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THE COMPARATIVE EFFICACY OF TWO BIOFEEDBACK TECHNIQUES IN THE TREATMENT OF GENERALIZED ANXIETY DISORDER.

Byline: Hitanshu Agnihotri, Maman Paul and Jaspal S. Sandhu

The present study compared the efficacy of two most commonly used biofeed-back relaxation techniques in the treatment of Generalized Anxiety Disorder (GAD). Forty five individuals, recruited on the basis of Diagnostic and Statisti-cal Manual of Mental Disorders-IV Text Revision criteria (DSM-IV-TR; APA, 2000) were randomly assigned to three groups: Group I (n = 15) received Elec-tromyographic (EMG) biofeedback relaxation training; Group II (n = 15) re-ceived Alpha-Electroencephalographic (EEG) biofeedback relaxation training; and Group III (n = 15) was a control group. Both EMG and EEG groups re-sulted in more consistent pattern of generalized relaxation changes reflected in alpha-EEG activity, frontalis-EMG activity, systolic blood pressure and Com-prehensive Anxiety Test (CAT) score as compared to control group. Significant changes were also observed on comparing EMG and EEG groups. At follow-up, maintenance of effects was observed in both treatment groups.

Generalized Anxiety Disorder (GAD) is a prototypical anxiety disor-der twice more common in women than in men (Hidalgo & Davidson, 2001) . Criteria for the diagnosis of GAD emphasize the presence of unre-alistic or excessive worry and appre-hension (DSM-IV-TR; APA, 2000). The symptoms of GAD are commonly found in a primary care setting with associated somatic symptoms; includ-ing restlessness, fatigability, difficulty in concentrating, irritability, muscle tension and sleep disturbances. Pa-tients of GAD generally experience great impairment in their social and

physical functioning; therefore, it is imperative to search for an effective modality for its treatment (Culpepper, 2002).

Psychotherapy has shown long term benefits in the treatment of GAD and may be useful approach alone and as an adjunct to pharmacotherapeutic options (Allgulander et al., 2003; Durham, 2007; Falsetti & Davis, 2001; Gorman, 2002; Siev & Cham-bler, 2007). The current treatment models of GAD focus on several re-lated cognitive behavioral treatments.

EMG biofeedback mediated re-laxation is an extension of progressive relaxation and autogenic training (Townsend, House, John, & Addorio, 1975). On the other hand, EEG bio-feedback or Neuro-feedback training is an encouraging development that holds promise as a method for modi-fying biological brain patterns associ-ated with a variety of psychological and physical disorders particularly because it is non-invasive and seldom associated with even mild side effects (Hammond, 2005).

An ample volume of literature shows a particularly positive research support for EMG biofeedback (Raskin, Bali, & Peeke, 1980; Rice & Blanchard, 1982) as well as EEG bio-feedback relaxation trainings in the treatment of anxiety disorders (Hardt & Kamiya, 1978; Moore, 2000; Moore, 2005; Vanathy, Sharma, & Kumar, 1998) . In the past few dec-ades, research has compared the effec-tiveness of various biofeedback train-ings to other conventional methods of relaxation. However, very little re-search has compared the effectiveness of various biofeedback relaxation techniques in the treatment of anxiety disorders. Moreover, much of the re-search work in this arena has occurred before 1990's, with practically very few published studies in the interven-ing years (Moore et al., 2000; Rice, Blanchard, & Purcell, 1993; Thomas & Sattleberger, 1997). The ongoing research, thereafter, has shifted its focus on investigating the application of biofeedback in the treatment of other disorders.

The literature documents EMG biofeedback training is more effective method of relaxation than EEG bio-feedback training for drug users as well as normal subjects (DeGood & Chisholm, 1977; DeGood & Edward, 1981; Lamontagne, Hand, Annable, & Gagnon 1977; Rice & Blanchard, 1982). An eminent work in this field has been done by Rice, Blanchard, & Purcell (1993) who compared the effi-cacy of EMG biofeedback and EEG increase and decrease biofeedback treatments in generalized anxiety pa-tients. Significant decrease in anxiety as given in self report was observed in all treatments groups. However, no significant results were yielded in be-tween group comparisons. The reason for such findings can be attributed to the small sample size and shorter treatment duration. Moreover, all sub-jects did not have diagnosable level of GAD. Furthermore, most of the re-search on biofeedback treatment of GAD has been done prior to publica-tion of DSM-IV-TR (APA, 2000).

