Biofeedback: helping people gain control of their health. (Research Update).

We have not been informed that our bodies tend to do what they are told if we know how to tell them.

-- Elmer Green

A Pioneer in Biofeedback 

The purpose of this research update is to apprise recreational professionals of the many uses for measuring and monitoring individual physiological changes and then feeding these signals back to the person who learns how to control them. This technique, known as biofeedback, has both clinical and non-clinical applications, and can be an important tool for recreation professionals seeking to quantify an individual's reactions to internal and external stimuli. Applications for biofeedback include the assessment of a person's responses to recreational experiences (e.g. marketing information gleaned from measuring physiological responses of individuals to park experiences) or feeding back the signals to patients who learn how to control pain, and decrease symptoms of insomnia, ADD/ADHD, depression, and anxiety. In addition, biofeedback is now used to predict mortality (Huikuri, et al, 1998), to measure multiple physiological variables during space flight (Friend, 2001), and to shape appropriate behaviors (Schwartz, 1995). The number of biofeedback applications grows daily.

Most of what is known about biofeedback is the result of medical studies where individuals have been taught to self-regulate their bodies by consciously altering physiological processes using signals that are fed back to them (Robbins, 2000). According to the National Institutes of Health (1999), biofeedback "is a treatment technique in which people are trained to improve their health by using signals from their own bodies" (p. 1). The word biofeedback became popularized in the 1960's when laboratory researchers were studying the potential of individuals to alter blood pressure, heart rate, and other "involuntary" bodily functions (NIMH, 1999). In 1969, a group of scientists met in California to discuss this emerging field and decided to use the term biofeedback to describe "the use of appropriate instrumentation to bring covert physiologic processes to the conscious awareness of one or more individuals" (Association for Applied Psychophysiology and Biofeedback, 1992, p. 2). Simply put, therapists, with the aid of instrumentation that feeds back physiological signals, utilize activities such as relaxation, imagery, computer games, and recreational activity to assist people in gaining control over inappropriate physiological responses which, if left unchecked, can cause or exacerbate illness and other dysfunctions. Biofeedback therapists use the principles of "classic conditioning" and "shaping" to assist clients with the identification and control of inappropriate physiological responses. For example, a child who has ADD/ADHD could be treated using EEG (electroencephalography) biofeedback by placing sensors on the scalp that pick up electrical impulses and then feeding these signals back to the child, who soon learns how to control them (Lubar, 1995). The child works at decreasing the electrical (brain wave) activity associated with ADHD and increasing those associated with a more relaxed state. In essence, the child would "condition" themselves toward more appropriate responses as they play a video game that requires the appropriate physiological responses to win. As the child succeeds at one level the "threshold" or short-term objective is raised, and shaping continues until the person reaches the end goal of increased attention and decreased hyperactivity.

The measurement of physiological signals using biofeedback instrumentation is evolving concomitant to technology, and now includes very sensitive measuring and monitoring sensors. Most modern computers are capable of processing and displaying biofeedback signals. Laptops offer portability and the subsequent advantages. Typical modalities used by biofeedback therapists include: Electromyography (EMG), for muscle re-education and relaxation; Skin Temperature (thermal biofeedback), used for treating cardiovascular (hypertension, migraine, and Raynaud's Disease) and cardio-respiratory disorders (asthma); Electrodermal Response (EDR), sometimes referred to as Galvanized Skin Response (GSR), is used in the treatment of anxiety and depression or to test an individual's fidelity (polygraph); and Electroencephalography (EEG), with indications that include the treatment of addictions, ADD/ADHD, and many emotional and cognitive disorders (AAPB, 1992). EEG is a rapidly growing separate field of biofeedback which calls for specialized certification. Finally, heart rate variability, a finite measurement of sympathetic/parasympathetic modulation of the heart, is now considered a marker for relaxation, good health, cardiovascular disease and depression (Mussleman, Evans, & Nemeroff, 1998), and mortality (Tsuji et al., 1994; Huikuri et al., 1998). In one sense the heart does indeed "think," or react to stimuli such as stress, by varying the rate and intensity of its response. Some responses are sympathetically driven and some parasympathetically driven. Harmony between the systems is sought after, and decreased heart rate variability is associated with a variety of pathological conditions as noted above.

In the past forty years biofeedback has come out of the laboratory and become an accepted treatment modality. Research continues to expand upon its indications and highlight its effectiveness. For example, an independent panel convened by the National Institutes of Health to study the efficacy of biofeedback concluded that it is an effective treatment for pain and insomnia and recommend its inclusion as a treatment option (National Institutes of Health, 1995). Other treatment indications for biofeedback include: excessive motor tone (e.g. spasticity, movement disorders); CNS Disorders (e.g. stroke, some neuropathies); Pain Disorders (e. g. neuromuscular pain, headache); Behavioral Disorders (e.g. post traumatic stress, anxiety, phobias); and Gastrointestinal Disorders (Urinary and Fecal Incontinence), (AAPB, 1992). As the data on the efficacy of biofeedback continues to mount, more and more consumers are requesting it. Medicare reimburses for muscle reeducation training (electromyography feedback), and major insurance companies reimburse for the treatment of hypertension, anxiety/panic attacks, pain disorder, and migraines.

