in order to provide a better estimate of the percentage of patients with ADHD who will demonstrate such gains in clinical practice.     

Dynamics of aerobic anoxygenic phototrophic bacteria in the East China Sea

Aerobic anoxygenic phototrophic bacteria (AAPB) are a group of heterotrophic bacteria capable of photosynthesis. The dynamics of AAPB in the East China Sea, a typical marginal sea characterized by diverse physical-chemical and ecological conditions, were investigated from April 2002 to September 2003. The results showed that the abundance of AAPB varied from 0.16 to 7.9 x 10(4) cells mL(-1) and the percentage of AAPB (AAPB%) in the total heterotrophic bacterial abundance varied from 0.5% to 11.6% over a gradient of environmental conditions. The abundance of AAPB and AAPB% was higher in coastal and continental shelf waters than in oceanic waters. An interesting seasonal pattern was observed in the Yangtze River estuary: the abundance of AAPB was highest in summer and lowest in winter; however, AAPB% was higher in winter than in the other seasons. Throughout the investigation period, variation of AAPB abundance with temperature was much less than that of nonAAPB abundance, suggesting that low temperature was not a limiting factor for AAPB in this case. Close correlation between AAPB and chlorophyll a was observed in each season, suggesting that dependence of AAPB on dissolved organic carbon produced by phytoplankton (PDOC) may be one key factor controlling AAPB distribution.     

Ethical and practice considerations for biofeedback therapists in the treatment of urinary incontinence

The treatment of incontinence presents many unique issues for biofeedback therapists that are routine for professionals in fields such as nursing or medicine. Although, all professional practice is guided by ethical standards, the unique circumstances encountered during biofeedback treatments for this disorder warrant the development of specific guidelines. This is true whether insertable or surface EMG devices are used. Therefore, the purpose of this article is to propose a set of ethical guidelines for biofeedback therapists. The intended audience includes professionals such as psychologists, clinical psychophysiologists, and other mental health-care providers who use biofeedback techniques. These are not formally endorsed by any professional organizations (e.g., APA, AAPB) at this time. Ethical considerations include proper medical evaluation, informed consent, patient instruction, disrobing, nonerotic physical contact, patient safety, and patient satisfaction.     

Twenty-five years of progress: Twenty-five more?

This address outlines important steps for ensuring the future of biofeedback and applied psychophysiology. These steps are contained in the acronym PHUTRE, wherein PH stands for Political activism of the Hard and fast variety, U represents United front, T encompasses Transfer of knowledge (from clinician to researcher, researcher to clinician, and from both to students in training), R refers to our Research base, and E represents the Excitement that our field has the potential to generate.This paper is based on the Presidential Address delivered at the annual meeting of AAPB, Atlanta, Georgia, March, 1994. Please address correspondence to Frank Andrasik, Ph.D., Center for Behavioral Medicine, The University of West Florida, 11000 University Parkway, Pensacola, Florida 32514.     

Effects of Biofeedback in Phonatory Disorders and Phonatory Performance: A Systematic Literature Review

The purpose of this article was to systematically review the literature on the effects of biofeedback therapy in the domain of phonatory disorders and phonatory performance, using studies in peer-reviewed journals. An extensive definition of biofeedback is given and its place in voice treatment is defined. Eighteen group or case studies or reports considering the effects of electromyographic, laryngoscopic and acoustic biofeedback in dysphonic patients (hyperfunctional voice disorders, hypofunctional voice disorders, psychogenic voice disorder, laryngeal trauma, total laryngectomy, vocal cord dysfunction) and participants with normal voices are included and an analysis of procedure as well as research design and results is presented. The usefulness of biofeedback in phonatory disorders and performance was to be interpreted based on tendencies, since there is a lack of randomized controlled efficacy studies. In only 3 of 18 studies (16.7%) did biofeedback therapy fail to improve voice quality or not result in better results than other forms of therapy. Recommendations for improved methodologies are made, which include the use of acoustic voice quality parameters.     

