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Volume 31, Number 2 Summer, 2003

“The Greatest Thing,


Then, Is to Make the
Nervous System Our
“Miracles Do Not Ally Instead of Our
Happen in Contradiction Enemy.”
to Nature, but Only in – William James
Contradiction to That
Which Is Known to
Us About Nature.”
— Saint Augustine

Launching New
Paradigms of
Psychophysiological
Self-Regulation
FROM THE EDITOR

From the Editor


Donald Moss, PhD

Donald Moss, PhD

The cover of the Summer Issue shows a graphic developed by tion in individuals with ADHD. This first article provides a histo-
Lynda Kirk, AAPB’s new president, conveying the inspirational ry of the development of audio-visual stimulation and an overview
message of her inaugural remarks as president, at AAPB’s of the relevant basic science.
Jacksonville conference in March 2003. Seb Striefel provides an article outlining some of the effects of
This issue of Biofeedback has a number of special treats for read- the new federal privacy legislation (HIPAA) on clinical practice.
ers. Randy Neblett is the editor for surface EMG topics, and has Both patient confidentiality and record keeping are significantly
recruited two SEMG articles for this summer issue: an article dis- affected by HIPAA. Eric Willmarth a reviews a new book edited
cussing a new approach for removing cardiac artifact from SEMG and written by a number of AAPB members, The Handbook of
recordings, and an introduction to the newly emergent field of Mind-Body Medicine for Primary Care. Polina Cheng reports on
aquatic biofeedback—using surface EMG with patients in the the current uses of biofeedback in Hong Kong.
water! Finally, the News and Events section includes columns from
Katherine Gibney and Erik Peper provide a thought provoking AAPB’s new President, Lynda Kirk, the new President-Elect Steve
article on the “Medicine of Fun,” suggesting that biofeedback ther- Baskin, and AAPB’s Executive Director, Francine Butler. News and
apy does not have to be all serious work, and that playfulness has a Events also provides a photo collage from AAPB’s March annual
critical role to play in therapy and healing. Jeff Leonards begins a meeting in Jacksonville, Florida, and a summary of awards present-
new series of articles on Sports Psychophysiology, with a review of ed in Jacksonville.
current approaches applying biofeedback and psychophysiology to Proposals and Abstracts are now invited for special issues on:
sports. David Siever also begins a new series, with an introduction Complementary and Alternative Medicine for Fall 2003, and Case
to the exciting use of audio-visual stimulation to entrain the brain Studies in Clinical Psychophysiology in Spring 2004. The editor also
therapeutically. AVS has been shown to be useful in a number of welcomes proposals for future special issues of the Biofeedback
applications, ranging from: 1) more effective induction of hypno- Magazine.
sis, to 2) assisting relaxation and sedation, to 3) improving atten-

2 Biofeedback Summer 2003


Biofeedback
Volume 31,
FROM THE EDITOR
No 2
From the Editor: Donald Moss, PhD 2
Summer 2003
Biofeedback is published four times per year and \ PROFESSIONAL ISSUES
distributed by the Association for Applied Psycho-
physiology and Biofeedback. Circulation 2,100. Confidentiality and Psychotherapy Notes 4
ISSN 1081-5937.
Sebastian Striefel
Editor: Donald Moss PhD
Associate Editor: Theodore J. LaVaque, PhD ADVANCED TOPICS:
sEMG Section Editor: Randy Neblett, MA
EEG Section Editor: Dale Walters, PhD
SURFACE ELECTROMYOGRAPHY
Reporter: Christopher L. Edwards, PhD
Reporter: John Perry, PhD Removing ECG Artifact from the Electromyographic Recording 6
Managing Editor: Michael P. Thompson Thomas W. Spaulding, Lawrence M. Schleifer, EdD, Bradley
D. Hatfield, PhD, Scott Kerick, PhD, and Jeffrey R. Cram, PhD
Copyright © 2003 by AAPB
Surface EMG and the Evolution of Aquatic Biofeedback 11
Editorial Statement
Ron Fuller, BA, PTA
Items for inclusion in Biofeedback should be for-
warded to the AAPB office. Material must be in pub- FEATURE ARTICLES
lishable form upon submission.
Deadlines for receipt of material are as follows:
• November 1 for Spring issue,
Exercise or Play? Medicine of Fun 14
published April 15. Katherine Gibney and Erik Peper
• April 1 for Summer issue, Sport Psychophysiology: I. The Current State of Biofeedback 18
published August 5. with Athletes
• May 15 for Fall issue, Jeff Leonards
published September 15.
• September 1 for Winter issue, Audio-Visual Entrainment: I. History and Physiological Mechanisms 21
published January 15. David Siever
Articles should be of general interest to the
AAPB membership, informative and, where possi-
ble, factually based. The editor reserves the right to
BOOK REVIEW AND BRIEF FEATURES
accept or reject any material and to make editorial
and copy changes as deemed necessary. Review of Handbook of Mind Body Medicine for Primary Care 28
Feature articles should not exceed 2,500 words; Eric Willmarth
department articles, 700 words; and letters to the Biofeedback in Hong Kong 30
editor, 250 words. Manuscripts should be submitted
on disk, preferably Microsoft Word or WordPerfect,
Polina Cheng
for Macintosh or Windows, together with hard copy Upcoming Workshops 32
of the manuscript indicating any special text for-
matting. Also submit a biosketch (30 words) and AAPB NEWS AND EVENTS
photo of the author. All artwork accompanying
manuscripts must be camera-ready. Graphics and
photos may be embedded in Word files to indicate From the President 1A
position only. Please include the original, high-res- Awards and Recognition at the AAPB Annual Meeting 3A
olution graphic files with your submission – at least
266dpi at final print size. TIFF or EPS preferred.
From the President-Elect 4A
AAPB is not responsible for the loss or return of
unsolicited articles.
Biofeedback accepts paid display and classified About the Authors: Profiles of Contributors 31
advertising from individuals and organizations pro-
viding products and services for those concerned
with the practice of applied psychophysiology and
Biofeedback. Inquiries about advertising rates and
discounts should be addressed to the Managing
Editor.
Changes of address, notification of materials not
received, inquiries about membership and other
matters should be directed to the AAPB Office:

Association for Applied


Psychophysiology and Biofeedback
10200 West 44th Ave., No. 304
Wheat Ridge, CO 80033-2840
Tel 303-422-8436
Fax 303-422-8894
The articles in this issue reflect the opinions of the authors, and do not
E-mail: aapb@resourcenter.com reflect the policies or official guidelines of AAPB, unless stated otherwise.
Website: http://www.aapb.org

Summer 2003 Biofeedback 3


PROFESSIONAL ISSUES

Confidentiality and Psychotherapy


Notes
Sebastian “Seb” Striefel, PhD, Logan, UT

Abstract: Confidentiality and trust are con- the information given by a police officer for protecting psychotherapy notes.
sidered to be critical components of psychother- (Mary Lu Redmond) to her therapist (a HIPAA established a new floor of protec-
apy, for without them clients may withhold licensed social worker) in confidence from tion for PHI. The regulations provide some
information that is critical to successful treat- being disclosed in a lawsuit (privileged helpful provisions for protecting confiden-
ment. The US Supreme Court has acknowl- communication) brought against her by the tiality, psychotherapy notes being one of
edged the importance of privileged family of a man she shot and killed in the those provisions. However, some argue that
communication (confidentiality in a legal pro- line of performing her police duties. The the core protection of privacy is missing
ceeding) and made a decision that binds all decision is binding only in federal courts, because informed consent from the client is
federal courts in both civil and legal cases to but the court ruled that the privilege is not not required before sharing PHI for treat-
confer privilege communication status to subject to a decision by individual judges ment, payment, or other health operations
information shared by a client with his or her on a case-by-case basis, rather it is binding (all defined in the regulations). Many pro-
licensed psychotherapist in confidence during in all federal civil and criminal cases (Corey, fessionals who commented on the original
counseling. More recently, HIPAA has recog- Corey, & Callanan, 1998). Each state court proposed regulations argued that requiring
nized the importance of confidentiality for can still decide whether to ignore or accept written informed consent in these areas
psychotherapy notes within certain guidelines. the decision in cases they preside over would be difficult to get and too costly
Psychotherapy notes can be protected if certain (Kitchener, 2000). (Basler, 2003). The US Department of
rules are followed, such as keeping them in a As such, practitioners still need to take Health and Human Services (HHS) agreed
separate file. Practitioners may well want to care to inform clients about the limits of that requiring informed consent before pro-
advocate for more stringent state laws to deal confidentiality, and exercise caution when ceeding in treatment could negatively
with the deficits in HIPAA for protecting receiving a subpoena for their psychothera- impact access, quality, and timeliness of
client confidentiality. When more stringent, py notes or testimony. There is always a services so they changed the regulations (45
state law supercedes HIPAA. concern whether a specific court will grant CFR Parts 160-164). For example, pharma-
the psychotherapy notes privileged commu- cists could not fill a prescription until the
Introduction nication status in a particular situation client came in and gave his or her consent;
In 1996 the US Supreme Court in Jaffee (DeBell & Jones, 1997). hospitals could not prepare for admitting a
v. Redmond ascribed the importance of priv- client for a procedure based on a physician’s
ileged communication to the communica- Health Information referral unless the patient came in and
tion that occurs between a licensed mental Portablility and signed a consent form first (perhaps they
health therapist and his or her patient when
that communication occurs in confidence as Accountablility Act have never heard of a fax machine or e-mail
signatures); and emergency room personnel
a part of a counseling (or psychotherapy) (HIPPA) were concerned that even getting consent as
session (Kitchener, 2000). In that ruling the HIPAA defines Protected Health soon as reasonably practical after an emer-
Supreme Court recognized that confiden- Information (PHI) as anything that gency would be an administrative burden.
tiality and trust are essential to the relation- includes information that could identify a So, the regulations were changed.
ship that a licensed therapist has with a patient (e.g., name, address, phone number, Mandatory consent for treatment, payment,
patient. The decision acknowledged that social security number, insurance number, and health operations was replaced by vol-
privacy is essential for psychotherapy to be etc.) (45 CFR 164.502). Such information untary consent at the provider’s option,
effective, essential for the patient to trust is to be protected by practitioners and is allowing them to obtain consent so as not
the relationship, and important to society as considered to be confidential. Non-identify- to disrupt treatment that they deem needed
well (Kitchener, 2000). ing information is not protected. The new (45 CFR Parts 160-164), thus largely ignor-
In practical terms, the decision prevented HIPAA regulations provide a new avenue ing the client’s right to confidentiality and

4 Biofeedback Summer 2003


the right to be involved in making decisions It is important for practitioners to they must be kept in a file separate from the
about their own health. remember that just because something is rest of the client’s record. If not kept sepa-
Each of the arguments given for changing not prohibited by law (i.e., is allowed legal- rate, the information may well be accessed
the regulations to not mandate informed ly), does not make it ethical. AAPB’s old without specific authorization by the client.
consent seems to be a convenience issue for and new (AAPB, 1995, in press) ethical In addition, certain information is not con-
practitioners who resist making changes in codes expect biofeedback practitioners to sidered to be part of the psychotherapy
the way they do things. This really brings inform clients about the limits of confiden- notes and does not require a separate
into question the ethics of practitioners. tiality, to do all they can to protect confi- patient authorization for release. That infor-
Clearly, practitioners need to be able to deal dential information, and to obtain mation includes:
with emergency treatment issues in a timely informed consent as an ongoing part of 1. Medical prescriptions and monitoring;
manner, but not mandating informed con- assessment and treatment. The American 2. Counseling session start and stop
sent before treatment in non-emergency sit- Psychological Association’s (2003) code of times;
uations sets the stage for infringing more ethics has similar expectations for psycholo- 3. Modalities and frequency of treatment;
and more on patients’ rights to autonomy. gists (APA, 2003). Aspire to the highest 4. Results of clinical tests (testing infor-
It seems that some practitioners are more level of ethical functioning. mation); and
than willing to compromise client confiden- 5. Any summary of diagnosis, functional
tiality when it makes their job easier and
Psychotherapy and status, treatment plan, symptoms, and
more convenient. Ethics codes generally Psychotherapy Notes prognosis or progress (Halloway,
make clear that clients have a right to Protecting confidentiality becomes espe- 2003b).
expect confidentiality unless the client is a cially important when dealing with very The APA argues that testing information
danger to self or others, an emergency sensitive information as often happens in and the theme of psychotherapy should be
exists, breaching confidentiality is required psychotherapy. As already mentioned, trust protected because they include the gist of
by law, or the client signs a release of infor- and confidentiality are essential to effective sensitive information (Halloway, 2003b).
mation form. Clients have always had a psychotherapy. Clients may well not be APA suggests that such information not be
right to be informed about what the limits frank and may not completely disclose all of released without a signed release by the
of confidentiality are, e.g., if and what kind the information needed by the therapist if patient (Halloway, 2003b).
of information is to be shared for treat- they believe the information will not be It should be recognized that practitioners
ment, payment or other purposes. kept confidential (Corey et al., 1998). should not automatically keep two records
According to Richard Sobel, a senior Supreme Court Justice, John Paul Stevens on every client, one for psychotherapy and
research associate of the psychiatry and law in Jaffee v. Redmond said, “effective psy- one for other information (Halloway,
programs at the Harvard Medical School, chotherapy depends upon an atmosphere of 2003b). A separate psychotherapy note
HIPAA makes it easier for practitioners and confidence and trust in which the patient is record should be kept only if sensitive infor-
Managed Care Organizations (MCOs) to willing to make frank and compete disclosure mation is included in the record. If sensitive
do a broad disclosure rather than to get of facts, emotions, memories, and fears” information arises during treatment, a prac-
informed consent. You yourself may have (Corey et al., 1998, p. 157). titioner can then create a separate file for
received a disclosure statement from your HIPAA requires the specific authorization psychotherapy notes from that date on and
health insurance provider or doctor in the of the client (via a signed release) for the then the HIPAA protections apply.
mail recently. Would you want to receive use and disclosure of psychotherapy notes Managed Care Organizations (MCOs) are
treatment without any further input? for treatment, payment, and other health barred from making payment contingent on
Hopefully, practitioners will strive to the operations (45 CFR 164, 508 (a) (2)). This a patient authorizing access to psychothera-
highest level of ethical functioning by aspir- sounds simple, but it isn’t. Several condi- py notes (Halloway, 2003a).
ing to involve patients by getting informed tions must be met in order for this require-
consent wherever possible before initiating ment to apply. The first is the definition of Minimally Necessary
treatment, billing or other health opera- psychotherapy notes. Psychotherapy notes Another HIPAA provision bars MCOs
tions. are defined as, “notes recorded in any medium from requesting information beyond what
HIPAA legally allows professionals to dis- by a mental health professional documenting is “minimally necessary” for payment and
cuss a patient’s condition or treatment at or analyzing the contents of a conversation other administrative tasks (Halloway,
nursing stations, over the phone, with during a private counseling session” 2003a). MCOs cannot request the com-
another provider, or with a family member (Halloway, 2003b, p. 22). Psychotherapy plete record. Unfortunately, the law did not
without taking any precautions to prevent notes may well contain sensitive informa- define what “minimally necessary” means. As
the information from being overheard by tion and impressions that are not appropri- such, practitioners and MCOs are likely to
others (45 CFR Parts 160-164). Such ate for placement in the medical record or define it differently. So HIPAA does not
behavior may be legally acceptable, but is it general client file. For special consideration, prevent too much information from going
ethically acceptable? and for a signed authorization for release by
the client to apply to psychotherapy notes, Continued on page 10

