Biofeedback Mastery

Biofeedback Mastery

Have you ever wondered what Biofeedback is all about? Uncover these unique information on Biofeedback! Are you in constant pain? Do you wish you could ever just find some relief? If so, you are not alone. Relieving chronic pain can be difficult and frustrating.

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Biofeedback

Twenty-nine patients with moderate to severe vulvar vestibulitis were given electromyographic assessment of the pelvic floor muscles. The patients were then given a portable home trainer biofeedback device and instructions to perform biofeedback-assisted pelvic floor muscle rehabilitation exercises. Patients were evaluated on a monthly basis for vestibulodynia and dyspareunia 51.7 demonstrated markedly reduced introital tenderness and 93.3 were able to resume sexual activity without discomfort 57 .

The Medical Community and Supplements

Not many studies have investigated physician attitude toward dietary supplement and CAM therapies. A literature search turns up two studies worthy of note. The first examines physician attitude toward CAM therapies. This study found most physicians, the majority being women and younger than 46 years old, were open-minded and would refer their patients to a CAM practitioner if they were affiliated with their group practice site (about 44 ). But most physicians did not discuss CAM with their patients unless the patient broached the subject first and few discussed possible harmful outcomes. The majority of physicians were familiar with biofeedback, chiropractic and massage

Sleep Disorders A Common Problem Among Kidney Patients

Summary In this article, the author provides readers with information about an often-encountered, but little-discussed complication of dialysis, insomnia. Topics include the adequacy of dialysis and its impact on the sleep habits of patients restless leg syndrome (RLS) and the role of peripheral neuropathy in its development the use of Sinemet to treat RLS using conventional sleep aids, including Ambien the use of muscle relaxants, or benzodiazepines, for milder forms of RLS psychological sleep disturbances and adjunctive therapies, including Qigong, biofeedback, and meditation. The author encourages readers to become more self-aware and to participate as an active member of their own health care team. The article includes a short list of references and organizations that may provide additional information about sleep disorders and their therapy.

Types Of Cam Therapies

There are many different types of CAM therapies that are available for treating pain. Some are very simple to use, such as hot or cold therapy. Others, such as biofeedback, require patients to be educated about using the technique. Still others, such as TT, require a trained practitioner to administer them. Cognitive behavioral approaches or mind body work, such as relaxation, biofeedback, meditation, distraction, and imagery Many patients are interested in using the complementary methods of relaxation, biofeedback, self-hypnosis, and imagery to provide additional pain relief (APS, 2002 D'Arcy, 2007). Not all patients find these techniques to their liking. For those patients who are willing to invest the time and energy in learning how to use these methods, a good outcome can be expected. Music is an easy to use and greatly Biofeedback, hypnosis, and meditation are other forms of relaxation techniques. Meditation, or mindfulness, has been found to reduce pain and help patients with...

Mindful Cam Therapies

Biofeedback is another MT frequently used for pain treatment. Biofeedback is a method that gives the patient conscious control over a physiologic function not normally under conscious control. This control is achieved by using computer technology to give the patient visual or auditory

Interventions not supported by evidence

The German FMS guideline group found inconsistent results in eight RCT on patient education as single intervention and seven studies with massage with conflicting results 24, 65 . Furthermore, inconsistent results of five controlled trials each on biofeedback and relaxation therapy (including autogenic training and progressive muscle relaxation) were found 69 .

Psychologic treatment

Skills training for adults, including relaxation Chapter 14, Biofeedback Chapter 15, Contextual cognitive-behavioral therapy and Chapter 16, Graded exposure in vivo for pain-related fear in the Practice and Procedures volume of this series. In principle, the management approach is as appropriate to chronic pain sufferers with neurologic disease as to other groups, with perhaps two qualifications.

Interventions supported by evidence

Some of the studies have included groups having biofeedback either on its own or in combination with CBT 30, 31 . These were methodologically sound RCTs that used no treatment as a control and the Gardea et al. 30 study included a 1-year follow-up. Improvements were found not only in pain intensity but in a range of other outcomes, including mood.

