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

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

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

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

Electromyographic biofeedback training for tension headache in the elderly: a prospective study.

This study evaluated the effects of a 12-session frontal electromyographic biofeedback training regimen on the headache activity of eight tension headache sufferers aged 62 and older. The biofeedback sessions were slightly modified for a geriatric population, essentially to increase comprehension and retention of rationale and instructions. Post-treatment assessment at three months revealed significant decreases in overall headache activity (50% or greater) in 50% of the subjects, and moderate improvement (35%-45%) in three of the remaining four subjects. Significant clinical and/or statistical pre-post differences were also found for the number of headache-free days, peak headache activity, and medication index. This is the first prospective study of biofeedback training for tension headache in an elderly population and, unlike previous retrospective studies, suggests that such therapy may be an effective intervention in the treatment of tension headaches in the elderly.     

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.     

The Raynaud's Treatment Study: Biofeedback Protocols and Acquisition of Temperature Biofeedback Skills

The Raynaud's Treatment Study (RTS) compared temperature biofeedback training and a behavioral control procedure (frontalis EMG biofeedback) with nifedipine-XL and a medication placebo for treatment of primary Raynaud's phenomenon (RP) in a large (N = 313) multicenter trial. The present study describes the RTS biofeedback protocols and presents data on the acquisition of digital skin temperature and frontalis EMG responses in the RTS. The findings point to substantial problems with acquisition of physiological self-regulation skills in the RTS. Only 34.6% of the Temperature Biofeedback group (N = 81) and 55.4% of the EMG Biofeedback group (N = 74) successfully learned the desired physiological response. In contrast, 67.4% of a Normal Temperature Biofeedback group (N = 46) learned hand warming. Multivariate analysis found that coping strategies, anxiety, gender, and clinic site predicted acquisition of hand-warming skills whereas variables related to RP disease severity did not. Physiological data showed vasoconstriction in response to the onset of biofeedback and also found that performance in the initial sessions was critical for successful acquisition. These findings indicate that attention to the emotional and cognitive aspects of biofeedback training, and a degree of success in the initial biofeedback sessions, are important for acquisition.     

Pelvic Floor Muscle Biofeedback in the Treatment of Urinary Incontinence: A Literature Review

Biofeedback is efficacious in the training of the pelvic floor musculature in order to enhance continence. This article reviews the anatomy and physiology of micturition as the underlying rationale for pelvic floor muscle biofeedback in the treatment of urinary incontinence. It critically reviews 28 studies published in peer reviewed journals from 1975 to 2005 that were prospective, randomized studies with parametric statistical analyses, operationally defined patient selection criteria, treatment protocols and outcome measures. The overall mean treatment improvement for patients undergoing biofeedback for urinary incontinence was 72.61%. In 21 of 35 (60%) paired comparisons, biofeedback demonstrated superior symptomatic outcome to control or alternate treatment groups. Larger studies and a standardization of technology and methodology are required for more conclusive determinations.     

Electromyographic biofeedback training for tension headache in the elderly: A prospective study

This study evaluated the effects of a 12-session frontal electromyographic biofeedback training regimen on the headache activity of eight tension headache sufferers aged 62 and older. The biofeedback sessions were slightly modified for a geriatric population, essentially to increase comprehension and retention of rationale and instructions. Post-treatment assessment at three months revealed significant decreases in overall headache activity (50% or greater) in 50% of the subjects, and moderate improvement (35%–45%) in three of the remaining four subjects. Significant clinical and/or statistical prepost differences were also found for the number of headache-free days, peak headache activity, and medication index. This is the first prospective study of biofeedback training for tension headache in an elderly population and, unlike previous retrospective studies, suggests that such therapy may be an effective intervention in the treatment of tension headaches in the elderly.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Department of Veterans Affairs. This study was supported by a Department of Veterans Affairs MERIT-Review awarded to the first author.     

