Biofeedback: A New Frontier for Biofeedback: A New Frontier for Recreation TherapyRecreation Therapy

West Virginia Therapeutic Recreation Association

Annual Conference – Cacapon State Park

November 5-7, 2008

Michael Duquette, CTRS, BCIAC, CCDCLead TherapistNational Institutes of HealthBethesda, Maryland

Benedict StoverRecreation Therapy Intern

National Institutes of HealthBethesda, Maryland

OutlineOutlineI.I. DefinitionsDefinitionsII.II. Biofeedback ClipsBiofeedback ClipsIII.III. Certification ProcessCertification ProcessIV.IV. Stress/Autonomic Nervous SystemStress/Autonomic Nervous SystemV.V. Operant ConditioningOperant ConditioningVI.VI. Relaxation ResponseRelaxation ResponseVII.VII. Biofeedback ModalitiesBiofeedback ModalitiesVIII.VIII. Stress TestStress TestIX.IX. Guided Imagery Assisted BiofeedbackGuided Imagery Assisted BiofeedbackX.X. Heart Rate Variability BiofeedbackHeart Rate Variability BiofeedbackXI.XI. QuestionsQuestions

Body Body →→ Mind Mind Physiological PsychologyPhysiological Psychology – How changes in the body – How changes in the body

(e.g., drinking, drugs, stress hormones) affect the way (e.g., drinking, drugs, stress hormones) affect the way people think and feel.people think and feel.

Physiological psychologistsPhysiological psychologists manipulate physiology, then manipulate physiology, then observe behavioral results.observe behavioral results.

Mind Mind →→ Body Body PsychophysiologyPsychophysiology – How changes in the mind (e.g. – How changes in the mind (e.g.

observations, thoughts, attitudes, emotions) affect the observations, thoughts, attitudes, emotions) affect the way the body responds to the environment.way the body responds to the environment.

PsychophysiologistsPsychophysiologists manage, guide, and obstruct human manage, guide, and obstruct human psychological variables, then observe physiological psychological variables, then observe physiological effects. effects.

Complementary Alternative Complementary Alternative Medicine (CAM)Medicine (CAM)

The termThe term “alternative medicine” “alternative medicine”, encompasses , encompasses any healing practice "that does not fall within the any healing practice "that does not fall within the realm of conventional medicine." realm of conventional medicine." ChiropracticChiropractic MeditationMeditation YogaYoga BiofeedbackBiofeedback HypnosisHypnosis Acupuncture Acupuncture PrayerPrayer

Applied BiofeedbackApplied Biofeedback

a)a) A group of therapeutic procedures…A group of therapeutic procedures…

b)b) utilizing electronic instruments…utilizing electronic instruments…

c)c) to accurately measure, process, and to accurately measure, process, and ‘feedback’ to persons information…‘feedback’ to persons information…

d)d) with reinforcing properties…with reinforcing properties…

e)e) about their neuromuscular and autonomic about their neuromuscular and autonomic activity, both normal and abnormal…activity, both normal and abnormal…

f)f) in the form of analog or binary, auditory, and/or in the form of analog or binary, auditory, and/or visual feedback signals.visual feedback signals.

Applied Biofeedback Cont.Applied Biofeedback Cont.

Best achieved with a competent biofeedback Best achieved with a competent biofeedback professionalprofessional

The objectives are to help patients:The objectives are to help patients:1.1. Develop greater awareness and voluntary control Develop greater awareness and voluntary control

over their physiological processes that are over their physiological processes that are otherwise outside awareness and/or under less otherwise outside awareness and/or under less voluntary control (ANS)voluntary control (ANS)

2.2. By first controlling the external signalBy first controlling the external signal

3.3. And then with the internal psycho-physiological And then with the internal psycho-physiological cuescues

Biofeedback VideosBiofeedback Videos

ECU BiofeedbackECU Biofeedback

Pediatric Biofeedback

BCIA Certification in General BCIA Certification in General BiofeedbackBiofeedback