In the light of above review, the present study was undertaken to com-pare the efficacy of 12 sessions (25 minutes daily) of alpha-EEG increase biofeedback and frontalis-EMG de-crease biofeedback trainings each on alpha-EEG activity, frontalis-EMG activity, blood pressure and CAT score in the patients of GAD as de-fined by DSM-IV-TR criteria. The following hypotheses were sought to be tested: First, both training groups will show decreased level of anxiety post training as compared to the con-trol group. Second, any of the two training groups may be better in re-duction of anxiety levels.

Method

Sample

Announcements in the community were made about the availability of relaxation therapy for generalized anxiety problems of 18-30 years age-group. Out of 45 individuals (24 fe-males and 21 males), 15 each were randomly assigned to (a) Group-I: EMG biofeedback group; (b) Group-II: EEG group and (c) Group-III: con-trol group.

Inclusion Criteria

Inclusion Criteria was based on a semi-structured interview conducted to screen out the patients of GAD us-ing DSM-IV-TR criteria.

Exclusion Criteria

Subjects already practicing any form of relaxation technique or de-pending on anxiolytics were excluded.

Instruments

The following parameters were assessed at pre- and post-treatment.

1. Comprehensive Anxiety Test (CAT) Questionnaire (Sharma,Bhardwaj, & Bhargava, 1992) CAT score was calculated using a self-report measure. Anxiety of both the covert and overt type and state and trait type is measured by this test. Re-liability coefficient of test is found to be .83 by test-retest method and .94 by split half method. Validity of the test is determined by computing the corre-lation scores of the present test and other tests like STAI (r = .82) and anxiety dimension of eight state ques-tionnaire 'form A' (r = .74). The cho-sen test is particularly useful and ad-ministration age range is 18-50 years for males and females, which covers the age limit selected for the study.

2. Alpha-EEG activity was measured in micro-volts with Medicaid system Alpha-EEG Biofeedback Biotrainer EBF-5000.

3. EMG activity of frontalis muscle was recorded in micro-volts with Medicaid system EMG biofeedback Biotrainer MBF-4000.

4. Systolic blood pressure was meas-ured with sphygmomanometer.

Procedure

The study was approved by Insti-tutional Medical Ethics Committee of Guru Nanak Dev University, Amrit-sar, prior to the start of data collection. Patients were explained about the training and previous research sup-porting the effectiveness of biofeed-back training in causing relaxation. Only subjects who volunteered to par-ticipate in the study were recruited. A written informed consent was taken from each subject prior to the begin-ning of the training. Patients in two experimental groups were treated in-dividually for 12 successive days at Sports Psychology Laboratory, De-partment of Sports Medicine and Physiotherapy, Guru Nanak Dev Uni-versity, Amritsar. The treatment was given under controlled conditions. All treatment sessions, except the first and last, lasted approximately for 35 min-utes as the assessment was done on day 1 as well as day 12. After the ap-plication of electrodes, the patient was asked to sit comfortably for a 5 minute baseline period.

Then, followed a 25 minute phase of either of two biofeed-back trainings. All the patients were asked to practice relaxation at home once a day for 25 minutes. It was de-termined by the therapist whether each patient regularly practiced at home throughout the treatment period. The patients in the control group were given no treatment. All the parameters were measured on day 1 and day 12. However, the participants were taught Jacobson's Progressive Muscle Re-laxation after the completion of study on ethical grounds.