Summer 2003 Biofeedback 5


ADVANCED TOPICS:
SURFACE ELECTROMYOGRAPHY

Removing the Influence of the


Heart from Surface-Recorded EMG
Thomas W. Spalding, PhD, Pomona, California,i Thomas W. Spalding, PhD

Lawrence M. Schleifer, EdD, Bradley D. Hatfield, PhD,


Scott Kerick, PhD, College Park, Maryland,
and Jeffrey R. Cram, PhD, Nevada City, CA
Abstract: Electrocardiographic (ECG) arti- EMG records (panels C and
fact is commonly observed in EMG recorded D). It is typically not observed
from the torso and is a potentially serious in EMG recorded from the
measurement problem, especially when muscle forearms unless a wrist-to-
activity is low. This artifact may result in wrist configuration is used
over-estimation of absolute EMG levels, and (Cram, Kasman, & Holtz,
in the identification of right/left muscle asym- 1998).
metry levels where none exist. A novel method The magnitude of the ECG
of removing ECG artifact is described in this artifact may be quite large rel- Bradley D. Hatfield, PhD Lawrence M. Schleifer,
article. An evaluation, the results of which are ative to that of the EMG sig- EdD
presented herein, indicates that (1) the new nal, especially when muscle
method is effective in removing ECG artifact activity is low (as during
from surface-recorded EMG and (2) the pres- biofeedback training), and
ence of ECG artifact results in a significant therefore poses a potentially
overestimation of mean resting EMG levels. serious measurement problem.
It is well known that the heart produces a If ignored, ECG artifact may
strong electrical signal that may contami- result in a significant overesti-
nate surface-recorded EMG. The waveforms mation of EMG activity levels.
introduced into an EMG record by cardiac Further, the asymmetry in the
activity are known as electrocardiographic magnitude of the artifact
(ECG) artifact. This source of noise is a recorded from homologous
concern whenever EMG is recorded from sites on the left and right sides
muscles in the torso of the body. An exam- of the body may yield an Scott Kerick, PhD Jeffrey R. Cram, PhD
ple of ECG artifact is illustrated in Figure apparent asymmetry in
1. This figure shows a 3-second sample of observed EMG levels when
EMG obtained from the upper left- and none actually exists. backs. Filtering the EMG signal to pass fre-
right-trapezius muscles and left- and right-
forearm extensor muscles of a 40-year-old
Limitations of the quencies >80 Hz will substantially reduce, if
not largely eliminate, ECG artifact.
man during seated rest. The corresponding Currently Available However, as a significant amount of the
ECG is also shown. ECG artifact is clearly Methods for Eliminating EMG signal (power) resides at frequencies
evident in the left trapezius muscle (panel
A). To a lesser extent, it is also evident in
or Reducing ECG Artifact below 80 Hz, high-pass filtering will attenu-
Currently, methods for eliminating or ate the signal and, hence, result in a loss of
the right trapezius muscle (panel B). information. The second strategy – gating –
However, it should be noted that the arti- reducing ECG artifact are largely limited to
high-pass filtering and “gating” (Schweitzer, involves excluding ECG-contaminated
fact is not always observed in right trapezius epochs of EMG from further processing and
EMG. In contrast to the trapezius muscles, Fitzgerald, Bowden, & Lynne-Davies,
1979). Both methods have serious draw- analysis. Hence, it results in a loss of data.
ECG artifact is not evident in the forearm

6 Biofeedback Summer 2002


The loss of data will be greater at higher merely educate the patient about this phe- Description of the
heart rates and, at high heart rates there may nomenon. However, it may no longer be
not be enough data to analyze or yield reli- necessary to accept ECG artifact as a fact of
New Technique
able estimates of EMG activity levels. life. A satisfactory solution to the ECG-arti- The method was first proposed by Bloch
In light of the drawbacks of filtering and fact problem now seems possible. Recently, (1983) as a means of eliminating ECG arti-
gating, it is difficult to know what to do we have explored a novel method of remov- fact from diaphragm EMG. It essentially
about ECG artifact. Not infrequently, the ing ECG artifact from EMG that does not involves electronically extracting epochs of
artifact is simply ignored. The sense of resig- appear to suffer from the drawbacks of cur- EMG data that contain an ECG artifact
nation regarding this problem is reflected in rently available techniques. The method is (see Figure 2); aligning those epochs on a
Cram et al. (1998, p. 67), an introductory an adaptation of a technique developed in readably identifiable feature of the artifact,
book on surface electromyography, in which the context of respiratory research (Bloch, such as the R-wave peak; and ensemble-
the authors note that many practitioners 1983). In this article we will describe the averaging the epochs. The result is a wave-
accept the ECG artifact as a fact of life and method and present some data which form that reveals the average shape of the
demonstrates its effectiveness. ECG artifact in the EMG record. Values of
the ensemble average will be approximately
0 when ECG contamination is absent and
nonzero when ECG contamination is pres-

Figure 1. A 3-second sample of left (A) and right


(B) upper trapezius EMG, left (C) and right (D)
forearm extensor EMG, and ECG (E) obtained Figure 2. Epochs of upper left trapezius EMG and the associated ensemble-averaged waveform. Each epoch
from a 40-year-old man during seated rest. EMG consists of 751 data points containing an ECG artifact: 250 points preceding the ECG R-wave peak and
signals were filtered, passing frequencies between 10 500 points after the R-wave peak. Each epoch is aligned on the R-wave peak. Ensemble-averaging proceeds
and 300 Hz, and sampled at 1 kHz. ECG was fil- by averaging data points at time 1 across all of the available epochs (i.e., epochs = 1 to N; N = number of
tered, passing frequencies between DC and 500 Hz. ECG artifacts in the measurement interval) and then repeating the averaging process for each of the
ECG artifact (indicated by arrows) is evident in the remaining data points in the epoch (i.e., time = 2 to 751). In this example, the result is an ensemble-aver-
left and right upper trapezius EMG but is more aged waveform with a length of 751 points that represents the average influence of the ECG activity on
prominent in the left upper trapezius muscle. No EMG activity. The expectation is that values in the ensemble-average will approximate 0 except when ECG
ECG artifact is present in the forearm EMG. activity is influencing the EMG.

Summer 2002 Biofeedback 7


correlation procedure may not be reliable
when applied to surface-recorded EMG,
especially if muscle activity levels are rela-
tively high or episodes of high activity are
evident. As we were interested in assessing
trapezius EMG during psychological stress
in computer work (Schleifer, Spalding,
Hatfield, Kerick, & Cram, 2001), we
expected to observe relatively high EMG
activity levels during the periods in which
participants were typing on the computer
keyboard. Secondly, the subtraction proce-
dure was simplified. In the previous studies
the subtraction template was adjusted via
regression to account for variation in the
observed ECG artifacts introduced by respi-
ration-related movements of the wire elec-
trodes. As surface electrodes are less
vulnerable than esophageal wire electrodes
to such movement artifact, this adjustment
was deemed unnecessary.
Evaluation of the
Ensemble-Average-Based
Subtraction Method
In order to determine if our method was
Figure 3. An epoch of upper left-trapezius EMG with a prominent ECG artifact (A), associated ensemble-
effective in removing ECG artifact from
averaged waveform (B), and corrected EMG series (C). The corrected EMG was obtained by subtracting
values of the ensemble average within the subtraction template (indicated by the vertical lines) from the surface-recorded EMG we compared con-
ECG-contaminated EMG. The corrected EMG series (C) shows that the ECG artifact has been completed taminated-, gated-, and corrected-EMG on
removed without a loss of data or information. mean activity level (mV rms). Left upper
trapezius EMG and ECG data were
acquired from 21 women (n = 17) and
ent. In the final step a subtraction template, Bartolo, Roberts, Dzwonczyk, & Goldman,
men, aged 18 to 49 years (M = 28.3, SD =
which represents the artifact (i.e., the 1996). We have recently adapted the tech-
9.1), during 5 minutes of rest while seated
nonzero portion of the ensemble-averaged nique to surface-recorded EMG (Spalding,
and with hands in the lap. Both signals
waveform), is aligned with each artifact in Kerick, Hatfield, Schleifer, & Cram, 2001).
were sampled at 1 kHz. The EMG data
the EMG record and subtracted from it, Our method differs from that employed in
were dual-pass filtered, passing frequencies
yielding an artifact-free data series. Figure 3 the respiratory research in two ways. First,
of 20-300 Hz. The data were dual-pass fil-
shows a sample of contaminated left-trapez- we recorded the ECG with a standard con-
tered because the initial (forward) filtering
ius EMG with the associated ensemble- figuration of chest electrodes and used it to
introduces a phase shift or a displacement
averaged waveform (with the subtraction unambiguously identify R-wave peaks in
of the series in time. This time displace-
template marked) and the corrected EMG. the EMG records. R-wave peaks were used
ment is highly undesirable in our applica-
to align epochs of contaminated EMG for
Adaptation of the Method ensemble-averaging and to align the sub-
tion. Hence, the data were filtered again,
to Surface-Recorded backwards, to correct the phase shift. The
traction template with individual artifacts
filtered data constituted the contaminated
EMG in the EMG record. ECG was not recorded
series. These data were further processed to
Variations of this basic method have been in the previous respiratory studies. In these
create the gated and corrected series. As
employed successfully in respiratory studies contaminated EMG epochs were
indicated above, gating involves excluding
research to remove ECG artifact from identified and aligned via a cross-correlation
from further analysis those epochs of EMG
diaphragm EMG obtained with esophageal procedure. This procedure is probably ade-
data that are contaminated by ECG artifact
wire electrodes in humans (Levine, Gillen, quate when applied to diaphragm EMG
(Schweitzer et al., 1979). Previous investiga-
Weiser, Gillen, & Kwatny, 1986) and hook obtained with wire electrodes during expira-
tors (Levine et al., 1986; Schweitzer et al.,
electrodes in anesthesized dogs (Bartolo, tion. Diaphragm EMG is quiescent during
1979) excluded epochs of a constant length
Dzwonczyk, Roberts, & Goldman, 1996; expiration and ECG artifacts can be identi-
(i.e., 380 ms). However, we determined the
fied unambiguously. However, the cross-

8 Biofeedback Summer 2002


“gate” length empirically for each partici- al., 1996). Our results indicate that, when high heart rates, there may be an insuffi-
pant individually as the interval between the ECG-to-EMG power ratio is high (as it cient amount of data to analyze.
the onset and offset of the nonzero portion typically will be in biofeedback applica- In contrast, high-pass filtering (e.g., pass-
of the ensemble average. Gated series were tions), ECG artifact will be a significant ing frequencies > 80 Hz) does not result in
included in the analysis in order to estimate measurement problem and should not be a loss of data or produce discontinuities in
the mean level of the true, uncontaminated ignored. In our study ECG contamination the data series. However, it does significant-
muscle activity. Although the true mean resulted in overestimating mean left-trapez- ly attenuate the signal and results in a loss
activity level cannot be known, it seems rea- ius EMG activity levels by 2.2 :V rms. As of information contained in the EMG spec-
sonable to estimate it using the gated series. mean resting levels of trapezius EMG activi- trum below the cutoff frequency. Further, at
As the participants were in a stable posture ty range from 2 - 5 mV, this error is quite low muscle activity levels such as in
and state (i.e., relaxed and behaviorally large. As a percentage of the estimated true biofeedback applications, high-pass filtering
inactive) throughout the recording period, mean level (i.e., 3.2 mV rms), the magni- may result in a disproportionately large loss
it is reasonable to expect that their EMG tude of overestimation was 69%. of information, as the relative amount of
activity was stable and, as such, the true Advantages of the Method power in lower frequencies is greater at
activity level in the contaminated epochs Our method is procedurally more com- lower levels of muscle activity. With the
(which cannot be known definitively) plicated than filtering or gating. The reader ensemble-average-based technique there are
should be similar to that in the artifact-free may, therefore, question the utility of the no restrictions on filter settings. The clini-
epochs. Hence, excluding contaminated technique. The primary advantage of the cian or investigator is free to set the high-
epochs of EMG should not bias the esti- method is that it eliminates ECG artifact pass filter cutoff frequency at or near the
mate of the true mean activity level. Finally, while preserving the continuity of the data lower boundary of the EMG spectrum (e.g.,
the corrected series were constructed by series (i.e., no data are lost) and retains 10 - 20 Hz). Hence, the ensemble-average-
removing the ECG artifact using the information in the lower frequencies of the based technique should enable more of the
ensemble-average-based subtraction tech- EMG spectrum. In contrast, gating results EMG signal to be preserved. The amount
nique. We expected that, if the ensemble- in a loss of data as well as produces discon- of signal preserved will, of course, depend
average method was effective, the mean of tinuities in the data series. The loss of data on how low the high-pass filter cutoff fre-
the corrected EMG series would be similar may be substantial. Assuming a constant quency is actually set.
to that of the gated data and, further, that gate length of 380 ms as employed by It is worth noting that the ensemble-aver-
both means would be lower than that of the Schweitzer et al. (1979), a heart rate of 60 age-based technique is applicable to surface-
contaminated series. The results supported bpm would result in a data loss of 38%. At recorded EMG obtained from any muscles
this expectation. a heart rate of 80 bpm, more than half of the torso and with any high-pass filter
cutoff frequency settings between 1 Hz and
Comparison of Mean (51%) of data will be lost; at 100 bpm, the
80 Hz. The shape and magnitude of ECG
loss of data reaches 63%. Hence, even for
EMG Activity Levels for heart rates that are commonly observed at artifact will vary, depending upon the mus-
Corrected, Gated, and rest, gating results in a substantial loss of cle being measured and the filter settings.
However, this is not a concern because the
Contaminated Series data. It would seem that such losses would
technique does not require any assumptions
Mean EMG activity levels of the correct- seriously compromise the reliability of
measures of activity levels. Additionally, at about the shape or magnitude of the arti-
ed, gated, and contaminated series are fact. The only requirements are that arti-
shown in Figure 4. Consistent with our facts be reliably identified and aligned for
expectations, mean activity levels of the cor- averaging and subtraction, and that the sig-
rected and gated EMG series were similar nal amplification is set such that the analog-
(identical, in fact) and both means were sig- to-digital converter does not saturate.
nificantly lower than that of the contaminat- Additionally, a high-pass filter with a cutoff
ed series. These results indicate that the frequency of at least 1 Hz should be
ensemble-average-based subtraction tech- employed in order to ensure that the EMG
nique effectively removed ECG artifact from series is centered about a mean of 0.
left-trapezius EMG and yielded an estimate Otherwise, the method should adequately
of mean activity equivalent to that of the model the shape of the artifact. Although
true uncontaminated EMG activity level. only one component of the ECG waveform
Discussion Figure 4. Mean (+/-SE) corrected, gated, and
(i.e., the QRS complex) was observed in
The influence of ECG artifact on meas- our trapezius data, it is possible that, in
ECG-contaminated upper left-trapezius EMG
ures of EMG activity may depend on the activity levels. The mean activity level of the cor-
other circumstances, additional components
magnitude of the ECG signal relative to rected EMG series was significantly lower than that (e.g., P- or T-waves) could be observed. The
that of the EMG signal (i.e., the signal-to- of the contaminated series and was identical to that ensemble-average-based technique should
noise or ECG-to-EMG ratio) (Bartolo et of the gated series. easily accommodate multiple components.