Bachelor or higher degree in a BCIA approved health care related fieldBachelor or higher degree in a BCIA approved health care related field Human Anatomy/PhysiologyHuman Anatomy/Physiology Didactic Biofeedback Education (48 hrs)Didactic Biofeedback Education (48 hrs) Practical Biofeedback Training - 20 contact hours with a BCIA approved Practical Biofeedback Training - 20 contact hours with a BCIA approved

mentormentor The 20 contact are used hours to review:The 20 contact are used hours to review: ··10 sessions of personal biofeedback, demonstrating self-regulation.10 sessions of personal biofeedback, demonstrating self-regulation. ··50 sessions of patient/client treatment as follows: 10 sessions each of 50 sessions of patient/client treatment as follows: 10 sessions each of

Thermal, EMG, and GSR. The remaining 20 sessions are to include any Thermal, EMG, and GSR. The remaining 20 sessions are to include any combination of EMG, Thermal, GSR, EEG, HRV, and respiration training.combination of EMG, Thermal, GSR, EEG, HRV, and respiration training.

··10 case conference presentations.10 case conference presentations.

*Sessions are a minimum of 20 minutes.*Sessions are a minimum of 20 minutes. Written ExaminationWritten Examination BCIA InformationBCIA Information

Reasons for Medical Visits to Primary ProvidersReasons for Medical Visits to Primary Providers

Chest pain, dyspnea, etc.

Functional GI

Panic, insomnia, anxiety, etc.

Headaches, back pain, fibromyalgia,

etc.

Colds, Flu, etc.

Others

Stress Related DisordersStress Related Disorders

StressStress

AcuteAcute MOST common form of MOST common form of

stress. stress. Comes from demands Comes from demands

and pressures of the and pressures of the recent past and recent past and anticipated demands and anticipated demands and pressures of the near pressures of the near future. future.

Can be thrilling and Can be thrilling and exciting in small doses, exciting in small doses, but too much is but too much is exhausting. exhausting.

ChronicChronic Comes when a person Comes when a person

never sees a way out of never sees a way out of a miserable situation. a miserable situation.

Insistent demands and Insistent demands and pressures for seemingly pressures for seemingly interminable periods of interminable periods of time. time.

With no hope, the With no hope, the individual gives up individual gives up searching for solutions. searching for solutions.

Autonomic Nervous SystemAutonomic Nervous System

1)1) Central Nervous System (CNS)Central Nervous System (CNS)

2)2) Peripheral Nervous System (PNS)Peripheral Nervous System (PNS)

Sensory – Afferent DivisionSensory – Afferent Division

Motor – Efferent DivisionMotor – Efferent Division

Somatic – Skeletal Muscles – VoluntarySomatic – Skeletal Muscles – Voluntary

Autonomic Nervous System (ANS) – InvoluntaryAutonomic Nervous System (ANS) – Involuntary

Sympathetic - ParasympatheticSympathetic - Parasympathetic

a)a) Smooth Muscle (stomach, bladder, blood vessels)Smooth Muscle (stomach, bladder, blood vessels)

b)b) Cardiac MuscleCardiac Muscle

c)c) Glands (tear, sweat, salivary, adrenal)Glands (tear, sweat, salivary, adrenal)

Cranial NervesIII,VII,IX,X

Spinal Nerves S1, S2

Spinal Nerves

T1-12 & L1, L2

SympatheticSympathetic

The “fight or flight” subdivision of the Autonomic Nervous SystemThe “fight or flight” subdivision of the Autonomic Nervous System Involves activation of the Involves activation of the adrenal medullaadrenal medulla Postganglionic axons secrete noradrenalinePostganglionic axons secrete noradrenaline Includes spinal nerves from T1 Includes spinal nerves from T1 →→ L2 L2

stimulates heartbeat raises blood pressure dilates the pupils dilates the trachea and bronchi stimulates the conversion of liver glycogen into glucose shunts blood away from the skin and viscera to the skeletal muscles, brain, and heart inhibits peristalsis in the gastrointestinal (GI) tract inhibits contraction of the bladder and rectum

ParasympatheticParasympathetic

Postganglionic axons secrete acetylcholinePostganglionic axons secrete acetylcholine Involves Cranial Nerves III, VII, IX, X, and Spinal Nerves S2 Involves Cranial Nerves III, VII, IX, X, and Spinal Nerves S2 →→S4S4 MOST active when the body is at restMOST active when the body is at rest

slows down of the heartbeat lowers blood pressure constricts the pupils increases blood flow to the skin and viscera allows peristalsis of the GI tract relaxes the bladder and rectum