自适应式与固定式生物反馈训练对出口梗阻型便秘患者肛直肠功能和心理状态的影响

目的:探讨自适应式与固定式生物反馈训练对出口梗阻型便秘(OOC)患者肛直肠功能和心理状态的影响。方法:选取2017年4月～2019年12月期间晋城大医院收治的OOC患者98例,根据随机数字表法将患者分为对照组(n=49,固定式生物反馈训练)和研究组(n=49,自适应式生物反馈训练),比较两组患者疗效、肛直肠功能、排便次数、排便困难评分和心理状态。结果:研究组治疗8周后的临床总有效率93.88%(46/49),高于对照组的77.55%(38/49)(P0.05)。两组治疗8周后排便次数增加,排便困难评分降低(P0.05),研究组治疗8周后排便次数多于对照组,排便困难评分低于对照组(P0.05)。两组治疗8周后直肠肛门抑制反射阈、肛管静息压均较治疗前下降,模拟排便时直肠肛管压力梯度较治疗前升高(P0.05)。两组治疗8周后焦虑自评量表(SAS)、抑郁自评量表(SDS)评分均较治疗前下降,且研究组低于对照组(P0.05)。结论:与固定式生物反馈训练相比,自适应式生物反馈训练可获得与之效果相当的肛直肠功能改善程度,并可进一步减轻患者症状及改善心理状态,疗效显著。     

Responses of aerobic anoxygenic phototrophic bacteria to algal blooms in the East China Sea

Aerobic anoxygenic phototrophic bacteria (AAPB) are a new functional group of heterotrophic bacteria capable of phototrophy, and are suggested to be closely related with phytoplankton. However, less known is the relationship between AAPB and dominant phytoplankton populations. In this tudy, the responses of AAPB to algal blooms (ABs) in the AB-frequent-occurrence area of the East China Sea were investigated during four cruises from March to June 2005, using an advanced ‘Time-series observation-based cyanobacteria-calibrated InfraRed Epifluorescence Microscopy (TIREM)’ approach. Generally, total bacterial abundances at the bloom stations were higher than or similar to those at the non-bloom stations during the same time period. Interestingly, the responses of AAPB to ABs seemed to be more diverse and complex. AAPB abundance was higher at the stations with ABs where Thalassiosira curviseriata Takano and Skeletonema costatum (Greville) Cleve, Noctiluca scintillans (Macartney) Kofoid et Swezy, or Prorocentrum donghaiense Lu and Karenia mikimotoi Hansen co-dominated than those at the non-bloom stations during the same time period. However at the stations with a bloom of Akashiwo sanguinea Hansen, AAPB abundance only accounted for ~20% of the average abundance of AAPB at the non-bloom stations. In addition, variations of AAPB’s proportion to total bacterial abundance (AAPB%) in response to ABs basically followed AAPB abundance. Overall, our results suggest that the responses of AAPB to ABs are AB-species specific and somewhat independent of chlorophyll a concentration.     

Treatment of posttraumatic stress disorder with relaxation and biofeedback training

This study investigated the use of biofeedback and relaxation training on six patients with posttraumatic stress disorder (PTSD) referred routinely for biofeedback treatment in a VA medical center. Subjects received between 8 and 14 sessions of training overall, as well as concurrent individual and group therapy. Measures used to assess treatment outcome include pre- and posttreatment MMPI, State-Trait Anxiety Inventory, Beck Depression Inventory, and Multidimensional Health Locus of Control scores, as well as electromyographic and subjective measures of tension within each session. Additionally, an overall posttreatment clinical rating of change and 1- to 2-year follow-up data were obtained for each subject. Slight to marked improvements were demonstrated for each subject, as evidenced by improvements on the State Anxiety Inventory Scale and the Beck Depression Inventory, a decrease in overall MMPI scores, and lowered EMG and subjective tension ratings for all participants. Possible alternative explanations for improvement (situational demand characteristics, regression toward the mean, lack of independent subject evaluation) are described, along with other study limitations. This preliminary investigation suggests that the use of relaxation training and biofeedback may be a particularly useful component within a comprehensive treatment program for this disorder.     