The research possibilities for biofeedback are endless and not limited to clinical applications. One only has to imagine the benefits of measuring physiological changes in real time to appreciate the possibilities. Do people truly relax (physiologically) when they are on a crowded beach, or do they just think they do? Do wellness programs really reduce stress as determined by changes in autonomic nervous system responses? Does participation in board games and card games produce an autonomic nervous system relaxation effect consistent with the hormonal relaxation effect Russoniello (1994) reported? Can feeding back signals to a child for desensitization purposes minimize anxiety around participation in social activities? Do individuals who use a wheelchair have autonomic nervous system tone? If not, can signals be fed back to assist them in achieving autonomic nervous system balance? Can virtual reality be tied with biofeedback to produce relaxation, fun, games, and other leisure experiences that promote health or decrease symptoms? These are a just a few of the applications (see Research Into Action Section of this article for more details).

Certification in Biofeedback

Recreational therapy is an accepted profession by the Biofeedback Certification Institute of America because practitioners hold a national health care certification (Certified Therapeutic Recreation Specialists) and meet other requirements of the biofeedback certifying body. Thus, recreational therapists can become certified after completing biofeedback training. Other non-medical professions like Certified Recreation and Parks Professionals (CPRP) may also be certified if their degree requirements and practical experiences meet the minimum standards set by the biofeedback certification board to sit for the exam. Certification by the Biofeedback Certification of America (BCIA), the only biofeedback certifying body, is granted after specific training and the passage of a written examination. Sitting requirements for the exam include a bachelor's degree in one of BCIA's approved fields. These fields include, but are not limited to, medicine, psychology, physical therapy, nursing, recreational therapy, and athletic trainers. A course in anatomy and physiology is a prerequisite. The testing candidate must also successfully complete 60 hours of didactic biofeedback training. "Candidates can meet this training from BCIA accredited training programs or a university course of three semester or four quarter hours covering the 11 blue print areas" (BCIA, 1999, p. 2). In addition, candidates must complete one hundred clinical training hours, thirty of which must be to be under a BCIA approved supervisor. The clinical hour breakdown includes personal biofeedback training (10 hours), case studies (10 hours), clinical biofeedback EMG and Thermal interventions (25 hours each), and clinical supervision (30 hours).

Advantages of Certification in Biofeedback

All professionals have a moral and ethical obligation to seek competence in areas where they practice in order to minimize harm and increase effectiveness. Formal training and certification is prerequisite to service delivery. The advantages of biofeedback certification are many, and include increased marketability. With this competency, recreation professionals can contract with physicians, psychologists, counselors, social workers, and others to provide the biofeedback portion of treatment services. Recreational services such as after-school programs and other parks and recreation programs could also use biofeedback to study the effects of their programs and use the information to demonstrate positive outcome. In addition, specific problems such as behavioral issues could be identified and addressed. Recreational therapy departments could specialize in biofeedback and work with the various disciplines to provide this service. This expertise would add to the overall consumer appeal of recreational therapy, and would help create an important niche. Again, a major advantage of biofeedback is its ability to measure and monitor physiological changes and report them quantitatively. This data can then be used to increase specificity and the overall effectiveness of the recreational services.

References

Association for Applied Psychophysiology and Biofeedback (1992). Standards and Guidelines for biofeedback applications in psychophysiological self-regulation. Wheat Ridge, CO: Author.

Biofeedback Certification Institute of America (1999). Biofeedback certification guidelines. Wheat Ridge, CO: Author.

Csikszentmihalyi, M. (1993). The evolving self. New York: Harper/Collins.

Huikuri, H. V., Makikallio, T. H., K. E. Juhani Airaksinen, Seppanen, T., Puukka, P., Raiha, I. J., & Sournader, L. B. (1998). Power-Law relationship of heart rate variability as a predictor of mortality in the elderly. Circulation, 97, 2031-2036.

Friend, T. 2001. Neurolab studies long-term space flights. USA Today. Internet Source: http://www.usatoday.com/life/science/space/lss190.htm

Mussleman, D. L., Evans, D. L. & Nemeroff, C. B. (1998). The relationship between cardiovascular disease and depression. Archives of General Psychiatry, 55, 580-591.

Lubar, J. (1995). Neurofeedback for the management of attention-deficit/hyperactivity disorders. In Schwartz, M. (Ed.). Biofeedback. New York: The Mayo Foundation.

National Institute of Mental Health (1999). What is biofeedback? DHHS Publication No (ADM) 83-1273 National Institute of Mental Health Internet http://www.psychotherapy.com/bio.html

National Institutes of Health (1995). NIH panel encourages wider acceptance of behavioral treatments for chronic pain and insomnia. National Institutes of Health, 1-2.