The Autonomic Nervous SystemThe Autonomic Nervous System

StructureStructure Sympathetic StimulationSympathetic Stimulation Parasympathetic StimulationParasympathetic Stimulation

Iris (eye)Iris (eye) Pupil DilationPupil Dilation Pupil ConstrictionPupil Constriction

HeartHeart Heart rate and force increasedHeart rate and force increased Heart rate and force decreasedHeart rate and force decreasedDecreased stroke volumeDecreased stroke volume Increased stroke volumeIncreased stroke volume

LungLung Bronchial muscle relaxedBronchial muscle relaxed Bronchial muscle contractedBronchial muscle contracted

Small IntestineSmall Intestine Motility reducedMotility reduced Digestion increasedDigestion increased

KidneyKidney Decreased urine secretionDecreased urine secretion Increased urine secretionIncreased urine secretion

Adrenal medullaAdrenal medulla Norepinephrine and Norepinephrine and epinephrine secretedepinephrine secreted

BladderBladder Wall relaxedWall relaxed Wall contractedWall contractedSphincter closedSphincter closed Sphincter relaxedSphincter relaxed

Stress PathwaysStress Pathways

Acute StressAcute Stress

Sympathetic-Adrenal-Medullary (SAM)Sympathetic-Adrenal-Medullary (SAM)

Chronic StressChronic Stress

Hypothalmus-Pituitary-Adrenal (HPA) Hypothalmus-Pituitary-Adrenal (HPA)

Sympathetic-Adrenal-MedullarySympathetic-Adrenal-Medullary(SAM)(SAM)

““Flight or Flight” – Walter B. CannonFlight or Flight” – Walter B. Cannon Primary Pathway – autonomic nervous SystemPrimary Pathway – autonomic nervous System Fast actingFast acting BrainBrain→ Spinal Cord →Adrenal Medulla→ Spinal Cord →Adrenal Medulla Epinephrine →Released in bloodstreamEpinephrine →Released in bloodstream Norepinephrine →Nerve Cells →Glands & MusclesNorepinephrine →Nerve Cells →Glands & Muscles ↑↑Heart RateHeart Rate ↑Blood Pressure ↑Blood Pressure Dilates PupilsDilates Pupils ↑↑MetabolismMetabolism Dilates Bronchi Dilates Bronchi ↑Saliva Flow↑Saliva Flow Converts Glycogen to GlucoseConverts Glycogen to Glucose Inhibits Inhibits

BladderBladder

HPA AxisHPA Axis

Involved in long term stress responseInvolved in long term stress response ↑ ↑ amount of energy to places most neededamount of energy to places most needed HypothalamusHypothalamus

↓ ↓

PituitaryPituitary

↓ ↓

AdrenalAdrenal

The Brain’s Stress Response The Brain’s Stress Response

Amygdala

HypothalmusCorticotropin

Releasing Hormone (CRF)

PituitaryGland

ACTH(adrenocorticotrophic

Hormone)

AdrenalCortex

Cortisol

Increase blood glucose

level

Decrease inflammation

Reduce pain

Resist long term stress

BrainStructure Chemical Emotion

FearFreeze

Flush

Flight/Flight

Faint

ParasympatheticParasympathetic SympatheticSympathetic

Operant ConditioningOperant Conditioning

Operant Operant conditioning conditioning forms an association forms an association between a behavior between a behavior and a consequence and a consequence

There are four There are four possible conse-possible conse-quences to any quences to any behavior. They are:behavior. They are:

1.1. Something Good can start or Something Good can start or be presented, so behavior be presented, so behavior increases = Positive increases = Positive Reinforcement (R+) Reinforcement (R+)

2.2. Something Good can end or Something Good can end or be taken away, so behavior be taken away, so behavior decreases = Negative decreases = Negative Punishment (P-) Punishment (P-)

3.3. Something Bad can start or Something Bad can start or be presented, so behavior be presented, so behavior decreases = Positive decreases = Positive Punishment (P+) Punishment (P+)

4.4. Something Bad can end or Something Bad can end or be taken away, so behavior be taken away, so behavior increases = Negative increases = Negative Reinforcement (R-)Reinforcement (R-)

The Relaxation ResponseThe Relaxation Response

Diaphragmatic breathing is a basic tool Diaphragmatic breathing is a basic tool in developing awareness, modulating in developing awareness, modulating stress and enhancing a healthy mind-stress and enhancing a healthy mind-body balance body balance (Benson, 1994)(Benson, 1994)