Frontalis EMG Biofeedback Training

A Medicaid system EMG Bio-feedback Biotrainer MBF-4000 device was used. The feedback was a visual display with 17 bars (11 green on left, 1 yellow in middle, and 5 red at right). The display showed green bars with decrease and red with increase in ten-sion of frontalis muscle, respectively. The patient was instructed to glow the green bars and not let the red bars to glow. Intermittent positive verbal rein-forcement was provided every few minutes by the therapist.

Alpha - EEG Biofeedback Training

Visual alpha enhancement bio-feedback training was given to the subject. A Medicaid Alpha-EEG Bio-feedback Biotrainer EBF -5000 device was used. The feedback display was similar to EMG feedback. The display showed green bars with increase and red with decrease in amounts of alpha activity, respectively. Similar positive intermittent instructions as for EMG group were given every few minutes by the therapist.

Follow-up

Two weeks after the completion of training all the patients of both treatment groups were again called for measurement of all the parameters.

Results

Intra-group comparisons were analyzed using paired t-test. Multi-variate ANOVA and Post Hoc Multi-ple Scheffe Tests were done pre- and post-treatment to find changes be-tween the groups.

CAT Score

Table 1 shows MANOVA com-parison at pre-treatment which yielded non significant differences between the groups, F = 2.70, p > .05. Intra group comparison of all three groups are shown in Figure 1, which revealed statistically significant de-crease in CAT score in EMG, t = 9.12, p < .001 and EEG, t = 7.46, p < .001, groups, while control group did not change significantly. MANOVA fol-lowed by Post Hoc Multiple Scheffe Range Test at post-treatment in Table 1 yielded EMG group to be at statisti-cally most significant level of relaxa-tion followed by EEG group, F = 26.25, p .05) at pre-treatment.

MANOVA at post-treatment with Post Hoc Multiple Scheffe Range Test, F = 153.37, p < .001, indicated EEGgroup to be at most significant level of relaxation followed by EMG group as shown in Table 1. Pre- to post-treatment comparison for EMG, t = 15.81, p < .001, and EEG, t = 13.73, p < .001, groups revealed statistically significant increase in alpha-EEG

Table 1

MANOVA between All Groups at Pre and Post-Treatment

Parameters###SS###MS###F###

EEG###Pre-treatment###181.64###90.82###0.50###

###Post-treatment###80.36###40178.87###153.37**###

EMG###Pre-treatment###22.71###11.35###2.15###

###Post-treatment###485,96###242.98###56.18**###

Systolic Blood###Pre-treatment###70.93###35.47###0.25###

pressure###Post-treatment###13333.51###666.76###4.05*###

Diastolic blood###Pre-treatment###236.98###118.49###1.10###

pressure###Post-treatment###526.80###263.40###2.67###

CAT Score###Pre-treatment###212.13###106.07###2.70###

###Post-treatment###2730.53###1365.27###26.25**

*p < .05. **p < .001.

Table 2

Inter Group Comparison for Alpha-EEG, Frontalis-EMG, Blood Pressure and CAT Score at Follow-up between EMG and EEG Groups

Parameters###EMG Group###EEG Group###t###

###M###SD###M###SD###

Alpha-EEG (micro-volts)###110.93###12.15###137.33###24.13###3.79**###

Frontalis-EMG (micro-###2.77###1.13###4.70###2.05###3.20*###

volts)###

Systolic blood pressure###118###12.56###117.20###6.75###0.22###

(mmHg)###

Diastolic blood pressure###74.80###9.56###77.20###4.95###0.86###

(mmHg)###

CAT score###22.73###7.28###26.27###8.41###1.23

*p< .05. **p < .001.

EEG activity followed by EMG group (155.31%) while, EMG group (75.64%) was most effective in reduc-ing frontalis-EMG activity followed by EEG group (59.65%). A feedback facilitates learning of any skill. Thus, feedback of physiological information of the patient assists him in gaining the self-regulation of the particular physiological process being monitored (Biswas, Biswas, & Chattopadhyay, 1995; Wenck, Len, & D'Amato, 1996). Substantial amount of research supports the findings of the present study (DeGood & Chisholm, 1977; Hardt, & Kamiya, 1978; Moore et al., 2000; Rice, Blanchard, & Purcell, 1993; Vanathy, Sharma, & Kumar, 1998; Sarkar, Rathee, & Neena, 1999).