Summer 2003 Biofeedback 9


Application of the Ensemble- Bartolo, A., Roberts, C., Dzwonczyk, R. R., & Spalding, T. W., Kerick, S., Hatfield, B. D.,
Goldman, E. (1996). Analysis of diaphragm EMG Schleifer, L. M., & Cram, J. R. (2001, August).
Average-Based Method in signals: comparison of gating vs. subtraction for Cardiac signal artifact and the interpretation of
Clinical Biofeedback removal of ECG contamination. Journal of Applied trapezius muscle activity during computer work. Paper
In our study the ensemble-average-based Physiology, 80(6), 1898-1902. presented at the 9th International Conference on
Cram, J. R., Kasman, G. S., & Holtz, J. (1998). Human-Computer Interaction, New Orleans,
technique was applied off-line. To be of use Louisiana.
Introduction to surface electromyography.
in clinical biofeedback it must be applied Gaithersburg, MD: Aspen Publishers, Inc.
on-line and in real-time. Unfortunately, soft- Levine, S., Gillen, J., Weiser, P., Gillen, M., & Acknowledgment
ware for removing ECG artifact on-line (or Kwatny, E. (1986). Description and validation of This research was supported by a grant
off-line) is not available commercially. an ECG removal procedure for EMGdi power spec- (#99-0001) from The Johns Hopkins
trum analysis. Journal of Applied Physiology, 60(3),
However, it seems quite possible to adapt University Center for Information
1073-1081.
the method for on-line, real-time applica- Schleifer, L. M., Spalding, T. W., Hatfield, B. Technology and Health Research.
tions. Given the strong interest in muscles of D., Kerick, S., & Cram, J. R. (2001, August).
the torso (e.g., trapezius muscles), the ubiq- Muscle activity of the upper extremities under high
Footnotes
and low mental demands during computer work:
i Direct correspondence to: Thomas W.
uitousness of ECG artifact, and the draw-
Preliminary findings. Paper presented at the 9th Spalding, PhD, Department of Kinesiology
backs of filtering and gating; it would seem International Conference on Human-Computer
that there is a large need for such software. and Health Promotion, California State
Interaction, New Orleans, Louisiana.
Schweitzer, T. W., Fitzgerald, J. W., Bowden, J.
Polytechnic University, 3801 West Temple
Future Research A., & Lynne-Davies, P. (1979). Spectral analysis of Avenue, Pomona, California 91768.
Further research is needed in at least human inspiratory diaphragmatic electromyograms. Telephone: 909-869-2772, FAX: 909-869-
three areas. First, it is known that there are Journal of Applied Physiology, 46, 152-165. 4797, Email: twspalding@csupomona.edu
large individual differences in resting heart
rate. The effect of such individual differ-
ences on measures of EMG activity, in both
the time- and frequency-domains (e.g.,
mean level in mV rms versus mean frequen- Confidentiality and Psychotherapy Notes
cy, respectively), is not known and merits continued from Page 5
investigation. Secondly, is there a threshold
for the ratio of ECG power-to-EMG power to MCOs, but it does provide grounds for a
beyond which the effect of ECG contami- References
practitioner to refuse to give some informa- American Psychological Association. (2003).
nation is negligible? For example, if EMG tion (Halloway, 2003a). The courts and Ethical principles of psychologists and code of conduct.
activity is high relative to the ECG signal, HHS will ultimately provide guidance on Washington, DC: Author.
can ECG artifact be ignored? The answer how to define “minimally necessary” Association for Applied Psychophysiology and
may depend on whether a time- or a fre- Biofeedback. (1995). Ethical principles of applied
(Halloway, 2003a). psychophysiology and biofeedback. Wheat Ridge, CO:
quency-domain measure is being consid- Interestingly, New Jersey’s psychology Author.
ered. Lastly, it is unclear if individual licensing law specifies that MCOs can Association for Applied Psychophysiology and
differences in resting heart rate have a detri- request only: administrative and diagnostic Biofeedback. (in press). Ethical principles of applied
mental effect (via ECG artifact) on skill information, the status of the patient, rea-
psychophysiology and biofeedback. Wheat Ridge, CO:
acquisition in EMG biofeedback training Author.
sons for continuing treatment (limited to Basler, B. (2003, April). Medical privacy
and/or treatment outcomes (e.g., pain rat- assessment of the patient’s level of function- improves – But, alas, not enough. AARP Bulletin,
ings). Further research in these areas will ing and distress), and a prognosis 44 (4), 12.
likely clarify the extent and nature of the (Halloway, 2003a). How well the law will Corey, G., Corey, M. S., & Callanan, P. (1998).
measurement problem that ECG artifact work remains to be seen. It should be Issues and ethics in the helping professions (5th Ed.).
poses and its impact on biofeedback therapy Pacific Grove, CA: Brooks/Cole Publishing
remembered that anytime a state law is Company.
and applied psychophysiology. more stringent than the requirements in DeBell, C., & Jones, R. D. (1997). Privileged
References HIPAA, state law supercedes HIPAA. It communication at last? An overview of Jaffee v.
Bloch, R. (1983). Subtraction of electrocardio- could be useful for practitioners to correct Redmond. Professional Psychology: Research and
graphic signal from respiratory electromyogram. Practice, 28, 559-566.
the problems inherent in HIPAA by getting
Journal of Applied Physiology: Respiratory, Halloway, J. D. (2003a, Feb.). More protections
Environmental, and Exercise Physiology, 55(2), 619-
more stringent state laws passed. Perhaps for patients and psychotherapy under HIPAA.
623. the New Jersey law could be used as a start- Monitor on Psychology, 34(2), 22.
Bartolo, A., Dzwonczyk, R. R., Roberts, C., & ing point. Halloway, J. D. (2003b, March). A stop-gap in
Goldman, E. (1996). Description and validation of flow of sensitive patient information. Monitor on
a technique for the removal of ECG contamination Monitor on Psychology, 34(2), 22. Psychology, 34(2),
from diaphragmatic EMG signal. Medical and 22. Monitor on Psychology, 34 (3), 22.
Biological Engineering and Computing, 34(1), 76-81. Kitchener, K. S. (2000). Foundations of ethical
practice, research, and teaching in psychology.
Mahwah, NJ: Lawrence Erlbaum Associates.

10 Biofeedback Summer 2003


ADVANCED TOPICS:
SURFACE ELECTROMYOGRAPHY

Surface EMG and the Evolution of


Aquatic Biofeedback
Ron Fuller, BA, PTA
Ron Fuller, BA, PTA, Concord, New Hampshire
Abstract: The union of aquatic therapy and hybrid of sorts, created out of necessity, it is (Figure 3). The corresponding (outer) elec-
surface EMG was derived out of necessity in a marriage of the two rehabilitative entities trode wires are plugged into the EMG unit,
order to help validate the effects of aquatic that offers patients the best of both worlds. and after the correct parameters are pro-
therapy exercise and to qualify its outcomes. The aquatic environment provides buoyan- grammed into the EMG unit, the biofeed-
The technique of aquatic biofeedback has cy to unload the joints and decrease pain
undergone several changes in its evolution. while SEMG biofeedback contributes quan-
Initially, waterproofing the electrode was done titative measurement and direction for both
with a bioclusive barrier that was expensive patient and therapist. Aquatic biofeedback
and difficult to apply. Now, with the advent now gives us the ability to quantify the
of a latex extremity sock that covers the elec- exercises performed in the pool and gives us
trode, application of the technique is much analytical data to direct our rehabilitative
easier and less time consuming. The aquatic efforts in a more specific and purposeful
biofeedback technique is currently being used direction.
in the treatment of orthopedic and neurologic
conditions, such as cerebral vascular accidents
Techniques of Aquatic
(CVA’s), anterior cruciate ligament repairs, Biofeedback Figure 1.
patellofemoral pain syndrome (PFPS) and The aquatic SEMG treatment model is
spinal cord injuries. the same as in land-based biofeedback, but
it has been adapted and modified to con-
Introduction to Aquatic form to the aquatic environment (specifical-
Biofeedback ly, drawing on hydrodynamic principles).
Biofeedback and surface electromyogra- The same skin preparation is followed prior
phy (SEMG) have a well-established rela- to the application of the sensors. The only
tionship with the fields of physical and difference is that once the set-up is com-
occupational therapy. The land-based use of plete, a waterproof covering (referred to as a
biofeedback in the treatment of various sock) is placed over the site, and the
upper and lower extremity conditions is extremity can be immersed. Exercises are
well documented and has proven to be an carried out, and training is facilitated and
important adjunct to established treatment practiced, until the desired effect is Figure 2.
methods. achieved. Then the sock and sensors are
Aquatic therapy has been around for cen- removed and physical therapy can continue
turies. From the community baths of Rome either in the pool or on land.
to the healing pools of Bad Ragaz, aquatic The whole process is quite easy. The
rehabilitation has been practiced in one desired muscle is selected and the site is pre-
form or another by utilizing the physical pared with an alcohol swab to remove dirt
properties of water to relieve pain and to and oils (Figure 1). After placing the elec-
strengthen weakened muscles. trodes over the appropriate muscle site, the
Extending land-based biofeedback proce- wires from the inside of the waterproof sock
dures to the aquatic environment, however, are hooked up, the whole sock is pulled up
has developed a new twist to both aquatic over the extremity (Figure 2), and the air is
therapy and biofeedback. A tangential pumped out to form an airtight barrier
Figure 3.

Summer 2003 Biofeedback 11


back training process begins (Figure 4). Box I. throughout the 4-month treatment pro-
Exercises are performed to either facilitate AquaSense™ Aquatic EMG Systems gram. The effects of gravity on land can
or inhibit activation of specific muscle Manufactured by inhibit the patient’s ability to successfully
groups. The SEMG biofeedback signal Thought Technology Ltd. stand or even walk. In the water, patients
assists with the treatment and enhances the 2180 Belgrave Ave with a muscle test grade of “Trace” or
aquatic treatment regimen. Box I shows an Montreal, Quebec, Canada “Poor” can hold themselves upright or even
instrumentation system currently available H4A 2L8 walk. This is possible by utilizing the
for aquatic use and contact information for Tel: (800) 361-3651 hydrodynamic principle of buoyancy to
the relevant manufacturer. Phone (514) 489-8251 support and assist the patient. Walking was
mimicked in deep water (7 ft. depth),
Safety Issues Fax: (514) 489-8255
where the effects of gravity are almost com-
When I first suggested using EMG in the http://www.thoughttechnology.com
mail@thoughttechnology.com pletely eliminated, and also in the shallow
aquatic environment, clinicians would look water (4 ft. depth), where the graduated
horrified at the thought of me taking such loading of the lower extremities could facili-
an expensive and sensitive piece of equip- the unit in a waterproof box during the ses-
tate potential neural adaptations of the
ment into the pool. The risk management sion. A friend of mine who has supported
locomotor circuitry at the spinal cord level
people literally scrambled to find me, in and believed in the aquatic biofeedback
(Wernig & Muller, 1992; Wernig, Muller,
order to remind me of the legal ramifica- technique was once asked (many years ago)
Nannasy, & Cagol, 1995). Pre- and post-
tions of mixing water, electricity and about the possibility of using EMG in the
testing consisted of ambulation assessment,
patients. Fortunately, the emergence of pow- water. He replied that it was possible … but
manual muscle testing and surface EMG
erful, battery-powered, hand-held EMG only once! His opinion of EMG in the
testing on land and in the water. At the
units has eliminated the need for a wall water has changed. A lot of people’s opin-
conclusion of the 4-month treatment inter-
plug. Using three “AA” batteries in an ions about EMG in the water have changed.
vention, the patient was able to ambulate
aquatic setting significantly reduces the
chance of electrocution to zero. Patients are
Applications five times farther than initially noted. The
I have used aquatic biofeedback with EMG readings showed significant improve-
never at risk of harm from the unit or the ment on land and in the pool, of all mus-
orthopedic and neurologic patients alike -
technique. The information gathered at a cles tested. The final manual muscle tests
specifically with cerebral vascular accidents
particular session is saved on the hand-held showed a decrease from the initial test read-
(CVA’s), anterior cruciate ligament (ACL)
unit and then downloaded later to a com- ings. Significant progress was made with the
reconstructions, rotator cuff tears/recon-
puter for further analysis. The only real con- patient’s functional ability and mobility in
structions, cerebral palsy (CP) and spinal
cern comes from dunking the EMG unit in spite of the plateau he had reached with
cord injuries. I have also published articles
the pool, and this is eliminated by placing manual muscle tests (one of the major dis-
testing the validity of aquatic biofeedback,
outlining its uses, and calling upon its charge “gold standards” in spinal cord reha-
measurements to investigate the mecha- bilitation).
nisms by which progress is achieved in cer- The emerging theory of facilitating the
tain conditions (Fuller, Awbrey, 1999; see Central Pattern Generator with body
also Stowell, Fuller, & Fulk (2001). weight supported treadmill gait training has
Recently, I co-published a case study that shown great promise in the realm of spinal
utilized aquatic biofeedback to validate the cord rehabilitation. This treatment tech-
progress made by a 20 year old spinal cord nique utilizes a harness to suspend the
injured patient one year post-injury patient upright and a treadmill to allow sta-
(Stowell, Fuller, & Fulk, 2001). Our patient tionary ambulation. The Central Pattern
had an incomplete C6 spinal cord lesion Generator theory suggests that assisted
from an automobile accident. He was seen walking may provide sensory stimulation,
for four months of land and aquatic based which generates an adaptation to the nor-
physical therapy that included ambulation mal neural pathway. This would occur at
training in the pool at various water depths the spinal cord level (more reflexive than a
(to manipulate the effects of weight bearing higher level function).
by utilizing buoyancy) as well as on land. Utilizing the buoyant property of water
Aquatic biofeedback was used to train the in lieu of the harness system was easy
abdominals, gluteals, quadriceps and ham- enough to manipulate. By employing aquat-
string muscles during aquatic exercise and ic biofeedback to record the improvement
to record the muscle activity of those partic- and to assist with muscle training, valuable
Figure 4. ular muscles (on land and in the pool) information was compiled that helped