Benson’s Basic Components to Benson’s Basic Components to Promote the Relaxation ResponsePromote the Relaxation Response

A Quiet EnvironmentA Quiet Environment Something to “dwell” onSomething to “dwell” on A passive attitudeA passive attitude A Comfortable PositionA Comfortable Position

The Relaxation ResponseThe Relaxation Response

The Relaxation Response is an integrated The Relaxation Response is an integrated hypothalamic response which results in hypothalamic response which results in generalized decreases in sympathetic generalized decreases in sympathetic nervous system activity. nervous system activity.

It is the physiologic antithesis of the flight-It is the physiologic antithesis of the flight-or-fight response.or-fight response.

(Benson, 1975, 1992)(Benson, 1975, 1992)

Benson’s Basic Components to Benson’s Basic Components to Promote the Relaxation ResponsePromote the Relaxation Response

A Quiet EnvironmentA Quiet Environment Something to “dwell” onSomething to “dwell” on A passive attitudeA passive attitude A Comfortable PositionA Comfortable Position

MindfulnessMindfulness

Being aware of, and paying attention Being aware of, and paying attention to, the moment in which we find to, the moment in which we find ourselves. ourselves.

Our past is gone, our future is not yet Our past is gone, our future is not yet here… so what exist between them is here… so what exist between them is the the present momentpresent moment. .

Mindfulness YouTube Clip 23-27min

Finger Temperature (FT)Finger Temperature (FT)

RespirationRespiration

Skin Conductance (SC)Skin Conductance (SC)

Electromyography (EMG)Electromyography (EMG)

Blood Pulse Volume (BVP)Blood Pulse Volume (BVP)

General Biofeedback ModalitiesGeneral Biofeedback Modalities

Surface Electromyography (Surface Electromyography (SEMGSEMG))

Three Fold Purpose:Three Fold Purpose:1.1. Receive the electrical Receive the electrical

signalsignal

2.2. Separate this electrical Separate this electrical output from other energy output from other energy on skin and amplify it on skin and amplify it greatlygreatly

3.3. Convert the amplified Convert the amplified EMG signal into useful EMG signal into useful forms of informationforms of information (Biofeedback)(Biofeedback)

Surface Electromyography (SEMG)Surface Electromyography (SEMG)

An electrical correlate of An electrical correlate of muscle contractionmuscle contraction

EMG is measured in EMG is measured in microvolts (millionths of a microvolts (millionths of a volt)volt)

The strength of The strength of contraction is directly contraction is directly proportional to the signal proportional to the signal levellevel

EMG is derived from 2 EMG is derived from 2 active electrodes and a active electrodes and a ground/referenceground/reference

Microvolts

Seconds

A

B

0 5

A – Bicep

B - Tricep

Skin Conductance (SC)Skin Conductance (SC) Electrodermal Response (EDR) or Galvanic Skin Electrodermal Response (EDR) or Galvanic Skin

Response (GSR)Response (GSR) Measurement of skin response to a small electrical Measurement of skin response to a small electrical

current being passed through it. current being passed through it. Changes in resistance of skin to an electrical current Changes in resistance of skin to an electrical current

due to opening and closing of sweat glands. due to opening and closing of sweat glands. Electrodes attach to the volar surface of finger tips or Electrodes attach to the volar surface of finger tips or

palm of hand.palm of hand. The more emotionally aroused you are, the more The more emotionally aroused you are, the more

active your sweat glands are and the greater the active your sweat glands are and the greater the electrical conductivity of your skin. electrical conductivity of your skin.

Indication of sympathetic arousal; quick to activate, Indication of sympathetic arousal; quick to activate, slow to recover.slow to recover.

Effective in treating: phobias, anxiety, excessive Effective in treating: phobias, anxiety, excessive sweating, and, at times, stuttering since these emotions sweating, and, at times, stuttering since these emotions will affect your skin's conductivity.will affect your skin's conductivity.