Interventions refuted by evidence or insufficient evidence

Jedel & Carlsson's systematic review of seven controlled clinical trials to assess the efficacy of biofeedback, acupuncture and TENS in TMD once again showed poor methodology and no evidence for effectiveness of these therapies 41 . Another systematic review on acupuncture came to the same conclusions 42 .

Commonly used interventions currently unproven

Mechanical exercises are often prescribed as it is thought that patients with pain are often reluctant to use the body part that is causing pain. Use of occlu-sal appliances is common as these are easy for dental surgeons to construct and they are more familiar with this method of treatment rather than systemic drugs. Patients with TMD pain can be divided into three treatment groups based on their response to the Graded Chronic Pain Scale minimal contact approach (one or two sessions with or without the help of a psychologist), integrated approach (with appliances, biofeedback and stress management led by hygienist) and a structured behavioral programme (psychologist led for six sessions) 45 .

Discussion of evidence

From the current evidence, it is clear that as with other chronic pain, a biopsychosocial approach is necessary as behavior and attitudes need to change and patients need to self-manage their condition. Turner et al. 32 and Gatchel et al. 33 have shown that changing TMD patients' beliefs and pain-coping strategies through the use of CBT can have a modest effect on future pain and functioning. Combining CBT with biofeedback may yield even better results as the latter has a more immediate effect and appears to be more physiologically orientated.

Nonpharmacological Options

Non-pharmacologic options for trauma patients include transcutaneous electrical nerve stimulation (TENS), acupuncture, and relaxation techniques. In general, these therapies tend to be most useful as adjuncts to either nerve blocks or pharmacotherapy or in patients with mild pain. Relaxation techniques such as guided imagery, self-hypnosis, and biofeedback are most beneficial in patients with high anxiety levels, whereas the best candidates for eye movement desensitization and reprocessing (EMDR) and cognitive-behavioral therapies are cognitively intact patients willing to take an active role in treatment. The treatment of coexisting psychopathology is critical to optimizing pain treatment outcomes and should not be underestimated. In fact, long-standing anxiety from poorly managed pain has been associated with depression and posttraumatic stress disorder.

Physical interventions

Therapies, such as biofeedback, relaxation exercises, lifestyle changes (e.g. diet, discontinuing bike riding, changing a workstation), acupuncture, massage therapy, chiropractic therapy and meditation have all been suggested to improve symptoms 19, 21 . biofeedback pelvic floor training, independent of other influences, may benefit this group of patients 43 . It is the author's clinical impression that treatment needs to be intensive and personalized and the role of the therapist is very important. Much has been written about trigger point therapy within the pelvis but there are few formal studies 44 . Individual patients appear to benefit providing they are managed as a whole with attention to posture, exercise and stretches as well as the trigger point release treatments. Grade B recommendations (well-conducted clinical studies without randomized trials) electromotive drug administration (EMDA) with lidocaine, sacral neuromodulation should be considered investigational , bladder...

Postintervention Role

It may become necessary to assist patients who are disappointed over unachieved outcomes, or less than optimal results, after an intervention has been undertaken. Pain relief may be only partial, and there may be residual physical activity limitations that persist after an intervention, necessitating psychiatric follow-up. Strong reactions such as alarm ( Something has gone wrong ), disappointment ( I was hoping I would be better. ), and futility ( Nothing will help. ) may undermine rehabilitative treatment measures and any potentially achievable gains. Adjunctive treatment modalities such as hypnosis, relaxation and imagery, guided imagery, and biofeedback may be helpful in mitigating pain perception and distress in such cases (see also Chapter 6 in this book). Psychotherapeutic measures may be helpful in assisting patients with reframing such reactions to mitigate any potential undermining of rehabilitative endeavors. Ongoing collaborative endeavors between the psychiatrist and...

Management And Prognosis

The first step in management of carefully diagnosed AFP is patient education. The patient may need help in order to accept the fact that there is no infection or bad tooth'' that can be easily treated or extracted. The next step is pharmacological treatment where the first choice is TCAs such as amitriptyline.60, 117 V Treatment with TCA must be continued for several months since the analgesic effect can take weeks to occur. When pain relief has been reached, TCA treatment can be phased out, but if the pain returns it may be necessary to continue TCA treatment.121 Anticonvulsants such as gabapentin may also have some effect.101,117 V Unfortunately, not many randomized controlled clinical trials have been performed. Surgery has been reported to cause pain aggravation and should only be performed after the confirmed presence of pathology, for example a periapical granuloma. Other types of treatments such as acupuncture, transcutaneous electric nerve stimulation (TENS), and biofeedback...