Treatment of posttraumatic stress disorder with relaxation and biofeedback training

This study investigated the use of biofeedback and relaxation training on six patients with posttraumatic stress disorder (PTSD) referred routinely for biofeedback treatment in a VA medical center. Subjects received between 8 and 14 sessions of training overall, as well as concurrent individual and group therapy. Measures used to assess treatment outcome include pre- and posttreatment MMPI, State-Trait Anxiety Inventory, Beck Depression Inventory, and Multidimensional Health Locus of Control scores, as well as electromyographic and subjective measures of tension within each session. Additionally, an overall posttreatment clinical rating of change and 1- to 2-year follow-up data were obtained for each subject. Slight to marked improvements were demonstrated for each subject, as evidenced by improvements on the State Anxiety Inventory Scale and the Beck Depression Inventory, a decrease in overall MMPI scores, and lowered EMG and subjective tension ratings for all participants. Possible alternative explanations for improvement (situational demand characteristics, regression toward the mean, lack of independent subject evaluation) are described, along with other study limitations. This preliminary investigation suggests that the use of relaxation training and biofeedback may be a particularly useful component within a comprehensive treatment program for this disorder.     

Distinct distribution pattern of abundance and diversity of aerobic anoxygenic phototrophic bacteria in the global ocean

Aerobic anoxygenic phototrophic bacteria (AAPB) are an important bacterial group with capability of harvesting light energy, and appear to have a particular role in the ocean's carbon cycling. Yet the significance of AAPB relative to total bacteria (AAPB%) in different marine regimes are still controversial, and variation trend of genetic diversity of AAPB along environmental gradients remains unclear. Here we present the first comprehensive observation of the global distribution of AAPB in the Pacific, Atlantic and Indian oceans, revealing a general pattern of high abundance of AAPB and AAPB% in coastal waters than oceanic waters. The Indian Ocean contained relatively high AAPB% compared with the other two oceans, corresponding to the high primary production in this region. Both abundance of AAPB and AAPB% were positively correlated with the concentration of chlorophyll a, while the diversity of AAPB decreased with increasing chlorophyll a values. Our results suggest that AAPB abundance and diversity follow opposite trends from oligotrophic to eutrophic regimes in the ocean.     

Heart-rate reactivity to cold pressor stress following biofeedback training

Three previous studies have shown that biofeedback training is useful in modifying heart-rate and pain ratings during ice water stimulation (cold pressor test). Subjects were given an initial cold pressor followed by heart-rate biofeedback training and a final cold pressor test in which they were instructed to control their heart rate in accordance with the prior training. It was assumed that a heart-rate control skill had been learned. In the present study, two groups of subjects (N = 9 each) were given either increase or decrease heart-rate biofeedback training following the same procedures as previously, but subjects were not instructed to control their heart rate during the final cold pressor test. Heart rate, skin conductance, electromyographic activity, and respiration were measured. The biofeedback training effects replicate the previous results. However, no heart-rate or pain rating differences were found between the two groups during the final cold pressor test. Thus, previous findings cannot be accounted for simply by a shift in heart rate and/or pain reactivity following training itself. The findings suggest that a biofeedback strategy may be useful in modifying physiological and subjective responses to painful stimuli but only if it can be used as an active coping skill.     