Model analyses of visual biofeedback training for EEG-based brain-computer interface

The primary goal of this study was to construct a simulation model of a biofeedback brain-computer interface (BCI) system to analyze the effect of biofeedback training on BCI users. A mathematical model of a man-machine visual-biofeedback BCI system was constructed to simulate a subject using a BCI system to control cursor movements. The model consisted of a visual tracking system, a thalamo-cortical model for EEG generation, and a BCI system. The BCI system in the model was realized for real experiments of visual biofeedback training. Ten sessions of visual biofeedback training were performed in eight normal subjects during a 3-week period. The task was to move a cursor horizontally across a screen, or to hold it at the screen’s center. Experimental conditions and EEG data obtained from real experiments were then simulated with the model. Three model parameters, representing the adaptation rate of gain in the visual tracking system and the relative synaptic strength between the thalamic reticular and thalamo-cortical cells in the Rolandic areas, were estimated by optimization techniques so that the performance of the model best fitted the experimental results. The serial changes of these parameters over the ten sessions, reflecting the effects of biofeedback training, were analyzed. The model simulation could reproduce results similar to the experimental data. The group mean success rate and information transfer rate improved significantly after training (56.6 to 81.1% and 0.19 to 0.76 bits/trial, respectively). All three model parameters displayed similar and statistically significant increasing trends with time. Extensive simulation with systematic changes of these parameters also demonstrated that assigning larger values to the parameters improved the BCI performance. We constructed a model of a biofeedback BCI system that could simulate experimental data and the effect of training. The simulation results implied that the improvement was achieved through a quicker adaptation rate in visual tracking gain and a larger synaptic gain from the visual tracking system to the thalamic reticular cells. In addition to the purpose of this study, the constructed biofeedback BCI model can also be used both to investigate the effects of different biofeedback paradigms and to test, estimate, or predict the performances of other newly developed BCI signal processing algorithms.     

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.     

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.     

Effects of EMG and thermal feedback training on tinnitus: A case study

This case report describes a patient who exhibited the usual complaints of frustration, annoyance, and lack of sleep associated with severe tinnitus. After 2 months of weekly biofeedback sessions along with home training with a portable thermal biofeedback unit, the patient was relieved of the psychological symptoms associated with the tinnitus. A 1-year follow-up demonstrated that the patient remained complaint-free of psychological symptoms although the subjective loudness of the rining was judged to be the same as at the onset of the tinnitus. The results indicate that biofeedback is a useful procedure in the treatment of severe tinnitus.Tallahassee Pain and Stress Management Institute     

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.     

EMG biofeedback and discriminative muscle control

The awareness model of biofeedback suggests that training teaches new skills or enhances performance at old skills, while the cognitive or feed-forward models suggest that biofeedback brings attention to the response of interest but does not actually increase task skill. In a test of the predictions made by these models, subjects were tested on one or more cross-modal matching tasks, provided brief training, and retested on the task(s). Thirty subjects participated in integer-matching tasks in which they were instructed to produce various levels of frontalis activity corresponding to the levels of a ratio scale. Forty-five subjects participated in a tone-matching task in which they tried to match their frontalis tension to the pitch of a tone. The results indicated that the groups receiving biofeedback training improved at the more difficult integer task and at the tone task. Subjects performed better on the integer tasks than at the tone task. Our findings suggest that an awareness model accounts for changes occurring during biofeedback training. However, an awareness model may be applicable only for tasks of moderate difficulty; for relatively easy tasks, a feed-forward model may be more appropriate. The clinical utility of cross-modal matching tasks is also described.This paper is based on a thesis conducted by the second author under the direction of the first author. Portions of this paper were presented at the annual meeting of the Association for Applied Psychophysiology and Biofeedback, March 1989, San Diego.     

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

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

Crosscultural differences in frontalis muscle tension levels: An exploratory study comparing Japanese and Westerners

This paper describes a comparison between Japanese (N=20) and Westerners (N=20) in their respective frontal EMG levels and their ability to relax during one 5-minute biofeedback training session. The data indicated a significantly lower baseline muscle tension level in Japanese than in Westerners. After EMG biofeedback, however, no significant difference was found between the two groups. Japanese females showed significantly higher tension levels both during baseline and biofeedback phases than did Japanese males.     

Crosscultural differences in frontalis muscle tension levels: an exploratory study comparing Japanese and Westerners

This paper describes a comparison between Japanese (N = 20) and Westerners (N = 20) in their respective frontal EMG levels and their ability to relax during one 5-minute biofeedback training session. The data indicated a significantly lower baseline muscle tension level in Japanese than in Westerners. After EMG biofeedback, however, no significant difference was found between the two groups. Japanese females showed significantly higher tension levels both during baseline and biofeedback phases than did japanese males.     