Thermal Feedback Thermal Feedback A device that monitors vasodilatation (A device that monitors vasodilatation (↑ blood volume↑ blood volume and and

vasoconstriction (vasoconstriction (↓ blood volume)↓ blood volume).. Usually, to the middle or small finger of your dominant hand. Usually, to the middle or small finger of your dominant hand. When you are tense or anxious, your skin temperature drops When you are tense or anxious, your skin temperature drops

as blood is redirected inward to muscles and internal organs, as blood is redirected inward to muscles and internal organs, (sympathetic nervous system). (sympathetic nervous system).

Like monitoring muscle tension, measuring skin temperature Like monitoring muscle tension, measuring skin temperature is a useful tool in learning how to manage stress, (is a useful tool in learning how to manage stress, (↑ in skin ↑ in skin temperature-activation of parasympathetic nervous system)temperature-activation of parasympathetic nervous system). .

↓ ↓ 85F = Aroused, Distressed 85F = Aroused, Distressed 85-89.9F = Anxious, Nervous85-89.9F = Anxious, Nervous 90-92.9 = Normal Range90-92.9 = Normal Range 93-94.9 = Calm, Quiet93-94.9 = Calm, Quiet Above 95 = Deeply RelaxedAbove 95 = Deeply Relaxed

Guided Imagery TreatmentGuided Imagery Treatment

Guided Imagery AudioGuided Imagery Audio

Heart Rate Heart Rate Variability Variability

BiofeedbackBiofeedback

OscillationsOscillations

TidesBreathing

Inhal

e

Exh

ale

Inhale

Exh

ale

Inh

ale

Exh

ale

Respiratory Sinus ArrhythmiaRespiratory Sinus Arrhythmia(RSA)(RSA)

Respiratory = BreathRespiratory = Breath Arrhythmia = Heart Rate ChangesArrhythmia = Heart Rate Changes Sinus = OscillationsSinus = Oscillations

Inha

le

Inha

le

Exh

ale

Exh

ale

RSA triggers very powerful cardio-vascular reflexes that help to balance the autonomic nervous system to include the Bainbridge Reflex (blood volume) and the Baroreceptor Reflex, (blood pressure).

OscillationsOscillations

In healthy individuals, a degree of In healthy individuals, a degree of interaction between activity of SNS and interaction between activity of SNS and PSNS allows more effective responses to PSNS allows more effective responses to demands. demands.

This interaction produces variability in HR. This interaction produces variability in HR. Oscillations in HR interact with other Oscillations in HR interact with other oscillating systems (hormones, blood oscillating systems (hormones, blood pressure, respiration, emotion, etc).pressure, respiration, emotion, etc).

Oscillations-Heart Rate VariabilityOscillations-Heart Rate Variability

Heart Rate

Breathing

Blood Pressure

Blood Volume

Ordinary Breathing produces three HR frequencies,

HF,LF,&VLF

Progression to approx. 6 BPM, (Diaphragmatically) in experienced breathers produces single summatedpeak at about .1hz:

RESONANT FREQUENCY

Daily practice in this state increases

homeostatic reflexes

Vaschillo’s Resonant Vaschillo’s Resonant Frequency Frequency

TheoryTheory

Respiration

Heart Rate

Blood Pressure

Delay~ 5 sec

Time

Time

Time

HR and BP Oscillations Elicited by the Stimulus of HR and BP Oscillations Elicited by the Stimulus of Respiration at Resonant FrequencyRespiration at Resonant Frequency

Inhale

Sympathetic

Exhale

Para-sympathetic

DiaphragmDiaphragm

Breathing VideoBreathing Video

Diaphragmatic Breathing - SittingDiaphragmatic Breathing - Sitting

ResourcesResources Biofeedback Institute of AmericaBiofeedback Institute of America

www.bcia.orgwww.bcia.org Association for Psychophysiology and BiofeedbackAssociation for Psychophysiology and Biofeedback

www.aapg.orgwww.aapg.org Biofeedback Foundation of EuropeBiofeedback Foundation of Europe

www.bfe.orgwww.bfe.org (this is where you can download the breathing (this is where you can download the breathing pacer, EZ-Air) pacer, EZ-Air)

ECU Biofeedback LabECU Biofeedback Lab www.ecu.edu/rcls/biofeedback/www.ecu.edu/rcls/biofeedback/

Stens BiofeedbackStens Biofeedback www.stens-biofeedback.comwww.stens-biofeedback.com

Thought Technology Thought Technology www.thoughttechnology.comwww.thoughttechnology.com