12 Biofeedback Summer 2003


guide the patient’s rehabilitation as well as effect that water has on the particular exer- Fuller, R.A. & Awbrey, B.J. (1999 Spring).
validate the outcome. cise, thereby allowing the manipulation of Activity levels of the VMO muscle during a single
leg mini squat on land and at varied water depths.
Aquatic biofeedback has helped quantify the signal to better enhance the exercise American Physical Therapy Association Aquatic
treatment in an area that has had its share routine. Each study utilized aquatic Journal, 7 (1), 13-18.
of skeptics and more that its share of tall biofeedback to validate a training method Fuller, R.A., (2001). Aquatic biofeedback
tales and half-truths. A common misnomer or to substantiate a theory, leading to a bet- treatment of PFPS. Sports Medicine Update, 5 (2),
27-30.
in aquatic therapy has been that you can’t ter treatment model for the rehabilitation of
Kasman, G.S., Cram, J.R., & Wolf, S.L. (!998).
treat specifics in the pool, only generalities. our patient population. Clinical applications in surface electromyography.
A familiar comment verbalized by some Gathersburg, MD: Aspen Publication.
skeptics is that the benefits of water are
Conclusion
Kelly, B.T., Roskin, L.A., Kirkendall, D.T. &
mostly subjective and that there is little Theory drives research. Research models Speer, K.P., (2000). Shoulder muscle activation dur-
documented, quantitative research to back treatment. Treatment begets knowledge, ing aquatic and dry land exercises in nonimpaired
and knowledge creates the opportunity for subjects. Journal of Orthopedic and Sports Physical
up the glowing affirmations voiced by Therapy, 30 (4), 204-210.
patients. This was true several years ago. theory … and so the cycle is perpetuated.
SEMG aquatic biofeedback has been Nuber, G.W., Jobe, F.W.,Moynes, D.R. &
However, with the release of NASA generat- Atonelli, D. (1986). Fine wire EMG analysis of
ed research (through the Freedom of tried, tested and now fine-tuned, giving muscles of the shoulder during swimming.
Information Act) and the rapidly growing therapists a new tool to help quantify American Journal of Sports Medicine, 14, 7-11.
field of aquatic rehabilitation, more aquatic progress in their aquatic therapy treatments. Stowell, T., Fuller, R.A., Fulk, G. (2001, Fall).
It has come a long way from an abstract An aquatic and land-based physical therapy inter-
related research has been published now vention to improve functional mobility for an indi-
than ever before. Several published studies idea to its present state. With continued vidual after an incomplete C6 spinal cord lesion.
have dealt with aquatic biofeedback and research bringing about new treatments and American Physical Therapy Association Aquatic
rehabilitation (Nuber, Jobe, Moynes, & creating new ideas, the sky (or the water) Journal, 9 (1), 27-32.
appears to be the limit! Wernig, A., & Muller, S. (1992). Laufband loco-
Atonelli, 1986; see also Becker, Erlanson, motion with body weight support improved walk-
Hemmesch, & Redfield, 1996; Kelly, References ing in persons with severe spinal cord injury.
Roskin, Kirkendall, & Speer, 2000; Fuller, Becker, K.M., Erlanson, M.O., Hemmesch, R.A. Paraplegia, 30, 229-238.
2001). The main goal of these studies has & Redfield, D.S. (1996). A comparison of serratus Wernig, A., Muller, S., Nannasy, A. & Cagol, E.
anterior muscle activity during prone exercise in water (1995). Laufband therapy based on rules of spinal
been two-fold: 1) to develop quantitative and on land as measured by a clinical EMG unit. locomotion. European Journal of Neurosciences, 70,
measurement methods for aquatic exercise, Unpublished Master’s Thesis, College of St. 823-829.
and 2) to observe muscle function as the Catherine, St. Paul, MN.
muscles are utilized during aquatic therapy. Cram, J.R., Kasman, G.S. & Holtz, J. (1998).
This allows us the ability to focus on the Introduction to surface electromyography.
Gathersburg, MD: Aspen Publication.

Summer 2003 Biofeedback 13


FEATURE ARTICLE

Exercise or Play?
Medicine of Fun
Katherine H. Gibney and Erik Peper,
San Francisco, CA Katherine H. Gibney Erik Peper

Abstract: Patients often equate biofeedback chronic shoulder pain. Convincing Betty to Subsequent sessions built upon the foun-
training homework to mandatory activities, drop her painful bracing pattern and to dation of diaphragmatic breathing: boosting
which are often viewed as one more thing to allow her arms to hang freely from her Betty’s confidence, increasing range of
do. Changing the perception from that of work shoulders as she breathed diaphragmatically motion (ROM), and bringing back some
to fun can encourage laughter and joy and was the first major step in regaining mobili- fun in life. Activities included many child-
help overcome a chronic pain pattern – all ty. She discovered in that first session that hood games: tossing a ball, swaying like a
necessary for healing. This paper encourages she could use her breathing to achieve con- tree in the wind, pretending to conduct an
therapists to explore utilizing childhood activi- trol over muscle spasms. During the first orchestra, bouncing on gym balls, playing
ties and paradoxical movement to help patients week, she practiced her breathing assiduous- “Simon Says” (following the movements of
release tension patterns and improve range of ly at home and had fewer spasms. Betty was the therapist), and dancing. Laughter and
motion. A strong emphasis is placed on linking able to move better during her physical childlike joy became a common occurrence.
diaphragmatic breathing to movement. therapy sessions. Each time she felt the She looked forward to receiving the sparkly
onset of muscle spasms she would stop all star stickers she was given after successful
When I went home I showed my grand- activity for a moment and ‘go into my sessions. With each activity Betty gained
daughter how to be a tree swaying in the trance’ to prevent a recurrence. For the first more confidence, gradually increased ROM,
wind, she looked at me and said, “Grandma, time in many months she was feeling opti- and began losing weight. Although she had
I learned that in kindergarten!” mistic. some days where the pain was strong and
‘Betty’ laughed heartily as she relayed this
story. Her delight in being able to sway her
arms like the limbs of a tree starkly con-
trasted with her demeanor only a month
prior. Betty was referred for biofeedback
training after a series of 9 surgeries – wrists,
fingers, elbows and shoulders. She arrived at
her first session in tears with acute, chronic
pain accompanied by frequent, incapacitat-
ing spasms in her shoulders and arms. She
was unable to abduct her arms more than a
few inches without triggering more painful
spasms. Her protective bracing and rapid
thoracic breathing exacerbated her pain and
contributed to limited range of motion of
her arms. Unable to work for over a year,
she was coping not only with pain, but also
with weight gain, poor self-esteem and
depression. Figure 1. Perform physical activity that could aggravate pain only during the exhalation phase to inhibit
Biofeedback training began with what we pain sensations. Discomfort can usually be minimized if activity (movement or treatment that induces
feel is the foundation of health: effortless, pain, such as an injection) is performed or given during the exhalation phase. During the inhalation phase,
diaphragmatic breathing (Peper, 1990). one pauses with the activity and resumes during the exhalation phase. The activity commences slightly after
Each thoracic breath added to Betty’s the initiation of exhalation and when the heart rate has started to decelerate.

14 Biofeedback Summer 2003


spasms threatened, Betty reframed the pain reeducation, youthful play, and pure exer- tion or youthful playing. Physical exercise is
as occurring as a result of healing and cise. How the patient performs the activity necessary for strength and endurance and at
expanding her ROM—she was no longer a may be monitored with surface electromyo- the same time, improves our mood (Thayer,
victim of the pain. In addition, her family graphy (SEMG) to identify muscles tight- 1996). However, many exercises are consid-
was proud of her, she was doing more fun ening that are not needed for the task and ered a burden and are often taught without
activities, and she felt confident that she how the muscle relaxes when not needed a sense of lightness and fun, which results
would return to work. for the task performance. This monitoring in the patient thinking in terms that are
Betty’s story is similar to many other can be done with a portable biofeedback powerless and helpless (depressive)—”I have
clients whom we have seen. The challenge device or multi-channel system when walk- to do them.” Helping your patients to
presented to biofeedback therapists is to ing or performing the exercises. Patients can understand that exercise is simply a part of
help the patient better cope with pain, even use a single channel SEMG at home. every day life, that it encourages healing
increase ROM, regain function and, often When working to improve ROM and and improves health, and that they can
the most important, to reclaim a joie de physical function, the following rules are “cheat” at it, may help them to reframe
vivre. Increasing function includes using the recommended: their attitudes toward it and accomplish
minimum amount of effort necessary for 1. Maintain diaphragmatic breathing – their healing goals.
the task, allowing unnecessary muscles to rhythm or tempo may change but the
remain relaxed (no dysponesisi), and quick- breath must be generated from the
Pure Physical Exercise—
ly releasing muscle tension when the muscle diaphragm with emphasis on full exha- Enjoyment through
is no longer required for the activity lation. Use strain gauge feedback Strength and Flexibility
(work/rest). The challenge is to perform the and/or SEMG feedback to monitor The major challenge of structured exer-
task without concurrent evocation of com- and train effortless breathing. Strain cises is that the person is very serious and
ponents of the alarm reaction, which tend gauge feedback is used to teach a slow- strives too hard to attain the goal. In the
to be evoked when “we try to do it perfect- er and diaphragmatic breathing pat- process of striving, the body is often held
ly,” or “it has to work,” or “If I do not do it tern, while SEMG recorded from the rigid: Breath is shallow and halted and
correctly, I will be judged.” For example, scalene to trapezius is used to teach shoulders are slightly braced. Structured
when people learn how to implement how to reduce shoulder and ancillary exercises are very helpful for improving
micro-breaks (1 – 2 second rest periods) at muscle tension during inhalation ROM and strength. Maintaining a daily
the computer, they often sit quietly believ- 2. Perform activities or chart is an excellent tool to show improve-
ing that they are relaxed. However, they stretching/strengthening exercises that ment (e.g., more repetitions, more weight,
may continue a bracing pattern. may trigger or aggravate pain during increased flexibility). When using pure exer-
Alternatively, tossing a small ball rather the exhalation phase of breathing. cise, remember that injured patients often
than resting at the keyboard will generally 3. Use the minimum amount of tension have a sense of urgency – they want to get
evoke laughter, encourage generalization of necessary for the task and let unneces- well quickly and, if work stress was a factor
skills, and covertly induce more relaxation. sary muscles remain relaxed. Use in developing pain, they often rush when
Ironically, therapists in their desire to help SEMG feedback recorded from mus- they need to meet a deadline. As much as
patients to get well commonly assign struc- cles not needed for the performance of possible make the exercise fun. Help the
tured exercises as homework that evoke the task to teach patients awareness of patient understand that he can be quick
striving for performance and often bore- inappropriate muscle tension and to while not rushed. For example, monitor
dom—this striving to perform the struc- learn relaxation of those muscles. SEMG from an upper trapezius muscle
tured exercises may inhibit healing. 4. Quickly release muscle tension when using a portable electromyograph. Begin by
Utilizing tools other than those found in the task is accomplished. Use SEMG walking slowly. Add a ramp or step to
the work setting helps the patient achieve a feedback to monitor and show that the ensure that there is no bracing when climb-
broader perspective of the healing/preven- muscles are completely relaxed. If rapid ing (a common occurrence). Walk around
tive concepts that are taught. relaxation is not achieved, teach the the room, down the hall, around the block.
Obviously, clients are active participants subject to first relax before repeating Maintain relaxed shoulders, an even swing
in their own healing process. This implies the muscle activity. of the arms, and diaphragmatic breathing.
that they practice exercises during the thera- 5. Perform the exercises as if you have Walk more quickly while emphasizing relax-
peutic session, at home and at work. never performed them and do them ation with speed rather than rushing. Go
Consequently, home practices are assigned with a childlike, beginner’s mind, and faster and faster. Up the stairs. Down the
to integrate the mastery of news skills into exploratory attitude (Kabat-Zinn, stairs. Walk backward. Skip. Hop. Laugh.
daily life. To help patients achieve increased 1990).
health through physical activity three differ- Movement and exercise can be taught as
ent approaches are often used: movement pure physical exercise, movement reeduca-

Summer 2003 Biofeedback 15


Movement Reeducation – ponetic, and frequently painful, pattern. do this in the privacy of your own home!).
Have the patient do movement reeducation Do movements differently such as, practic-
Be ‘Oppositional’ And Do exercises in which they are guided through ing alternating hands when leading with the
It Differently practices in which they have no expectancy vacuum or when sweeping, changing routes
Movement reeducation, such as and the movements are novel. The focus is when driving/walking to work or the store,
Feldenkrais, Alexander Technique or on awareness without triggering any getting out of bed differently. Or, break up
Hannah Somatics, involves conscious fight/flight or startle responses. habitual conditioned reflex patterns such as
awareness of movement (Hanna, 1988; Ask the patient to explore performing eye, head and hand coordination. For
Murphy, 1993). Many daily patterns of many functional activities with the opposite example, when doing a movement, slowly
movement become imbedded in our con- hand, such as brushing her hair or teeth, rotate your head from left to right and
sciousness and, over the years, may include eating, blowing her hair dry, or doing simultaneously shift your eyes in the oppo-
a pain trigger. A common trigger is lifting household chores, such as vacuuming. (Try site direction (e.g., turn your head fully to
the shoulders when reaching for the key- this for yourself, as well!). Be aware of how the right while shifting your eyes fully to
board or mouse. Patients suffering from much shoulder muscle tension is needed to the left, and then reverse) or before reaching
thoracic outlet syndrome (TOS) often have raise the arms for combing or blow-drying forward, drop your elbows to your sides
such patterns. A keyboard can often inad- the hair. Explore how little effort is required then, bend your elbows and touch your
vertently cue the patient to trigger this dys- to hold a fork or knife (you might want to shoulders with your thumbs then, reach for-
ward. Often, when we change our patterns
we increase our flexibility, inhibit bracing
Free Your Neck and Shoulders* and reduce discomfort.
— Push away from the keyboard and sit at the edge of the chair with your knees bent at right angles Youthful Playing –
and your feet shoulder-width apart and flat on the floor. Do the following movements slowly. Do
NOT push yourself if you feel discomfort. Be gentle with yourself.
Pavlovian Practice
— Look to the right and gently turn your head and body as far as you can go to the right. When you Remember the story of Pavlov in the hos-
have gone as far as you can comfortably go, look at the furthest spot on the wall and remember that pital? Many, including his family, thought
spot. Gently rotate your head back to center. Close your eyes and relax. he was slipping into death when he quietly
— Reach up with your left hand; pass it over the top of your head and hold on to your right ear. Then, lay in his hospital bed and gently played
gently bend to the left lowering your elbow towards the floor. Slowly straighten up. Repeat for a few with a bowl of water and dirt. Yet, the next
times feeling as if you are a sapling flexing in the breeze. Observe what your body is doing as it morning he awoke and ate a hearty break-
bends and comes back up to center. Notice the movements in your ribs, back and neck. Then, drop fast. Soon he was out of the hospital. Pavlov
your arm to your lap and relax. Make sure you continue to breathe diaphragmatically throughout knew that evoking the playful joy of child-
the exercise.
hood would help to encourage mental and
— Reach up with your right hand and pass it over the top of your head and hold on to your left ear.
Repeat as above except bending to the right.
physical healing (Peper, Gibney, & Holt,
— Reach up with your left hand and pass it over the top of your head and hold on to your right ear. 2002). Having patients play can encourage
Then, look to the left with your eyes and rotate your head to the left as if you are looking behind laughter and joie de vivre, which helps in
you. Return to center and repeat the movement a few times. Then, drop your arm to your lap and physical healing. Often being involved in
relax for a few breaths. childhood games or actually playing these
— Again, reach over your head with your left hand and hold onto your right ear. Repeat the same games with children removes one from wor-
rotating motion of your head to the left except that your eyes look to the right. Repeat this a few ries and concerns—both past and future—
times then, drop your arm to your lap and relax for a few breaths. and allows one to be simply in the present.
— Reach up with your right hand and pass it over the top of your head and hold on to your left ear. Just being present is associated with playful-
Then, look to the right with your eyes and rotate your head to the right as if you are looking behind ness, timelessness, passive attention, creativ-
you. Return to center and repeat a few times. Then, drop your arm to your lap and relax for a few
ity and humor. A state in which one’s
breaths.
— Again, reach over your head with your right hand and hold onto your left ear. Repeat the same
preconceived mental images and expectan-
rotating motion of your head to the right except that your eyes look to the left. Repeat this a few cies—the personal, familial, cultural, and
times then, drop your arm to your lap and relax for a few breaths. healthcare provider’s hypnotic suggestions—
— Now, look to the right and gently turn your head and body as far as you can go. When you can not are by-passed and for that moment, the
go any further, look at that point on the wall. Did you rotate further than at the beginning of the present and the future are yet undefined.
exercise? This is often the opposite of the patient’s
— Gently rotate your head back to center, close your eyes, relax and notice the feeling in your neck, expectancy. Namely, the past experiences
shoulders and back. and the diagnosis create a fixed mental
image that expects pain and limitation.
*This practice was adapted from a demonstration by Sharon Keane Explore some of the following practices as
and developed by Ilana Rubenfeld (2000).
strategies to increase movement and flexibil-
ity without effort and to increase joy. Use