EMG biofeedback treatment of torticollis: a controlled outcome study.

Successful treatment of torticollis with electromyographic (EMG) biofeedback has been reported in a number of single case and single group studies. The present investigation represents the first controlled outcome study. Twelve torticollis patients were randomly assigned to EMG biofeedback or relaxation training and graded neck exercises (RGP). The procedure involved three sessions of baseline assessment, 15 sessions of EMG BF or RGP, 6 sessions of EMG BF or RGP plus home-management, 6 sessions of home-management alone, and follow-up 3 months after the end of treatment. A variety of outcome measures were used including physiological (EMG from the two sternocleidomastoid muscles, skin conductance level), behavioral (angle of head deviation, range of movement of the head), and self-report (depression, functional disability, body concept), therapist and "significant other" reports and independent observer assessment of videos. In both groups, neck muscle activity was reduced from pre- to posttreatment. This reduction was greater in the EMG biofeedback group. There was evidence of feedback-specific neck muscle relaxation in the EMG biofeedback group. Therefore, the outcome was not due to nonspecific factors and could be attributed to feedback-specific effects. Changes in skin conductance level showed that neck muscle relaxation was not simply mediated by a general reduction of "arousal." Significant improvements of extent of head deviation, and range of movement of the head, as well as reductions of depression were present, which were not different in the two groups. At the end of treatment, no patient was asymptomatic. Any therapeutic benefit was generally maintained at follow-up. The results and the procedural simplicity of RGP make the issue of cost-efficacy of EMG biofeedback a pertinent one. Further controlled outcome studies of EMG biofeedback treatment of torticollis with larger samples are required.     

Electromyographic biofeedback for tension control during fine motor skill acquisition

The presence of residual muscular tension has been implicated as a detrimental influence on the performance and learning of motor skills. A method for reducing muscular tension has been provided by the advent of biofeedback training. This study investigated the effects of tension-control training by electromyographic (EMG) biofeedback on learning and performance of the pursuit-rotor backing task. Thirty young adult males were pretested for pursuit-rotor (PR) tracking skill, ranked by performance scores, and divided into identical triplicates to form two experimental groups and a control group. After a total of 3 hours of EMG biofeedback training for the experimental groups, all subjects were reevaluated on the PR test. One experimental group received biofeedback during the posttests. Analysis of variance of pretest-posttest difference means andt tests of scores representing performance and tension indicated that the EMG biofeedback training (1) significantly reduced tension induced by the novel motor skill and (2) significantly improved performance of the motor skill. Transfer of tension-control training was shown to facilitate learning and performance more than direct EMG biofeedback during performance. Residual tension reduction during learning was particularly facilitated by EMG biofeedback training, a profound implication for the management of stress in a variety of situations.This investigation formed part of a Ph.D. dissertation research (1976) conducted by the author under the guidance of Dr. Donald E. Campbell, Department of Physical Education, and Dr. Carol A. Saslow, Department of Psychology, at Oregon State University.     

EMG biofeedback and discriminative muscle control

The awareness model of biofeedback suggests that training teaches new skills or enhances performance at old skills, while the cognitive or feed-forward models suggest that biofeedback brings attention to the response of interest but does not actually increase task skill. In a test of the predictions made by these models, subjects were tested on one or more cross-modal matching tasks, provided brief training, and retested on the task(s). Thirty subjects participated in integer-matching tasks in which they were instructed to produce various levels of frontalis activity corresponding to the levels of a ratio scale. Forty-five subjects participated in a tone-matching task in which they tried to match their frontalis tension to the pitch of a tone. The results indicated that the groups receiving biofeedback training improved at the more difficult integer task and at the tone task. Subjects performed better on the integer tasks than at the tone task. Our findings suggest that an awareness model accounts for changes occurring during biofeedback training. However, an awareness model may be applicable only for tasks of moderate difficulty; for relatively easy tasks, a feed-forward model may be more appropriate. The clinical utility of cross-modal matching tasks is also described.