Ronald Glick, MDMedical Director—Center for

Integrative Medicine at UPMC Shadyside

Biofeedback and Cardiac Coherence

Training

Lazarus and Folkman—External pressure exceeds one’s perceived ability to cope

Associated with both psychological and physiological changes

Impact of Stress

Herbert Benson—A physical state of deep rest that changes the physical and emotional responses to stress

Associated with i Metabolismi HR, BP, RRMuscles relaxChange in brain wave activityChange in immunity

Relaxation Response

MeditationGuided imageryRhythmic breathingHypnosisAutogenic trainingYogaBiofeedbackQiGong

Mind-Body Approaches

A process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance.

Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature.

These instruments rapidly and accurately "feed back" information to the user.

The presentation of this information — often in conjunction with changes in thinking, emotions, and behavior — supports desired physiological changes.

Over time, these changes can endure without continued use of an instrument.  BCIA, AAPB, ISNR

Biofeedback

Education regarding connections between symptoms & physiology

Skills training in changing biofeedback signals corresponding to specific physiologic processes

Development of awareness of the internal states linked to arousal and relaxation

Development of carry-over in recognizing and modifying internal states without the aid of instrumentation

Development of an overall sense of self-efficacy and empowerment for contributing to one’s health and well-being, regardless of the extent to which the presenting problem has been resolved

Goals of Biofeedback

Fun/Gimmicky—Tends to engage people who might not otherwise be interested

Can help to engage someone who isn’t “psychologically-minded”

Depending on modality, doesn’t require quiet room with closed eyes—may be more acceptable to patients who have concerns with loss of control or those somewhat energetic or restless

Can tie in with other phenomena besides relaxation response

Advantages of Biofeedback

Like the Criminal Justice System, the Autonomic Nervous System is represented by 2 separate yet equally important groups

Extensive connections going both ways between the heart and the brain/brainstem

Autonomic Physiology 101

ExcitatoryChemically mediated by adrenalsAss’d with epinephrine/norepiResult in cortisol releaseAssociated with fight or flight

response

Sympathetic System

Braking or dampening systemVagally mediatedAssociated with relaxation response

Parasympathetic System

What you’re measuring is beyond conscious awareness

It’s tied in with a useful physiologic function/system—eg sympathetic/parasympathetic tone

The measure can be altered via awareness and exercises

Altering the measure results in improvement of some symptom

How do you pick a modality for Bioveedback?

Migraines & TTH AAD/HD AUrinary Incontinence AAnxiety D/O BFS/MPS BHeart Dz/HTN BCOPD/Asthma

Level of Evidence (Glick & Greco)

Uses surface electrodes to read out muscle activity

Especially helpful for headaches and myofascial pain

Also can be used for pelvic pain and urinary incontinence

Exercises can be direct—eg PMR vs indirect eg breathing, imagery, autogenics

Some connection with autonomics

Targets for Biofeedback-EMG

Skin conductance related to autonomics/ stress levels—think sweaty palms

Unlike muscles, no direct imagery so relies on other indirect methods

Targets for Biofeedback-GSR

Simplest—both in terms of technology and to learn—simple forms bio-dot and mood rings

Cool hands are ass’d with stressFor migraines rationale is that HA ass’d

with dilatation of cerebral vessels—may be offset by peripheral dilatation

May also help for Raynaud’sMay tie in with visual and sensory

imagery

Targets for Biofeedback-Thermal

Neurofeedback—uses computer algorithm to form Quantitative EEG and analyzes for predominant frequency

Most commonly used/studied for AD/HDProtocols include:Decrease theta/Increase betaIncrease slow cortical potentials

Also may help for Asperger’s & Anxiety D/O’s

Targets for Biofeedback-EEG

Initially described in perinatology with changes associated with fetal distress

Provides a barometer of autonomic balance

Can be described in terms of frequency components

Sorry but a short lesson in Fourier Analysis follows:

Heart Rate Variability

Mediated by parasympathetic system/vagus

i associated withAnxietyDepressionHeart disease

h associated with relaxation response and cognitive focus

Elicited by mind-body approaches & exercise

High Frequency HRV

Physiologic process—HR h with inspiration & i with expiration

Reflects balance between sympathetic & parasympathetic systems

Considered to be vagally mediated

Respiratory Sinus Arrhythmia

Describes a similar cyclic phenomenon to RSA

Relatively consistent frequency Oscillations in blood pressure—ass’d

with baroreceptor reflexOccurs at around 6 cycles/min

slower with athletes & meditators faster in kids and older adults

Mayer Wave

The increase in amplitude of oscillation of a system exposed to a periodic force whose frequency is equal or very close to the natural un-damped frequency of the system

Occurs when the respiratory frequency (RSA) overlaps with baroreceptor frequency (Mayer’s wave)

Explains why much of yogic breathing is practiced at 6 breaths/min

Resonance

Chaos—random pattern from 1 point to the next

Coherence—predictable pattern; from 1 point to the next you can make a pretty good guess as to where it’s heading

Chaos vs. Coherence

Positive emotion fg Negative emotion

Low arousal fg High arousal

Emotional Awareness/Mastery

High Arousal

Creativity AngerJoy Agitated DepressionFocus

+ Emotions - Emotions

Contentment DepressionCreativity Passivity

Low Arousal

Emotional Awareness/Mastery

Typically relies on infrared probe (ear or finger), picking up on change in skin color with systole

Programs have an algorithm that defines coherence vs chaos & feeds-back info to help a person shift to a coherent pattern

Cues that are used are paced breathing and imagery

HRV Biofeedback

HeartMath Institute has done extensive research, writing of books and monographs, and training

Has developed very engaging software for kids & adults

Has a PC or Mac based system as well as a handheld unit

Focus on heart-centered imagery and positive emotion

HeartMath Emwave

Focus is on achieving resonance of RSA & Mayer’s wave

As the Mayer’s wave frequency varies from person to person, the ideal respiratory rate varies as well

Can be determined by having the patient breathe at various frequencies & see which elicits the greatest spike in HRV amplitude & in the amplitude on the frequency plot

Typically between 4-6 breaths per minuteHas been used for hypertension, asthma,

anxiety, and depression

Resonant Frequency Biofeedback

Glick RM, Greco CM. Biofeedback and primary care. Primary Care: Clinics in Office Practice. 37(1): 91-103. 2010 March.Childe, D. & Martin, H. : The HeartMath Solution, Harper, San Francisco, 1999.Lehrer PM, Vaschillo E, Vaschillo B. Resonant frequency biofeedback training to increase cardiac variability: rationale and manual for training. Applied Psychophysiology & Biofeedback. 25(3):177-91, 2000 Sep. Andrasik F. Biofeedback in headache: an overview of approaches and evidence.  Cleveland Clinic Journal of Medicine. 77 Suppl 3:S72-6, 2010 Jul.

References