16 Biofeedback Summer 2003


your creativity and explore your own per- Back-To-Back Massage gets the painful past and a future fraught
mutations of the practices. Observe how With a partner stand back-to-back. Lean against
with promises of continued pain and inac-
your mood improves and your energy each other’s back so that you provide mutual sup- tivity. Instead, the moment is lived in a joy-
increases when you play a childhood game port. Then each rub your back against each ful present—one in which the pain cycle is
instead of an equivalent exercise. For exam- other’s back. Enjoy the wiggling movement and interrupted and which can provide hope
ple, instead of dropping your hands to your stimulation. Be sure to continue to breathe. and a glimpse into a healthy future.
lap or stretching at the computer terminal
during a micro- or meso-breakii, go over to faster and add ball squeezes prior to passing
References
Hanna, T. (1988). Somatics. Reading, MA:
your coworker and play “pattycake.” This is the ball. Addison-Wesley.
the game in which you and your partner Gym Ball Bounces: Sit on a gym ball Kabat-Zinn, J. (1990). Full catastrophe living.
face each other and then clap your hands and find your balance. Begin bouncing New York: Delacorte Press.
and then touch each other’s palms. Do this slowly up and down. Reach up and lower Murphy, M. (1993). The future of the body. New
in all variations of the game. York: Jeremy P. Tarcher/Perigee
your left then, right hand. Abduct your
Peper, E. (1990). Breathing for health with
For increased ROM in the shoulders arms forward then, laterally. Turn on the biofeedback. Montreal: Thought Technology Ltd.
explore some of the following (remember radio and bounce to music. Peper, E., Gibney, K. & Holt, C. (2002). Make
the basics: diaphragmatic breathing, mini- Simon Says: This can be done standing, health happen: Training yourself to create wellness.
mum effort, rapid release): sitting in a chair or on a gym ball. When Dubuque, IA: Kendall-Hunt.
Ball Toss: a hand-sized ball that is easily on a gym ball, bounce during the game. Rubenfeld, I. (2000). The listening hands: Self-
squeezed is best for this exercise. Monitor Have your patient do a mirror image of healing through Rubenfeld Synergy method of talk and
touch. New York: Bantam Doubleday
respiration patterns, and SEMG forearm your movements: reaching up, down, left, Thayer, R.E. (1996). The origin of everyday
extensors and/or flexors, and upper trapezii right, forward or backward. Touch your moods—Managing energy, tension, and stress. New
muscles. Sit quietly in a chair and focus on head, nose, knees or belly. Have fun and go York: Oxford University Press.
a relaxed breathing rhythm. Toss the ball in more quickly. Whatmore, G. and Kohli, D. The
the air with your right hand and catch it Physiopathology and Treatment of Functional
with your left hand. As soon as you catch
Summary: Disorders. New York: Grune and Stratton, 1974.
the ball, drop both hands to your lap. Toss An Attitude of Fun Footnotes
the ball back only when you achieve relax- In summary, it is not what you do; it is i Dysponesis involves misplaced muscle
ation—both with the empty hand and the the attitude by which you do it that affects activity activities or efforts that are usually
hand holding the ball. Watch for over- health. From this perspective, flexibility and covert and, which do not add functionally
efforting in the upper trapezii. Begin slowly movement are enhanced, discomfort to the movement. From: “Dys” meaning
and increase the pace as you train yourself decreased and health increased when exer- bad, faulty or wrong, and “ponos” meaning
to quickly release unnecessary muscle ten- cises are performed with joy and experi- effort, work or energy (Whatmore and
sion. Go faster and faster (just about every- enced as fun. Inducing laughter promotes Kohli, 1974)
one begins to laugh, especially each time healing and disrupts the automatic negative
they drop the ball). hypnotic suggestion/self-images of what is ii A meso-break is a 10 to 90 second
Ball Squeeze/Toss: Expand upon the expected. The patient begins to live in the break that consists of a change in work
above by squeezing the ball prior to tossing. present moment and thereby decreases the position, movement or a structured activity
When working with a patient, call out dif- anticipatory bracing and dysponetic activity such as stretching that automatically relaxes
ferent degrees of pressure (e.g., 50%, 10%, stirred-up by striving. By decreasing striving those muscles that were previously activated
80%, etc.). The same rules apply as with and concern for results, patients may allow while performing a task.
the ball toss. themselves to perform the practices with a
Ball Hand to Hand: Close your eyes and passive attentive attitude that may facilitate
hand the ball back and forth. Go faster and healing. For that moment the patient for-

Summer 2003 Biofeedback 17


FEATURE ARTICLE

Sport Psychophysiology: the


Current Status of Biofeedback with
Athletes (Part 1)
Jeffrey T. Leonards, PhD, Farmington, Maine Jeffrey T. Leonards, PhD

Abstract This article is the first in a three- than being content with who is intrinsically that applied psychophysiology has con-
part series on the use of biofeedback (BFB) in the better contestant, people have long tributed to the sports sciences (Collins,
helping athletes reach their optimal competi- thirsted to discover new techniques to 1995). What is of concern is whether and
tive potential. The author’s extensive literature increase one’s odds of winning. While in to what extent research in sports psy-
review suggests that however compelling the earlier times technological improvements chophysiology (SPP) will continue to bene-
outcomes, research in this area has been sur- may have been limited to weaponry, con- fit elite athletes and their coaching staff?
prisingly quite limited. Perhaps chiefly temporary sports technology addresses both
responsible for the lack of growth in this field, objective and subjective variables. Objective
Efficacy of Biofeedback
a field considered otherwise fraught with technology encompasses entities external to in Sport
potential, has been inconsistent methodology, the competitor, such as the design of better Myriad studies over the past 30 years
which at times has bordered on little more shoes, lighter bats, more versatile skis, faster have concluded that athletes are no differ-
than untested assumptions. Happily, studies bicycles, wider tennis racquets, and the like. ent from other clinical populations in hav-
today seem increasingly rigorous, the findings Innovations in this area enable the same ing the potential to benefit from feedback
more empirically robust, leaving little doubt athlete to perform differently depending of physiological processes. In their now clas-
that research in this field can pass scientific upon the equipment used (May, 2000). In sic book, Biofeedback and Sports Sciences,
muster. The author is thereby optimistic that contrast are subjective variables that focus Sandweiss and Wolf (1985) provide an
this new field, which he refers to as sport psy- more on psychological factors (images, self- excellent introduction to the topic as well as
chophysiology (SPP), could eventually achieve statements, beliefs, etc) as well as physiolog- copious research supporting the use of BFB
recognition as distinct yet complementary to ical events (sleep, breathing, muscle tone, in athletic training. It is important to note,
the myriad other established disciplines mak- and related autonomic states). Over the however, that subsequent to that publica-
ing up the sports sciences. Such an achieve- years, the reality in the sports world has tion, SPP research came under harsh scruti-
ment would certainly augur well for a new become one where “it is no longer a case of ny because of methodology that was often
generation of applied and research-oriented the athlete responding to the coach- it’s the found wanting. While recent research has
BFB enthusiasts. In short, this three-part series coach responding to the physiological and appeared more empirically robust, there
will review the trends, problems, and ulti- psychological world of the athlete” (Braden, remains a strong need for tighter method-
mately the potential for SPP as an applied sci- 1985, p. x). ological controls in order to enhance credi-
ence in its own right. As engineers have continued to push the bility not just in SPP, but BFB in general
envelope in terms of equipment design, (see Yucha, 2002). Part III of this series will
“Cyclists are computer slaves; we hover over researchers over the past few decades have address some of the common inadequacies
precise calculations of cadence, efficiency, reached new heights in recognizing the in SPP outcome research.
force, and wattage. I was constantly sitting importance that psychophysiological states Most of the attention in SPP focuses on a
on a stationary bike with electrodes all over non-distressed population- healthy athletes
can have on competitive outcomes.
my body, looking for different positions on
Biofeedback (BFB) has figured prominently working towards improved functioning. A
the bike that might gain mere seconds…”
– Lance Armstrong in this regard as studies have increasingly smaller, yet important body of research is
(Armstrong, 2000. p. 63.) shown that subtle modifications in such specifically directed towards rehabilitation
variables as respiration, muscle tone, brain of the injured athlete. Whether it be with
Since time immemorial, combatants and waves, and heart rate can have appreciable distressed or non-distressed subjects, all of
contestants alike have endeavored to opti- impact on performance, especially with elite the studies can be differentiated according
mize their performance, be it in battle or athletes whose outcomes are often differen- to three distinct aims (Landers, 1985). The
simply in a competitive sports arena. Rather tiated by milliseconds. There is no doubt first, arousal reduction, is perhaps the most

18 Biofeedback Summer 2003


heavily researched and is based on the Because under those conditions heart rate (Blumenstein, Bar-Eli, M., & Tenenbaum,
premise that an athlete’s performance suffers (HR) is not just rapid but subjectively pal- 1997).
when tension exceeds their capacity for pable, the athlete can learn where in either
optimal functioning. This rather dated the respiration or HR cycle to initiate their
Current Issues
concept is often referred to as the “inverted shot in order to achieve maximal results. In Despite the potential for this field as sug-
U hypothesis” (Yerkes & Dodson, 1908), such a situation, reduction of arousal is not gested by the research cited above, several
which basically contends that optimal ath- important, because after shooting, the ath- trends should be of some concern to BFB as
letic performance is found somewhere in lete must resume several kilometers of race- a profession, and more specifically to SPP as
the midrange between calmness and ten- pace skiing. The competitor must therefore a sub-discipline within the exercise sciences.
sion. In other words, performance will maintain existing levels of arousal while The first observation in reviewing the litera-
improve with heightened arousal, but only learning to use proprioceptive cues as sig- ture is that notwithstanding the seeming
up to a certain point, after which perform- nals for when to pull the trigger. importance of psychophysiological variables
ance will actually begin to deteriorate as The third area of SPP research involves in athletic performance, the literature in this
arousal continues to increase. Students of rehabilitative interventions with injured ath- area is not nearly as prolific as one might
economics may recognize a similarity letes. Much of the work in this area centers guess. Zaichkowsky and Fuchs (1988), two
between this theory and the “law of dimin- around physical therapy applications of of the more prolific researchers in this field,
ishing returns.” While the inverted-U electromyography (EMG). referred to the total number of SPP studies
hypothesis has been challenged and/or Chondromalacia, for example, can often as “extremely limited.” While BFB in gener-
refined over the years (Gould & Udry, result from muscle imbalances reinforced by al, unlike research in countless other areas of
1994), suffice it to say that exceptional per- repetitive cycling or running. Concomitant psychology, may tend to be a rather esoteric
formance corresponds with an optimal level patellofemoral pain can actually be amelio- topic by itself, studies that specifically focus
of pre-competition arousal (Spielberger, rated through differential strengthening of on BFB applications in sport are decidedly
1989). The goal is to find this level in each vastus medialis and vastus lateralis, two more obscure. Such a literature search would
athlete, and then train them to reproduce it muscles which can be neatly individuated yield only a handful of studies, even fewer
in competition. Hyperarousal suggests relax- and retrained through EMG. This approach when narrowing in on either a specific sport
ation strategies, whereas hypoarousal neces- was reported by Swanik, Lephart, Giraldo, (e.g., BFB with cross country skiers) or a
sitates interventions aimed at energizing or Demont, & Fu (1999) in a study of female specific BFB modality (EMG in sport). To
“psyching up” (Zaichkowsky & Takenaka, athletes with injuries to the anterior cruci- look at both a specific sport and specific
1993). Pinel and Schultz (1978) used sur- ate ligament (ACL). The authors deter- BFB modality (EMG with cross country
face electromyography (sEMG) to demon- mined that sEMG made it possible to skiers) may yield only a few studies at best,
strate not only how high levels of differentially strengthen quadicreps and depending on the sport, sometimes none at
pre-competitive muscle tension can disrupt hamstrings to restore functional stability of all. In the preparation of this manuscript, a
athletic performance, but that BFB-assisted the knee as well as protect it from subse- rather extensive literature search yielded less
relaxation can ameliorate this same arousal. quent ligamentous injury. A somewhat dif- than 100 studies reporting on BFB applica-
Blais and Vallerand (1986) also found BFB ferent rehabilitative application involved tions of any kind in any sport between 1976
effective in reducing competitive arousal. In sEMG being used to encourage hamstring and 2001. Compare that 25 year period, for
short, BFB in a variety of forms has been relaxation in order to measure anterior tibial example, to the 2700 or so studies on relax-
found empirically capable of transforming displacement in ACL-deficient patients, an ation alone that were counted between 1972
debilitative anxiety into constructive energy otherwise difficult procedure (Feller, Hoser, and 1997 (Friedman, Sedler, Myers, &
that can maximize performance across a & Webster, 2000). Other BFB modalities Benson, 1997) or to the 7000 studies in the
wide variety of sports. have also shown utility in sports medicine, field of sport psychology that were pub-
The second key area in SPP centers e.g., Zaichkowsky and Fuchs (1988), who lished between 1971 and 1991 (Kunath,
around optimizing autonomic control. This discuss applications of HR, blood flow, and 1995). The inference here is that, for what-
approach is also geared to healthy athletes respiration feedback to limit, for example, ever reason, SPP may be a grossly under-
whose performance is adversely affected by the cardiorespiratory impact of rehabilita- researched area.
autonomic phenomena, such as HR, sweat, tive exercise. Perhaps even more striking is the paucity
hand/foot temperature, respiration, and the To summarize, SPP approaches can be of SPP research published by the
like. The aim is to teach self-regulatory differentially adapted for use with both dis- Association for Applied Psychophysiology
skills that enable the competitor to become tressed and non-distressed athletes. The and Biofeedback (AAPB), considered by
aware of these physiological processes in three major directions just identified in SPP many the official voice for BFB practition-
order to manipulate them to his or her have been uniquely incorporated into a five- ers in the U.S. The present study found
advantage. An example might be a biath- step schema that shows promise in regulat- that over the ten years between March,
lete who is required to shoot a target after ing HR, increasing flexibility and muscle 1991 through September, 2001, the Journal
skiing several kilometers at race-pace. strength, and/or reducing pain and fatigue of Applied Psychophysiology and Biofeedback