Peniston, E. G. & Kulkosky, P. J. (1990). Alcoholic personality and alpha-theta brain wave training. Medical Psychotherapy, 3, 37-55.

Robbins, J. (2000). Symphony in the brain. New York: Atlantic Monthly.

Russoniello, C. V. (1994). Physiological and psychological changes in alcoholic patients after behavioral medicine treatments. Annals of Behavioral Medicine.

Schwartz, M. (Ed.). Biofeedback. New York: The Mayo Foundation.

Tsuji, H., Venditti, F. J., Manders, E. S., Evans, J. C., Larson, M. G., Feldman, C. L. & Levy, D. Reduced heart rate variability and mortality risk in an elderly cohort: The Framingham Heart Study, Circulation, 90, 878-883.

RELATED ARTICLE: Research into action: quantifying the effectiveness of specific recreational services.

Biofeedback is an assessment and treatment tool in which recreational therapists and, possibly in the future, other recreation professionals, can be trained and certified. Biofeedback provides a means to quantify the effectiveness of specific treatments and recreational services. Moreover, and most importantly, biofeedback is an excellent tool for assisting individuals to gain control over their health. Technology has allowed recreation professionals to accurately measure minute physiological changes and feed them back to the person, allowing for increased treatment specificity and positive outcome. Biofeedback provides a mechanism for recreational professionals to quantify physiological changes occurring as a result of products and services. When indicated these same signals can be fed back to the person who can use the information to alter patterns that contribute to poor health or performance. The indications for the use of biofeedback are increasing. Some specific applications are illustrated.

Application 1: Physiological Measuring and Monitoring in Recreational Therapy

Recreational therapists can quantify the results of treatments (aquatics, exercise, board games, crafts, sport) using any number of biofeedback modalities i.e., EMG, EDR, EEG, HRV, and report the results. Knowing (mathematically and visually) that an individual was sympathetically dominated before an activity, and is more balanced afterwards adds credibility to a recreational therapy intervention designed to produce physiological relaxation. This improved treatment specificity can increase positive health outcomes, and consequently, the credibility of the service.

Application 2: Recreational Therapy Biofeedback

One way recreational therapists who are certified can employ biofeedback is in the treatment of addictive disorders utilizing the Peniston addictions protocol (Peniston, & Kulkosky, 1990). In this EEG protocol, individuals are trained to change brain wave patterns associated with addiction. EEG signals are fed back to patients who subsequently learn to identify and access brain wave states associated with relaxation and to decrease those associated with addiction.

Application 3: Recreation and Leisure Services: Physiological Measuring and Monitoring

Csizsentmihalyi (1993) has done an excellent job of describing a psychological experience he called "flow." He believes this experience "usually occurs when there are clear goals a person tries to reach, and there is unambiguous feedback as to how well he or she is doing" (p. 179). Biofeedback helps a person set clear goals (physiological goals that have health benefits) and then feeds back these signals very unambiguously to the person in real time. In this sense it may help a person identify and access flow. Flow is a very important concept in the recreation and leisure profession and may have tremendous healing properties. Yet we know little about the physiological correlates of this experience. Physiological measuring and monitoring could help us further understand this experience and devise methods to help individuals access this state.

Application 4. Recreation and Leisure Services: Feeding the signal back to the person

It is possible that biofeedback could be used to increase the performance (as well as improve the health) of Wheelchair Athletes and Special Olympians by utilizing stress and fatigue reduction techniques? It seems plausible that biofeedback training could be used to decrease the anxiety and stress of athletes, thereby increasing performance. Other applications might include muscle reeducation to increase flexibility, or as a natural method to reduce muscle spasticity.

Other biofeedback applications include the study of park customers' reactions to conditions such as dogs or bicycles while walking on a path. Biofeedback may, one day, be used to help people select vacations, match compatible people, select recreation programs, and convince policy makers of the important positive physical changes that occur when people are in recreation.

For more information on biofeedback, biofeedback certification, and biofeedback education, contact:

Professional association for biofeedback professionals: The Association of Applied Psychophysiology and Biofeedback: www.aapb.org

For information on biofeedback certification: The Biofeedback Certification Institute of America: www.bcia.org

For information on biofeedback education: East Carolina University, Department of Recreation and Leisure Studies, Greenville, NC: www.ecu.edu/rcls/biofeedback

Dr. Carmen V. Russoniello is an assistant professor in the Department of Recreation and Leisure Studies at East Carolina University. He is an Associate Fellow of the Biofeedback Association of America and dually certified in EEG and General Biofeedback. Dr. Russoniello currently teaches biofeedback courses on campus and on the Internet.

Research Update is edited by Cheryl A. Estes, Ph.D., assistant professor in recreation and leisure studies at East Carolina University in Greenville, North Carolina.