Table 81 Evaluation of the headache patient

Effective psychotherapeutic modalities include biofeedback training and relaxation training (see Chapter 6, Psychotherapy, of this book). Stress management therapy and cognitive-behavioral therapy (CBT) may also be helpful in reducing stress levels, but they are probably most effective when combined with relaxation or biofeedback training (Holroyd et al. 1977). Characteristics of patients who are likely to improve with the use of psychotherapeutic treat- ment are summarized in Table 8-3. Of these factors, the most striking is that those patients in relaxation training who show positive responses by the fourth session (as measured by muscle level reactivity on electromyogram EMG ) are likely to have an excellent response to relaxation or biofeedback training (Bogaards and ter Kuile 1994). Uncontrolled studies have revealed that dental complications may predispose some persons to tension headache, and these persons may

Table 815 Treatment of patients with complex regional pain syndrome

Substance abuse disorders also are common among this population. There is controversy about whether premorbid psychological disturbances predispose one to CRPS. In any event, psychiatric treatment for these conditions is warranted. Biofeedback and relaxation training can reduce distress and foster adaptive strategies with which to deal with pain (Barowsky et al. 1987).

Nonpharmacologic therapies

Unencumbered by significant side effects and efficacious, nonpharmacologic therapies are highly recommended in the treatment of both acute and chronic pediatric headaches. Such modalities include biofeedback with relaxation and cognitive-behavioral therapies and may modify the multiple factors that trigger and or exacerbate the migraine headaches and disability cycle.113 I Less information is currently available for acupuncture and alternative medicine therapies.114 II , 115 III

Persistent Somatoform Pain Disorder F454

There are two established treatments for this condition, antidepressants and CBT. Antidepressants that inhibit both serotonin and norepinephrine uptake, such as amitriptyline and venlafaxine, are more effective than the SSRI group of antidepressants.19,25 II CBT has been shown to be of definite value in those who have reached the stage to accept that medical or surgical interventions are not indicated.34 I The value of biofeedback is yet to be established, despite suggestions that this treatment may be valuable in chronic headache.65 II

Adjunctive Interventions

Biofeedback Biofeedback refers to a procedure in which physical parameters (e.g., muscle tension) are continuously monitored and fed back to the patient, who then attempts to alter the physical parameter. For example, an individual attempting to regulate and modify the degree of muscle tension in forehead muscles would have electromyographic electrodes placed on the forehead. The electrical signals from these electrodes would be relayed to a monitor and presented in any of a number of formats (e.g., visual, auditory). The patient, attending to the signal, would then use the information presented to develop strategies to reduce muscle tension. The principle relies on the idea that the patient uses the feedback signal as an indicator of the degree of physical activity that can be modified. In pain management, the idea is that the physical parameter measured and ideally altered is somehow linked to the genesis of pain (Turk et al. 1979 Turner and Chapman 1982b). Various biofeedback...

Descending Pathways

Inhibitory flow and increased sensitivity of neurons to descending noradrenergic and opioid-mediated inhibition. Unlike the other senses, pain has important subjective and emotional components. Outflow of descending inhibitory impulses from frontal cortex, cingulate gyrus, and hypothalamus contribute are influenced by the patient's psychological and emotional state. Anxiety, psychological stressors, and depression can reduce descending inhibition, thereby lowering the threshold for central sensitization and increasing pain intensity scores. Conversely, psychological support, including imagery, biofeedback, and music therapy can reduce pain intensity by either facilitating descending pathways or inhibiting cortical perception. This may explain the beneficial role of cognitive therapies, which marshal descending inhibitory mechanisms to reduce long-term synaptic strength in acute and persistent pain states.