Summer 2003 Biofeedback 19


(formerly called Biofeedback and Self- al questions emerge, some of which will be Carlstedt, R.A. (2002). Ambulatory psychophys-
Regulation) published only four articles that addressed in this review. Have traditional iology and ecological validity in studies of sports
performance: issues and implications for interven-
were in any way related to this topic (von BFB modalities in sport outlived their use- tion protocols in biofeedback. Biofeedback, 29(4),
Scheele & von Scheele, 1999; Cassisi, fulness? Does the paucity of empirical stud- 18-22.
Sexton-Radek, Castrogiovanni, Chastain, & ies in this field suggest that BFB in general Cassisi, J., Sexton-Radek, K., Castrogiovanni,
Robinson, 1993; Nixon, 1994; Ceugniet, lacks utility in the sports sciences? Are tra- M., Chastain, D., & Robinson, M. (1993). The use
of ambulatory EMG monitoring to measure com-
Cauchefer, & Gallego, 1994) with half of ditional BFB approaches inherently flawed, pliance with lumbar strengthening exercise.
them appearing in just one issue. AAPB’s or are we simply needing new more Biofeedback and Self-Regulation, 18(1), 45-52.
sister periodical, Biofeedback, over the same portable technology that will make tradi- Ceugniet, F., Cauchefer, F., & Gallego, J. (1994).
ten year period fared similarly, with only six tional instrumentation less obtrusive and Do voluntary changes in inspiratory-expiratory
articles addressing BFB in sport (Tremain, therefore of greater utility to athletes and ratio prevent exercise-induced asthma? Biofeedback
and Self-Regulation, 19(2), 181-188.
1996; Kall, 1997; Wilson & Gunkelman, coaches? Are there intrinsic methodological
Chartier, D. (2001). Biofeedback and optimum
2001; Sime, Allen, & Fazzano, 2001; weaknesses to SPP research, and if so how performance. Biofeedback, 29(1), 19- 22.
Chartier, 2001; Carlstedt, 2002). Again, can we in the profession encourage more Collins, D. (1995). Psychophysiology and sport
three of those articles (60%) appeared in empirical rigor so as to promote greater performance. In S.J.H. Biddle (Ed.), European
just one issue (Spring, 2001), an intriguing credibility to BFB’s role in sport. And, Perspective on Exercise and Sport Psychology. (pp.
154-178). Champaign: Human Kinetics Press.
reflection of the lack of research in this finally, we need to look at whether NF is
Feller, J., Hoser, C., & Webster, K. (2000).
important area. actually becoming the preferred medium in EMG biofeedback assisted KT-1000 evaluation of
Another possible trend, as reflected by SPP, or is this simply the prevailing Geist? anterior tibial displacement. Knee Surgery in Sports
what this author gleaned from the available Traumatology Arthroscopy, 8(3), 131.
research, is the possibility that professional
Summary Friedman, R., Sedler, M., Myers, P., & Benson,
interest in SPP might actually have declined It should be clear from the above that H. (1997). Behavioral medicine, complementary
BFB has considerable potential to benefit medicine and integrated care: economic implica-
somewhat over the past ten years. Although tions. Primary Care, 24, 949-962.
any effort to quantify this was beyond the athletes, particularly on the elite level.
Moreover, the current literature review sug- Gould, D. & Udry, E. (1994). Psychological
scope of the present paper, fewer studies skills for enhancing performance: arousal regulation
may have been published in recent years as gests that only a small part of this promise strategies. Medicine and Science in Sports and
compared to what seemed like burgeoning has been realized thus far. In Part II of this Exercise, 26(4), 478-485.
interest in the 1970s and 80s. This possibil- series, we will explore traditional BFB Kall, R. (1997). Optimal functioning training.
modalities (sweat, respiration, muscle tone, Biofeedback, 25(4). 8-10.
ity seems deserving of further investigation, Kunath, P. (1995). Future directions in
particularly in light of continuously favor- heart rate, etc.) and how they have already
exercise and sport psychology. . In S.J.H. Biddle
able outcome studies. Also of interest been adapted with varying degrees of suc- (Ed.), European Perspective on Exercise and Sport
(though not within the context of this cess to a broad range of sports. Attention Psychology. (p. 329). Champaign: Human
will also be given to the importance of Kinetics Press.
paper) is that while biofeedback research in
sound methodology as the sine qua non for Landers, D.M. (1985). Psychophysiological
the sports sciences admittedly continues, assessment and biofeedback: applications for ath-
much of the current work, unlike in the establishing credibility in SPP research and
letes in closed-skills sports. In J.H. Sandweiss &
past, may be occurring outside North practice. In a subsequent issue, Part III will S.L. Wolf (Eds.), Biofeedback and Sports Sciences.
America. examine future directions in this field by (pp. 63-105). New York: Plenum.
A final anecdote is that BFB research considering specific indices widely used in May, M. (2000). The athletic arms race.
exercise physiology (cortisol, cate- Scientific American Presents, 11(3), 74-79.
involving traditional applications seems to Nixon, P.G. (1994). Effort syndrome: hyperven-
be increasingly supplanted by research cholamines, blood lactate, oxygen con-
tilation and reduction of anaerobic threshold.
focusing on neurofeedback (NF: Wilson & sumption, etc.) and their possible utility as Biofeedback and Self-Regulation, 19(2), 171-180.
Gunkleman, 2001). In fact, the Spring BFB measures with athletes. Pinel, J. & Schultz, T. (1978). Effect of
antecedent muscle tension levels on motor behav-
2001 edition of Biofeedback devoted an References ior. Medicine and Science in Sports and Exercise,
entire issue to “optimal functioning,” and Armstrong, L. (2000). It’s not about the bike: My 10(3), 177-182.
although that issue did include several arti- journey back to life. New York: Putnam.
Sandweiss, J.H. & Wolf, S.L. (1985), Biofeedback
cles on BFB in motor skills development, Blais, M.R. & Vallerand, R.J. (1986). and Sports Sciences. New York: Plenum.
Multimodal effects of electromyographic biofeed-
each was geared exclusively around neuro- back: looking at children’s ability to control pre- Sime, W., Allen, T., & Fazzano, C. (2001).
feedback (NF), with almost no mention of competitive anxiety. Journal of Sport Psychology, 8, Optimal functioning in sport psychology: helping
283-303. athletes find their “zone of excellence.” Biofeedback,
EMG, HR, oxygen consumption (VO2), 29(1), 23- 25.
galvanic skin response (GSR), heart rate Blumenstein, B., Bar-Eli, M., & Tenenbaum, G.
(1997). A five-step approach to mental training Spielberger, C.D. (1989). Stress and anxiety in
variability (HRV), and thermal feedback, sports. In D. Hackfort & C.D. Spielberger (Eds.),
incorporating biofeedback. The Sport Psychologist,
historically the gold standards in clinical 11, 440-453. Anxiety in Sports: An International Perspective. (pp.
biofeedback. 3-17). New York: Hemisphere.
Braden, V. (1985). Forward. In J.H. Sandweiss
If in fact these are bonafide trends, sever- & S.L. Wolf (Eds.), Biofeedback and sports sciences.
(p. x). New York: Plenum Press. Continued on page 27

20 Biofeedback Summer 2003


FEATURE ARTICLE

Audio-Visual Entrainment:
I. History and Physiological
Mechanisms
David Siever1, Edmonton, Alberta, Canada David Siever

Abstract: Since the discovery of photic driv- plished other important developments in products and a lack of research, about 40
ing by Adrian and Matthews in 1934, much photic stimulation. Kroger was a physician L&S companies have come and gone, most
has been discovered about the benefits of brain investigating why radar operators were of them during the 1980s and 1990s.
wave entrainment (AVE) or audio visual going into trances in front of their radar However, since the time of Adrian and
entrainment (AVE) as it is commonly known sets and of course, leaving the ship or plane Matthews, a considerable number of studies
today. Studies are now available on the effec- at great risk to the enemy. He concluded have verified photic and auditory “driving”
tiveness of AVE in promoting relaxation, hyp- that the rhythmic “blip” of the radar was of the EEG. I have since re-named this phe-
notic induction and restoring somatic “pulling” the radar operators into a trance nomenon as “audio-visual entrainment” or
homeostasis, plus improving cognition, and for state. These findings compelled Kroger to AVE, as any given frequency of stimulation
treating ADD, PMS, SAD, migraine team up with Sydney Schneider of the that is reflected in brain wave activity and
headache, chronic pain, anxiety, depression Schneider Instrument Company of Ohio to observable on an EEG or QEEG can be
and hypertension. construct and market the first electronic entrained. Many more studies on photic or
clinical photic stimulator, called the combined audio/photic stimulation exist
History “Brainwave Synchronizer.” It comprised an than pure audio stimulation studies, howev-
Clinical reports of flicker stimulation intense xenon strobe light complete with a er audio-only stimulation studies have con-
appear as far back as the dawn of modern rotating dial that could be set to the fre- firmed audio entrainment (Chatrian,
medicine. It was at the turn of the 20th quencies of the standard four brain wave Petersen, & Lazarte, 1959) and its effect on
century when Pierre Janet, at the Salpêtrière rhythms. They found the Brainwave calming masseter muscle tension (Manns,
Hospital in France, reported that when he Synchronizer had powerful hypnotic quali- Miralles, & Adrian, 1981).
had his patients gaze into the flickering ties and soon published a study on hypnotic
light produced from a spinning spoked induction (Kroger & Schneider, 1959).
Physiology of Audio-
wheel in front of a kerosene lantern, it low- They also prompted other studies involving Visual Entrainment
ered their depression, tension and hysteria hypnotic induction in surgery and dentistry, In order for entrainment to occur, a con-
(Pieron, 1982). Then, in 1934, Adrian and and studies of general interest to the hypno- stant, repetitive stimuli of sufficient
Matthews published their results showing sis profession (Sadove, 1963; Margolis, strength to “excite” the thalamus must be
that the alpha rhythm could be “driven” 1966; Lewerenz, 1963). present. The thalamus then passes the stim-
above and below the natural frequency with In 1981, Comptronic Devices Limited uli onto the sensory-motor strip, the cortex
photic stimulation (Adrian & Matthews, was incorporated, with a focus on designing in general and associated processing areas
1934). TENS units and EMG feedback devices for such as the visual and auditory cortexes.
This discovery further propagated a host dental (TMJ) applications. In 1984, I Figure 1 shows the visual pathway with the
of small physiological outcome studies on designed the “Digital Audio-Visual retina of both eyes becoming excited and
the “flicker following response” by many Integration Device” (DAVID1), used for sending pulses down the optic nerve,
well respected researchers (Bartley, 1934, hypnotic induction and to calm anxiety in through the optic chiasm, and into the lat-
1937; Durup & Fessard, 1935; Jasper, performing arts students at the University eral geniculate of both thalami. From here,
1936; Goldman, Segal, & Segalis, 1938; of Alberta. The “light and sound” (L&S) the visual signals are passed onto the visual
Jung, 1939; Toman, 1941). Finally in 1956, market at this time was in its infancy and and cerebral cortexes for further processing.
W. Gray Walter published the results on resided primarily within the new age sector. Notice that there is very little delay from
thousands of test subjects comparing flicker There was little “known” research to sup- the onset of the flash to the response in the
stimulation with the subjective emotional port L&S technology, and professionals by optic nerve, but a delay of approximately
feelings it produced (Walter, 1956). and large showed disinterest in L&S tech- 100 msec occurs by the time the visual
Meanwhile, William Kroger accom- nology. Due in part to poor quality L&S evoked potential (VEP) is elicited in the

Summer 2003 Biofeedback 21


visual cortex. This delay may be why entrainment occurs best at the
natural alpha frequency — as 100 msec equates to 10 Hz.
Photic entrainment begins its process as a series of overlapping
evoked potentials (Kinney, McKay, Mensche, & Luria, 1973).
Kinney broke down a simple VEP into its various components
(Figure 2) representing the passage of time for 4, 8, 12 and 20 Hz.
As can be seen, much of the VEP occurs within 250 msec, correlat-
ing to four Hz. The various overlapping parts were then vector
summed into the mathematical VEP and compared with the actual
VEPs observed by EEG at the higher, entrained frequencies, shown
in Figure 2.
When this mathematical model was compared with the actual
observed EEG of the entrained stimuli (Figure 3), a high degree of
predictability was observed, demonstrating that photic entrainment
is indeed a vector summation of VEPs and not a novel neuronal
process. Figure 1. The EEG Photic Stimulation Path
By definition, entrainment occurs when an EEG reflects the brain
wave frequency duplicating that of the stimuli, be it audio, visual or
tactile (Siever, 2002). Entrainment occurs best near one’s own natu-
ral alpha frequency (Toman, 1941; Kinney et al., 1973). LEDs and
xenon strobe lights contain much harmonic content due to the
“squareness” or rapid turn-on and turn-off transitions of the stimuli
and these harmonics are reflected within the EEG. Figure 4 shows a
strong and pure entrainment at 12 Hz. The harmonics (small
wavelets) seen in the EEG are a reflection of the actual harmonics
contained within the stimulus. Square wave stimulation is associat-
ed with an increased risk of seizure (Joyce & Siever, 2000;
Ruuskanen-Uoti, 1994). The only way to produce entrainment
without harmonics is via sine wave stimulation in which the stimuli
turn on and turn off in slow, gentle transitions and do not contain
harmonics. (Van der Tweel, 1965; Townsend, 1973; Regan, 1966;
Siever, 2002).
AVE at 18.5 Hz has also been shown to produce dramatic
increases in EEG amplitude at the vertex (Frederick, Lubar, Rasey,
Brim, & Blackburn, 1999). The results of this study showed that:
a) eyes-closed 18.5 Hz. photic entrainment increased 18.5 Hz
Figure 2. EEG Wavelet
EEG activity by 49%.
b) eyes-open auditory entrainment produced increased 18.5 Hz.
EEG activity by 27%.
c) eyes-closed auditory entrainment produced increased 18.5 Hz
EEG activity by 21%.
d) eyes-closed AVE produced increased 18.5 Hz. EEG activity by
38.3%.
The bulk of entrainment shows itself near the vertex and frontally
(Siever, 2002). Figure 5 is a QEEG, or “brainmap” from the SKIL
(Sterman-Kaiser Imaging Labs) database, in 1Hz bins showing the
frequency distribution of AVE at 7.8 Hz. Notice the area within the
circle at 8Hz showing maximal effects of AVE in central, frontal
and parietal regions (at 10uv in this case) as referenced with the oval
area on the legend. It is through these effects that AVE has proven
effective in treating depression, anxiety and attentional disorders. A
harmonic is also present at 16 Hz. (the circled image), which is typ-
ical of semi-sine wave (part sine/part square wave) stimulation.
Figure 3. EEG VEPs - Vector Addition (Theoretical) Model vs. Observed EEG

22 Biofeedback Summer 2003


Figure 5. Brain Map in 1Hz Bins — During 7.8 Hz AVE (SKIL-Eyes Closed)