A significant reduction in systolic blood pressure occurred in both EMG (10.18%) and EEG (10.13%) groups as shown through percentages calcu-

lated separately while control group showed a change of 1.20% only. For diastolic blood pressure, percentage decreased from pre- to post-treatment for EMG, EEG and control groups was found to be 14.40%, 11.45% and 1.20%, respectively. According to Singh and Sahni (2000), an increase in sympathetic activity increases heart rate, stroke volume and peripheral blood flow. One can monitor and through relaxation, control the effects of stress, tension or anxiety. The ex-tensive research work done in past on the impact of biofeedback training on hypertensives provides sufficient evi-dence to support these results (Blanchard, Haynes, Kallman, & Louis 1976; Datey, 1980; Jacob, Kraemer, & Agras, 1977; Najafian, & Hashemi, 2006; Taylor, Farquhar, Nelson, & Agras, 1977).

At follow-up, EMG group showed a change of 1.54% in alpha-EEG activity, 6.94% in frontalis-EMG activ-ity, 5.61% in systolic blood pressure, 4.36% in diastolic blood pressure and 9.27% in CAT score while EEG group showed a change of 4.71% in alpha-EEG activity, 25.66% in frontalis-EMG activity, 4.27% in systolic blood pressure, 3.95% in diastolic blood pressure and 9.78% in CAT score. Lamontagne et al. (1977) observed analogous findings. The reason for slight decrement at follow-up may be that the patients did not practice at home post-treatment. However, mean values indicated a significant level of relaxation as compared to pre-treatment values. Therefore, willing-ness on the part of the patient to par-ticipate in the treatment process, in-cluding compliance with home prac-tice, has a specific impact on the treat-ment efficacy of these techniques.

Decreased muscle tension through EMG biofeedback training leads to generalization of relaxation by de-creasing the signs of sympathetic and increasing the parasympathetic tone as well as by deactivation of hormonal signs of hypothalamic-pituitary adre-nal axis. A similar belief was pro-posed by Khanna, Paul, and Sandhu (2007) for progressive muscle relaxa-tion training. Sahni (2005) suggested that achievement of deep muscle re-laxation with electromyographic feed-back can contribute to overall level of relaxation and have significant clinical impact on stress related disorders.

EEG biofeedback training leads to operant conditioning and has been found to be effective in modifying brain functions associated with mental health and medical disorders (Hammond, 2005).

Conclusions

From the present study, it can be concluded that biofeedback treatment demonstrably leads to reduction in the anxiety levels. However, biofeedback training should be used in a manner specific to the individual patient's psy-chophysiological profile, i.e., patients experiencing symptoms of muscle tension should be treated with EMG biofeedback to reduce their muscle tension. An EEG component should be added, if assessment documents cerebellar dysfunction. Therefore, a thorough evaluation of each patient is mandatory before deciding the appro-priate biofeedback treatment for him. An attempt was made to address the methodological limitations of previous research on biofeedback treatment of anxiety disorders.

Limitations

Nonetheless, the present study has certain limitations. The future research should focus on a longer treatment duration as well as follow-up. The comparative efficacy of alpha de-crease and EMG decrease biofeedback relaxation trainings in the treatment of GAD also needs to be investigated. One avenue of additional investigation may be to assess whether serial appli-cation of EMG and EEG biofeedback relaxation trainings has any substan-tial effect on GAD patients.

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Received March, 2008

Hitanshu Agnihotri, Maman Paul, and Jaspal Singh Sandhu, Department of Sports Medicine and Physiotherapy, Guru Nanak Dev University, Amritsar, India.

Correspondence should be made to Maman Paul, Department of Sports Medicine and Physiotherapy, Guru Nanak Dev Univer-sity, Amritsar (Punjab), India-143005 E-mail: mamanpaul8@gmail.com
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