Relaxation

This may be taught using a single technique, such as diaphragmatic breathing or progressive muscular relaxation, but patients may find one technique easier to use than another and may learn to use different techniques in different settings.30,31 V It is preferable to aim for a well-integrated and broadly applied set of techniques that facilitate goal attainment. Biofeedback is an effective technique for pain control and is more commonly used in the USA than elsewhere,32 but it is not essential to the process of achieving relaxation. Practice of techniques while moving, exercising, and otherwise working on goals is necessary to improve generalization.

The Evidence Base

Despite the complexity of CBT and the heterogeneity of the client group, there are a large number of treatment evaluations reported and a respectable number of randomized controlled trials. Reviews of CBT for chronic pain in adults have reported strong evidence for the efficacy of CBT in restoring function and mood and in reducing pain and disability-related behavior. Evidence for CBT ranges from unimodal treatments, such as biofeedback to complex multicomponent packages and studies fall into the top three categories of Bandolier's criteria

Multiple Trial Arms

The third problem was how to manage multiarmed trials, i.e. trials that compared two or more treatments with a control. This presents two issues (1) how to classify and combine treatment groups and (2) the choice of comparison (control) group for estimating ES values. We estimated treatment effects by including all treatment arms within a trial and acknowledged that the mean of the combined ES estimates in this comparison were not independent because those drawn from a single trial had a common control condition. Coding the details of treatments reported in the papers revealed wide variation between treatments described with a generic term, for example cognitive therapy, but there was marked variability between studies in the detail provided. We categorized the treatments into three primary classes biofeedback and relaxation, behavior therapy, and cognitive-behavior therapy. We anticipated that further

Case

Her physician advises her to discontinue all of them if possible. What alternative therapies can be recommended This case highlights the importance of CAM in the everyday practice of medicine. Herbal or nutriceutical treatments will most likely be avoided because of the uncertainty of these agents in pregnancy. Acupuncture may also carry at least a theoretical risk of premature labor. Self-management techniques such as biofeedback, yoga, and hypnosis can all be recommended. Osteopathic and chiropractic treatment can be beneficial, particularly if musculoskeletal factors trigger or influence headache. The herbal agent feverfew, which is commonly used in migraine, should be avoided during pregnancy.

Management

Exercises, biofeedback and EMG, hypnosis, relaxation, imagery, ultrasound, phonophoresis and iontophoresis, acupuncture and TENS. It is thought that provision of an ideal occlusion will reduce abnormal muscle activity and so reduce pain. A variety of so-called stabilization splints have been used which are worn at night when it is thought most likely that patients clench and grind their teeth (parafunctional habit). The oral appliances predominantly cover one or other arch either completely or partially. Some attempt to realign the maxillomandibular relationship whereas others do not seek to change the relationship. They can be made of soft plastic but many are rigid and attached to the teeth by clasps. Evidence for their efficacy has not been proven.

Physical therapy

There are few randomized studies in the area of physical therapy and pelvic pain. One open randomized study found that distention of painful pelvic structures in women with CPP resulted in significant relief of pain and improvement in quality of life measures.142 II However, in the multidisciplinary approach of treatment for CPP, physical therapy is often incorporated in the management,143 especially in cases of myofascial syndrome. TENS and biofeedback are often used in conjunction by the physical therapist.144 A meta-analysis of seven randomized controlled trials found that high frequency TENS is more effective for pain relief than placebo.21 I Intravaginal TENS provides electrical stimulation to the pelvic floor muscles and is also available.145 III

Treatment Strategies

Neuropsychological rehabilitation is often by default a primary treatment strategy. Patients (and occasionally their primary-care physicians) readily attribute paresis, aphasia or hemispatial neglect to brain injury but often need to be educated to the fact that disorders of emotional behaviour, too, can be the direct result of brain injury rather than a purely psychological reaction to newly acquired deficits. This knowledge promotes acceptance, reduces guilt, and facilitates symptom-oriented problem-solving. It is difficult to overemphasize the utility of simple education. Detailed explanations of the type and location of brain injury, replete with pictures, diagrams and imaging studies, lend the message all-important scientific gravitas. Beyond that, intensive cognitive rehabilitation can often improve the patient's perception of affective cues intensive re-education can improve output of or control over overt emotional expression. For example, biofeedback and modelling have been...