Figure 4. EEG Showing Photic Entrainment


stress load, whether we are aware of it or was found to be more effective than dot
not. In essence, when we focus on some- staring or stimulus deprivation (Leonard,
Body/Mind Effects of thing, we dissociate from other things. The Telch, & Harrington, 1999) as shown in
Audio-Visual Entrainment saying, “a change is as good as a rest,” has Figure 7.
We conceptualize AVE as achieving its much more truth to it than initially meets Furthermore, Leonard completed a sec-
effects through several mechanisms at once the eye (Siever, 2000). ond study with people who experience dis-
(Siever, 2000). These include: The first study on dissociation induced sociative anxiety (Leonard, Telch &
1) dissociation / hypnotic induction, via entrainment involved hypnotic induc- Harrington, 2000). People with dissociative
2) increased neurotransmitters, tion, and found that photic stimulation at anxiety feel a need to have a sense of con-
3) possible increased dendritic growth, alpha frequencies could easily put subjects trol in their lives and become anxious or
4) altered cerebral blood flow, and into hypnotic trances (Kroger & Schneider, panicky when they dissociate, be it driving
5) normalized EEG activity. 1959; Lewerenz, 1963). Figure 6 shows the home, at the office, or in a clinical setting.
results of Kroger and Schneider’s study in The Acute Dissociation Inventory (ADI) is
Dissociation which nearly 80% of the participants in the a 35-item self-report scale (Leonard, et.al.,
Dissociation is described as a process in study were in a hypnotic trance within six 1999). It assesses dissociative sensations
which feelings, memories and physical sen- minutes of photic entrainment. (ADI-Dissoc) and subjective anxiety, or dis-
sations are kept apart from other informa- Psychologists have been looking for ways sociative anxiety in response to dissociative
tion with which they would normally be to dissociate their clients as a part of fear provocation (ADI-Anx). Leonard and her
logically associated. In pathological terms, and phobia treatment. Inducing dissocia- colleagues clinically dissociated people who
dissociation is a maladaptive disruption in tion using AVE delivered by the DAVID1 become anxious when dissociating, by using
integrated functioning typically associated
with depersonalization, stress, identity,
amnesia and depersonalization disorders
(Brownbeck & Mason, 1999).
On the other hand, dissociation occurs
when we meditate, exercise, read a good
book, take in a movie or enjoy a sporting
event, because we get drawn into the pres-
ent moment and dissociate from all of our
daily hassles, worries, anxieties and the
resulting unhealthy mental chatter. ). Audio
dissociation analgesia using white noise
and/or has been shown to effectively
increase pain threshold and pain tolerance
during a dental procedure (Morosko &
Simmons, 1966). Regardless of the activity,
this type of dissociation reduces our weekly Figure 6. Photic Stimulation Induction of Hypnotic Trance (Kroger & Schneider, 1959)

Summer 2003 Biofeedback 23


cept that in order for AVE to occur, the
stimulating frequency must have a direct
impact on brain wave frequency and be
observable on an EEG.
Dissociation and
Restabilization
Dissociating clients with trauma histories,
during the course of treatment is important.
The state of mind that a person has at any
given moment is made up of the brainwave
activity associated with apprehension, anxi-
ety, physical tension (proprioceptive/affer-
Figure 7. AVE Induced Dissociation (Leonard, et al., 1999)
ent associations), destructive thoughts, and
conditioned responses relating to the colors,
smells, sounds, etc. Once the mind is clear,
a DAVID Paradise HemistepTM alpha ses- Glicksohn studied photic entrainment and all of these tensions, conditioned responses
sion. As expected, the participants’ anxiety the ASCs produced. He monitored the (bracing habits), fearful thoughts and the
(ADI-Anx) had almost doubled by the end EEGs of subjects during photic entrain- effects of afferance (sensory information)
of the AVE session. The surprise, however, ment. They all described a wide variety of subside, allowing the mind and brain to
was that their heart rate actually decreased, reactions to the stimulation with some relax, become more malleable and open to
contrary to normal anxiety reactions (Figure reporting incredible imagery consisting of new healthy thoughts, post-hypnotic sug-
8). With the ability to clinically dissociate items they had seen before in their lives, gestions, brainwave activity and so on.
these people, yet simultaneously calm them intertwined with geometrical patterns while During AVE, the EMG and electro-dermal
down somatically, AVE can be used as a others reported no visual changes at all. At responses fall, finger temperature increases
desensitization tool for reducing dissociative the end of the study, Glicksohn concluded and breathing becomes smooth and
anxiety. that: diaphragmatic. These changes reflect a
A dissociative mindstate or hypnotic 1) It is the increase in alpha activity creat- return to homeostasis or restabilization,
trance may be described in terms of an ed by photic driving, and not the nat- hence the term dissociation and restabiliza-
altered state of consciousness (ASC) in ural alpha activity itself, that is tion (DAR) (Siever, 2000).
which the subject (or an independent conducive to an ASC. Figure 9 shows a typical reduction in
observer of the subject) observes a qualita- 2) The appearance of visual imagery is forearm EMG and Figure 10 shows a typi-
tive shift in the normal pattern of mental neither necessary nor all that is cal increase in finger temperature. Notice
functioning (Glicksohn, 1986-87). ASCs involved to indicate the experience of that restabilization begins after about six
produced via overstimulation also occur an ASC. minutes of AVE, when the user begins dis-
when a person is bombarded with higher 3) If a photic driving response is not sociating. Figure 11 shows normalization of
than normal levels of sensory input, usually elicited, the subject will not experience breathing and heart rate variability follow-
in more than one sensory modality (Hear, an ASC. ing exposure to AVE at 7.8 Hz.
1971, Lipowsky, 1975, Goldberger, 1982). Glicksohn’s observations support the con-

Figure 8. Dissociative Anxiety and Somatic Arousal (Leonard, et al., 2000) Figure 9. Forearm EMG Levels During AVE (Hawes, 2000)

24 Biofeedback Summer 2003


orders. CBF increases dramatically during AVE (Fox & Raichle,
1985; Sappy-Marinier et al., 1992). Figure 18 shows an increase of
28% in cerebral blood flow within the striate cortex, a primary
visual processing area within the occiput. As an interesting note,
maximal CBF occurs at 7.8 Hz, the Schumann Resonance of the
earth.

Figure 10. Peripheral Temperature Levels During AVE (Hawes, 2000)

Neurotransmitters
There is evidence that blood serum levels of serotonin, endor-
phine, and melatonin rise considerably following 10 Hz., white-
light AVE (Shealy, 1989). Increases in endorphines reflect increased
relaxation while increased norepinephrine along with a reduction Figure 12. Cerebral Blood Flow at Various AVE Repetition Rates (Fox &
Raichle, 1985)
in daytime levels of melatonin, indicate increased alertness
(Figure 11).
Following Fox & Raichle’s study came a whole head PET analysis
of visual entrainment at 0, 1, 2, 4, 7, &14 Hz (Mentis, et. al.,
1997). This study on 19 healthy, elderly (mean age=64 years) found
that regional cerebral blood flow (rCBF) was activated differentially
with the:
1) left anterior cingulate showing maximal increases in rCBF at 4
Hz.
2) right anterior cingulate showing decreases in rCBF with fre-
quency.
3) left middle temporal gyrus showing increases in rCFB at 1 Hz.
4) striate cortex showing maximal rCBF at 7 Hz.
5) lateral and inferior visual association areas showing increases in
rCBF with frequency.
While there may be benefits to increasing occipital CBF, there is
even greater concern regarding conditions involving hypoperfuson
Figure 11. Neurotransmitter Levels Following AVE (Shealy, 1989) of CBF in frontal regions. Frontal disorders include: anxiety,
depression, attentional and behavior disorders, and impaired cogni-
tive function (Amen, 1998). Figure 13 shows an increase in frontal
Dendritic Growth CBF recorded on Hershel Toomin’s “Thinking Cap” (or
There is evidence that stimulating neurons with mild electrical “Hemoencephalogram”) using infra-red light to measure perfusion
stimulation promotes growth of dendrites and dendritic shaft of CBF. Notice that CBF at FPZ increases by 15% in 10 minutes
synapses in the cells being stimulated (Beardsley, 1999; Lee, (Toomim, personal communication).
Schottler, Oliver, & Lynch, 1980). However, studies do not yet Figure 14 shows a fairly typical brain map in 1 Hz bins of a per-
exist on the influence of AVE on dendritic growth, although it is son with mild depression and anxiety as shown on the Skil data-
suspected because many people with autism, palsy, stroke and base. Notice that alpha is slowed and approaching +2SD from the
aneurysm (Russell, 1996) have gained significant motor and cogni- norm and that some beta frequencies (16-18 Hz) are high (>1SD)
tive function following a treatment program of AVE. in central frontal areas.
Following an AVE session of 7.8 Hz., both alpha and beta activi-
Cerebral Blood Flow ty are normalized as shown below in Figure 15.
Cerebral blood flow (CBF) is essential for good mental health
and function. SPECT and FMRI imaging of CBF show that
hypoperfusion of CBF is associated with many forms of mental dis-

Summer 2003 Biofeedback 25


Conclusion
In closing, AVE has the ability to quickly and effectively relax
people out of high sympathetic activation and traumatic states of
mind, bringing about a return to homeostasis. AVE may be used
alongside hypnotic suggestions on tape/CD or live via a micro-
phone. At the same time however, AVE exerts a powerful influence
on brain/mind stabilization and normalization. At the end of an
AVE session, the user may realize that he/she has never felt so
relaxed for years — perhaps not since childhood.

Parts II of this article series will address several studies where


AVE was the clinical intervention. Part III will address the applica-
tion of AVE in treating attention deficit and cognitive disorders.
Footnote:
Figure 13. Hemoencephalographic Measure of Cerebral Blood Flow During 10 1. For more information, address all correspondence to:
Hz AVE (Toomin) David Siever, Comptronic / Mind Alive, 9008-51 Avenue,
Edmonton, Alberta, Canada T6E 5X4. Toll Free: 800-661-6463,
Phone: 780-461-9551, Web: comptronic.com, Email:
info@comptronic.com
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Summer 2003 Biofeedback 27


BOOK REVIEW AND
BRIEF FEATURES

Review of Handbook of Mind-Body


Medicine for Primary Care.
Eric Willmarth, PhD
Editors: Donald Moss, Angele McGrady, Terence C. Davies and
Ian Wickramasekera. Sage Publications, Thousand Oaks,
California. http://www.sagepub.com/ Copyright 2003. $99.95.
Reviewed by Eric Willmarth, PhD

No one who has attended meetings of the this case. sion of each of the fine chapters in Part I, I
Association of Applied Psychophysiology The main course of this book is divided did find the chapters by Angele McGrady ,
and Biofeedback or who has followed recent into four Parts including Part I: Models and and Sebastian Striefel, both past presidents
writing in the field of neurofeedback, Concepts for Mind-Body Medicine, Part II: of AAPB, very useful. While Dr. McGrady
biofeedback or complimentary complemen- Basic Clinical Tools, Part III: Applications provides the Psychophysiological Foundations
tary medicine can look at this wonderful to Common Disorders, and Part IV: of Mind-Body Therapy, Dr. Striefel considers
handbook without being amazed and Education for Mind-Body Medicine. Don Ethics and Practice Standards as they relate to
pleased at the list of contributing authors Moss, director of West Michigan Behavioral Mind-Body Medicine.
who participated in this project. Don Moss Health Services and past president of While Dr. Moss lists 16 Complementary
and his fellow editors have brought together AAPB, begins Part 1 with an overview of and Alternative Medicine Therapies in his
a group representing hundreds of years of Mind-Body Medicine and Clinical first chapter, only a few of these are given
practical clinical experience and have done Psychophysiology and does this in the con- in-depth consideration in the Basic Clinical
so without sacrificing the readability and text of Evidence-Based Medicine. He pro- Tools section. In addition to the the section
utility required of any effort entitled vides working definitions of each of these on Hypnotherapy, there are chapters on both
Handbook. You will find a full-course meal terms and conveys the insight of a seasoned Biofeedback and Biological Monitoring;,
contained in the 545 pages of this book and clinician making conceptual models blend Neurofeedback, Neurotherapy, and QEEG;,
I believe anyone with a hunger to learn nicely into practical clinical usefulness. Ian Acupuncture;, Cognitive-Behavioral Therapies
about behavioral medicine in primary care Wickramasekera, who has contributed for for the Medical Clinic;c, and Relaxation,
will have their craving satisfied. many years in both biofeedback and hypno- Autogenic Training, and Meditation. This
The appetizer that quickly engages you in sis research, has two chapters in this first section also contains an outstanding chapter
the need for this book is provided in the section. In his first chapter he introduces by Stanley Krippner, of the Saybrook
Foreword, written by Terrence C. Davies, his time-tested High Risk Model of Threat Graduate School, on Spirituality and
MD (Chair of Family and Community Perception and elaborates on issues of Healing. In completing the Mind-Body-
Medicine Eastern Virginia Medical School) Somatization and Psychophysiological Spirit triad, Dr. Krippner provides a histori-
and Frank V. deGruy, MD (Chair of Family Disease. In Chapter 5 Dr. Wickramasekera cal and world-view context for spirituality
Medicine, University of Colorado School of reviews the literature on the Placebo Effect in healing while at the same time pointing
Medicine). After developing the historical and applies this to the use of biofeedback out how deficient current Western
context of primary care and its crucial role instrumentation in clinical practice. He also Medicine is in providing this type of care to
in today’s society, they note that mind-body provides a broad overview of Hypnotherapy our patients. He goes on however to offer
problems hold a “central place” within pri- in Part II, Basic Clinical Tools. He includes practical suggestions on how to begin to
mary care. The authors also clearly chal- in this review both traditional “State” theo- address spiritual issues with clients and
lenge the separation of “mental” vs. ries of hypnosis represented, by researchers enter this crucial but “uncharted” area.
“physical” health and stress the need for such as Hilgard, as well as more recent cog- Building on the discussion of Conceptual
integration in any effective primary care nitive theories presented by Irving Kirsch Models and Clinical Tools, Part III provides
program. I would advise readers who gener- and others, giving his chapter a well-round- a full 17 chapters applying these tools to
ally skip a book’s Foreword not to do so in ed feel. While space doesn’t permit a discus- “Common Disorders”. Some of these chap-

28 Biofeedback Summer 2003


ters cover a broad category area such as including those of Steve Baskin and Randall The dessert comes in the final chapter
Sharon Williams Utz chapter on Caring for Weeks on Headache, Gabe Sella’s chapter on when Dr. Moss offers Existential and
the Person With a Chronic Condition or the Musculo-skeletal Skeletal Pain Syndrome, the Spiritual Dimensions of Primary Care:
chapter on The Metabolic Syndrome by chapter on Functional Bowel and Anorectal Healing the Wounded Soul. Following up on
Angele McGrady, Raymond Bourey and Disorders by Olafur Palsson and Robert Sharon Utz’s earlier reference to “the
Barbara Bailey. Most of the chapters howev- Collins, Stuart Donaldson and Gabriel Kingdom of the Sick”, Don provides eight
er are quite specific and include topics such Sella’s chapter on Fibromyalgia and the key perspectives to build the case that an
as Headache;, Asthma;a, Temporomandibular chapter regarding Asthma by Paul Lehrer, existential and spiritual outlook is needed
Disorders and Facial Pain;, Back Pain;, Mahmood Siddique, Jonathan Feldman, not only in Mind-Body Medicine, but in all
Coronary Disease and Congestive Heart and Nicholas Giardino. The use of hypnosis of medicine. I have no doubt that if this
Disorder;, Urinary Incontinence;, The is suggested in disorders including asthma, chapter was required reading for all physi-
Functional Bowel and Anorectal Disorders;, sleep disorders, fibromyalgia, back pain, cians, nurses, psychologists, and administra-
Fibromyalgia;, Chronic Fatigue;, chronic fatigue and irritable bowel syn- tors, our patient care, our outcomes and
Premenstrual Syndrome and Premenstrual drome. our job satisfaction would all be much
Dysphoric DisorderMS;, and Rheumatoid The final section of this book deals with- improved.
Arthritis. focuses on the education of professionals in In short, this book does a remarkable job
One of the true values of this Handbook Mind-Body Medicine. Separate chapters are in bringing together an impressive cast of
comes from being able to cross-reference dedicated to the education of physicians, authors to deal with a difficult and neglect-
the material in Part II and Part III. For (Margaret Davies and Olafur Palsson), ed area. Gabe Sella laments in his chapter
example, Theodore J. La Vaque provides a physician assistants, (Robert Jarski), nurses concerning back pain that “...there are no
nice history and overview, including a (Debra Lyon and Ann Gill Taylor), and funds available to look into what society
vocabulary lesson related to Neurofeedback, behavioral health providers, (Richard does not want to see” (pg. 270). This book
Neurotherapy and Quantitative EEG. While Gevirtz). In both of the chapters dealing goes a long way in providing the evidence
he also discusses applications, more detailed with physicians and physician assistants that what mainstream medicine has not
use of EEG can be found in Joel Lubar’s there is quick acknowledgment that the for- wanted to see has been to the detriment
chapter on Attention Deficit Hyperactivity mal training has been quite neglectful defi- of our health and that the integration
Disorder, Charles Lapp’s chapter on Chronic cient regarding Mind-Body Medicine. The of Mind-Body Medicine into traditional
Fatigue Syndrome, in Don Moss’s chapter on authors of the chapter on nursing education primary care is an essential step in provid-
Anxiety Disorders, and in Elsa Baeher and point out that the roots of nursing come ing new paths back to the Kingdom of
Peter Rosenfeld’s chapter on Mood from a holistic nurse-patient relationship the Well.
Disorders. In Chapter 8 Christopher Gilbert but that a desire to be “scientific” redirected This book is available from AAPB’s book-
and Don Moss provide an overview of much of the training in this area. Dick store, and 40 % of each purchase price will
many of the “traditional biofeedback” tech- Gevirtz deals with the controversy within go to support AAPB.
niques including EMG, Skin Temperature, behavioral medicine over who should be Eric K. Willmarth, PhD
Skin Conductance, Heart Rate, and providing services and clearly does not take President, Michigan Behavioral Consultants.
Respiration Feedback. Applications for the traditional “PhD only” stance in train-
these tools are found in many chapters ing or service delivery.