Salinity and DOC Influence the Distribution of Free-living and Particle-attached Aerobic Anoxygenic Phototrophic Bacteria in the Qinghai–Tibetan Lakes

Aerobic anoxygenic phototrophic bacteria (AAPB) are widespread and play an important role in carbon cycling in the lakes of the Qinghai–Tibetan Plateau. However, little is known about how free-living and particle-attached AAPB distribute with salinity in the Qinghai–Tibetan lakes. In the present study, the abundance and diversity of free-living and particle-attached AAPB were investigated in seven Qinghai–Tibetan lakes with salinity ranging from freshwater to almost saturation (1.2 g L^?1 241.1 g L^?1). An integrated approach was employed including pufL-M gene (encoding the photosynthetic reaction center of AAPB) based quantitative polymerase chain reaction (qPCR) and PCR-cloning phylogenetic analysis. The qPCR data showed that the ratio between particle-attached and free-living AAPB was positively correlated (R² = 0.73, p < 0.01) with increasing salinity. The phylogenetic analysis of pufL-M gene showed that the composition of AAPB population varied with salinity in the studied Qinghai–Tibetan lakes. These results suggested that salinity may be the important factor shaping the AAPB distribution in the studied Qinghai–Tibetan lakes, and AAPB may be adapted to the harsh conditions in the Qinghai–Tibetan lakes by attaching to particles.     

Biofeedback efficacy studies

Biofeedback, a field still in its infancy, has developed treatments that have been used with clinical success in the treatment of a number of disorders. Many have expressed their public concern that biofeedback has not lived up to its early promise and that it has not developed treatments that are, in fact, efficacious. A number of factors, which are inherent in biofeedback research, confound the results of clinical efficacy studies of biofeedback treatments. Researchers interested in the efficacy of biofeedback must address several issues: (1) Rejecting the null hypothesis is not equal to proving the null hypothesis (without the use of power analysis); (2) control for nonspecific effects is not equal to a double-blind experimental design; (3) ignorance of a mechanism of action is not equal to a lack of clinical efficacy; (4) the administration of training is not equal to the subject's learning to criterion; (5) untrained therapists are not equal to trained therapists; (6) statistical significance is not equal to clinical significance; and (7) the laboratory setting is not equal to the clinical setting.     

Efficacy of EEG biofeedback procedures in correcting stress-related functional disorders

A promising approach to nondrug correction of human stress-induced functional disorders based on double EEG biofeedback (EEGBF) has been substantiated and experimentally tested. According to this approach, narrow-band EEG oscillators that are characteristic of each patient and detectable in real-time are simultaneously used in two independent feedback loops: the traditional adaptive biofeedback loop and an additional resonance stimulation loop. In the latter loop, the feedback signals from individual narrow-band EEG oscillators serve for automatic modulation of the parameters of sensory stimuli and are not perceived consciously by the subject. The combined use of the active (conscious perception) and passive (automatic modulation) feedback signals from narrow-band EEG components of the patient have been demonstrated to offer the possibility of a substantial increase in the efficacy of EEGBF.     

Using biofeedback to optimize scapular muscle activation ratios during a seated resisted scaption exercise

Impairments in muscle activation have been linked to increased risk of developing shoulder pathologies such as subacromial impingement syndrome (SIS) and associated rotator cuff injuries. Individuals with SIS have demonstrated increased upper trapezius (UT) muscle activation and reduced serratus anterior (SA) and lower trapezius (LT) muscle activation, which can be collectively represented as ratios (UT/SA and UT/LT). Targeted exercise is an important component of shoulder rehabilitation programs to re-establish optimal muscle activation and ratios. Electromyography (EMG) biofeedback during exercise has been shown to reduce UT activation and favorably alter scapular muscle activation ratios, however, a literature gap exists regarding the efficacy of other types of biofeedback. Therefore, we compared the effects of three types of biofeedback (visual EMG, auditory, verbal cues) on UT/SA and UT/LT ratios during a seated resisted scaption exercise in fifteen subjects without shoulder pain. Baseline muscle activation was recorded and compared to real-time muscle activation during each randomized biofeedback trial. All biofeedback types showed improvements in the UT/SA and UT/LT ratios, with visual EMG demonstrating a significant change in UT/LT ratio (p < 0.05). These results suggest that biofeedback could be utilized as a component of rehabilitation programs to prevent or treat shoulder pain.