Does AAPB have your e-mail address?


• e-mail communications enable Please send your
AAPB to communicate better with
members. e-mail address today to the
• E-mail communications also save following address:
AAPB money, and enable the
Association to use your dues
aapb@resourcenter.com
money for other critical activities.

Summer 2003 Biofeedback 29


A Report from Hong Kong
Polina Cheng, Hong Kong
Use of biofeedback in Hong Kong can be ence support center for all the elite/scholar-
categorized into three settings: the universi- ship athletes in Hong Kong. Since 1992,
ty, the hospital, and the sports institute. biofeedback has been used to help elite ath-
University: At the Polytechnic University letes in Hong Kong to better understand
the Department of Rehabilitation Sciences their biological response in order to achieve
has conducted research on mental workload self-regulation of arousal level. At the
using EEG on normal working subjects. moment, we utilize two Procomp+™
Polina Cheng, M.Phi.,
They utilize a 40-channel NeuroScan™ and biofeedback systems (Thought Technology).
a 16-channel Harmoni™ system. The parameters we usually use are Skin
Hospitals: I have identified three hospi- Conductance (SC), Skin Temperature (ST),
tals in Hong Kong applying biofeedback Heart Rate (HR), and Respiration, not this case, the physiologist monitors the
therapy with their patients. They all use the much different from other biofeedback power output using Cybex, the biochemist
Procomp+ ™ biofeedback system and the practitioners. We did one research study monitors the effort level using blood lactate,
modalities are surface EMG, Heart Rate, regarding whether an individual’s preference and the sport psychologist teaches mental
Skin Temperature, Skin Conductance, and of visual versus verbal imagery could influ- skill to elevate the feeling of competency.
Respiration, but not EEG. The hospitals ence the effectiveness of systematic desensi- Skin Conductance is used to monitor the
and departments involved are: (1) the tization in reducing competition anxiety. relaxation and arousal level during imagery
Psychiatry and Clinical Psychology HR is used to monitor the changes during training. We find that both control and
Department of the Queen Mary Hospital, desensitization training. The results indicate experimental group have increased power
which treat patients with Raynaud’s disease that the athletic population preferred visual output at the post-tests. Most probably the
(loss of circulation to the hands and feet), imagery as their cognitive style over verbal imagery effect was confounded with the
insomnia, anxiety, and muscle tension/pain, imagery. The results also demonstrate that biochemistry feedback, blood lactate level.
(2) the Clinical Psychology Service the imagery based systematic desensitization In normal practice, athletes learn to look at
Department of the Tuen Mun Hospital, procedure appeared to be equally effective their lactate level as an indicator of their
which treats patients with chronic muscle for the reduction of anxiety for all partici- effort in each training session. In this inves-
pain, anxiety, and stress-related disorders, pants, regardless of preferred cognitive style. tigation, we failed to prove that an increase
and (3) the Clinical Psychologists of the Another research study we did used a of power output is due to the effectiveness
Staff Clinic of the Hospital Authority, multi-disciplinary approach with collabora- of motivational imagery. However, we were
which treats hospital staff members with tion of the Exercise Physiologist, the able to prove that, with the help of objec-
insomnia, psychosomatic pain, muscle pain, Biochemist and the Sport Psychologist, tive feedback (either biochemical, physio-
and motor tension (tension throughout the looking at the effect of motivational logical or biological response), one’s
entire body, which restricts mobility). imagery on increasing power output. The self-awareness can be improved, thus, full
Sports Institute: I am employed at the reason we use a multi-disciplinary approach potential is more likely to be elicited.
Hong Kong Sports Institute, of the Hong is that we believe that, most of the time,
Kong Sports Development Board, a govern- individuals undermine their potential/pain
ment funded training center and sports sci- tolerance due to their past experiences. In

30 Biofeedback Summer 2003


ABOUT THE AUTHORS
Jeffrey R. Cram, PhD, is currently the and New Hampshire Community Technical research papers, and co-producer of Healthy
clinical director of the Sierra Health College where he teaches aquatic physical Computing Email Tips. She is co-director
Institute of Nevada City and the executive therapy and advanced orthopedic tech- of Work Solutions, USA, which provides
director of the Auburn Pain Clinic in niques to physical therapy students. He is work-site prevention and employee training
California. He is the founding president of on the teaching faculty of Aquatic utilizing biofeedback.
the Surface EMG Society of North America Consultants of Georgia and clinical faculty Jeff Leonards, PhD, is a licensed psychol-
(SESNA), now the SEMG Division of the of the Biofeedback Foundation of Europe. ogist with Evergreen Behavioral Services, a
Association for Applied Psychophysiology He has authored several articles on aquatic division of the Franklin County Health
and Biofeedback. He has authored three rehabilitation and lectures nationally and Network (http://www.fchn.org/) in
books on surface EMG and 35 scientific internationally on aquatic physical therapy Farmington, Maine. Through this network,
articles on a variety of topics related to for orthopedic and neurologic conditions Dr. Leonards coordinates behavioral medi-
applied psychophysiology. He is on the edi- and the use of aquatic biofeedback in the cine services including consultation to
torial board for four journals (American treatment of upper and lower extremity Franklin Memorial Hospital, a rural 70-bed
Journal of Pain Management; Applied conditions. facility where he is an affiliate member of
Psychophysiology and Biofeedback; Journal of Bradley D. Hatfield, PhD, is a full pro- the medical staff. Dr. Leonards is an avid
Manipulative and Physiologic Therapies; and fessor in the Department of Kinesiology at athlete, participating regularly in cycling,
International Journal of Healing and Caring) the University of Maryland, College Park, hockey, weight training, and nordic skiing.
and is an advisor to the Biofeedback Society with adjunct appointments in the Center He holds a black belt in Tae Kwon Do, is a
of California. Dr Cram is an international for Neural and Cognitive Sciences and the former ski-patroller, and is current president
expert on surface electromyography and Center on Aging. He received his PhD in of the Western Mountains Hockey and
teaches both nationally and abroad multiple 1982 from the Pennsylvania State Skating Association.
times a year. University where he was supported by the Erik Peper, PhD, is Professor and
Polina Cheng, M.Phi., is currently a Research Council of Canada as a predoctor- Director of the Institute for Holistic
Sport Psychology Officer with the Hong al fellow. He has published in a number of Healing Studies at San Francisco State
Kong Sports Development Board. She scholarly journals such as Psychophysiology University. He is President of the
earned her bachelors degree at Cornell and Biological Psychology. Biofeedback Foundation of Europe and past
College in Mt. Vernon, Iowa, and her mas- Scott E. Kerick, PhD, earned his PhD in President of the Biofeedback Society of
ters degree at the University of Hong Kong. 2001 from the Department of Kinesiology America, now AAPB. His most recent
She conducts workshops teaching sport psy- at the University of Maryland, College Park books are Healthy Computing with Muscle
chology theory to coaches and workshops and is currently a National Research Biofeedback and Make Health Happen:
on performance enhancement to elite ath- Council Postdoctoral Research Associate at Training Yourself to Create Wellness. He is
letes and coaches. She worked with partici- the Human Research and Engineering co-producer of Healthy Computing Email
pants in the 1998 and 2002 Asian Games Directorate of the U.S. Army Research Tips. His research interests focus on psy-
and 2000 Olympic Games preparing them Laboratory, Aberdeen Proving Ground, chophysiology of healing, healthy comput-
for competition preparation and conducting Maryland 21005. Dr. Kerick has published ing, respiratory psychophysiology and
post-game intervention. She is also prepar- scholarly work in Biological Psychology, voluntary self-regulation. Correspondence
ing the Olympic qualifiers for the 2004 Medicine and Science in Sport and can be directed to ihhs@sfsu.edu
Olympic Games in Athens. Exercise, and Neurobiology of Aging. Lawrence M. Schleifer, EdD, CPE, is an
Ron Fuller, BA, PTA, is a licensed physi- Katherine Gibney is a biofeedback thera- Industrial Psychologist and Certified
cal therapy assistant and the national aquat- pist and Clinic Manager at NovaCare Professional Ergonomist (CPE) with the
ic specialist for HealthSouth Corporation, Rehabilitation in Oakland, California. She National Safety and Health Program,
practicing at HeathSouth Rehabilitation collaborates with Erik Peper in student Internal Revenue Service, Washington,
Hospital in Concord, New Hampshire. Mr. research and Risk Management Prevention D.C. He also holds an appointment as an
Fuller attended the University of Texas in Programs at San Francisco State University. Adjunct Associate Professor in the
San Antonio, Texas where he received his She is co-author of two books, Healthy Department of Kinesiology, University of
certificate in Physical Therapy and Computing with Muscle Biofeedback and Maryland and is currently the Principal
Occupational Therapy techniques. He is an Make Health Happen: Training Yourself to Investigator of a research grant titled “EMG
adjunct faculty at Franklin Pierce College Create Wellness, of numerous articles and Gaps, Psychosocial Factors and

Summer 2003 Biofeedback 31


Musculoskeletal Disorders in Computer Thomas W. Spalding, PhD, is an assis- He is a past president of the Association of
Work,” which is funded by the Johns tant professor in the Department of Applied Psychophysiology and Biofeedback
Hopkins Center for Information Kinesiology and Health Promotion at the (AAPB), current president of the
Technology and Health Research. California State Polytechnic University, Neurofeedback Division of AAPB,
David Siever graduated in 1978 as an Pomona. He earned his PhD in health Secretary/Treasurer of the International
engineering technologist. He later worked education in 1989 from the University of Section of AAPB and regularly writes an
in the Faculty of Dentistry at the University Maryland, College Park. His research focus ongoing ethics column and conducts work-
of Alberta designing TMJ Dysfunction is human stress reactivity and he has pub- shops on ethics, standards, and professional
related diagnostic equipment and research lished scientific articles in journals such as conduct.
facilities. He organized research projects, Biological Psychology, Medicine and Eric K. Willmarth, PhD, is the president
and taught basic physiology and a TMJ Science in Sport and Exercise, and the of Michigan Behavioral Consultants, P.C., a
diagnostics course. Dave observed anxiety American Journal of Industrial Medicine. private practice specializing in pain manage-
issues in many patients suffering with TMJ Sebastian “Seb” Striefel, PhD, became a ment. He received his PhD in clinical psy-
dysfunction, prompting him to learn and Professor Emeritus in the Department of chology from the Fielding Graduate
practice biofeedback and design biofeed- Psychology at Utah State University in Institute. He is the past-president of the
back devices. In 1984, Dave designed his September 2000. For twenty six years he Michigan Society of Behavioral Medicine
first audio-visual entrainment (AVE) device- taught graduate level courses in ethics and and Biofeedback, and the Chair of the
the DAVID1. Since then he has researched professional conduct, clinical applications of Ethics Committee for the American Society
and refined AVE technology, specifically for biofeedback, clinical applications of relax- of Clinical Hypnosis. He served as the
use in relaxation, and treating anxiety, ation training and behavior therapy. He Program Chair for the 33rd AAPB annual
depression, PMS, ADD, FMS, SAD, hyper- was also the Director of the Division of meeting is Las Vegas and was the 2001 win-
tension and insomnia. He presents AVE Services at the Center for Persons with ner of the APA’s Division 30 Hilgard
technology applications regularly at confer- Disabilities at Utah State University. In Award. He has over 25 years of experience
ences and for special interest groups. that role he managed a variety of programs, in biofeedback, hypnosis, and behavioral
including an outpatient clinic, a biofeed- medicine.
back lab and an early intervention program.

UPCOMING WORKSHOPS

Using Heart Rate Variability Biofeedback


(HRVB) to Treat Functional Disorders
Richard Gevirtz
October 12, 2003 • Arlington, Texas
This workshop has as its objectives 1) familiarizing participants with the theory and measurement of heart rate variability, 2) presenting
biofeedback protocols which include HRVB techniques, and 3) applying these techniques to the treatment of disorders such as IBS,
Asthma, Migraine, or Myofascial Pain. Demonstrations and hands on training will be offered to compliment the background information.
Course Objectives:
Each participant should be able to:
1) Describe the basic theory and measurement considerations involved in HRV
2) Demonstrate ability to administer a HRVB protocol to a sample patient
3) Apply the above principles to various "functional" disorders
Bio: Dr. Richard Gevirtz is a professor in the Health Psychology Program at the California School of Professional Psychology at Alliant
International University in San Diego. He has been in involved in research and clinical work in applied psychophysiology for the last 25
years. His primary interests are in understanding the physiological and psychological mediators involved in disorders such as chronic mus-
cle pain and gastrointestinal pain. He is the author of many journal articles and chapters on these topics.
More information: biofdbk1@aol.com

32 Biofeedback Summer 2003


UPCOMING WORKSHOPS

The Heart and Mind of Biofeedback


Biofeedback Society of California
29th Annual Conference
Co-sponsored by the Biofeedback Society of California and the Association for Applied
Psychophysiology and Biofeedback
November 6 - 9, 2003 • Pre-Conference Workshops: November 6-7, 2003
15 Hours of General Conference CEU are already approved
The pre-conference workshops, sponsored by AAPB, are the ratory sinus arrhythmia (RSA). We will theorize and/or show
beginning of a journey through the depths of the Heart and Mind howthis method can improve homeostatic capacities, improve per-
of Biofeedback. Internationally know presenters Lynda and Michael formance, enhance resistance to functional illness, and how RSA
Thompson, and Paul Lehrer will be the faculty for these outstand- biofeedback is influenced by cardiovascular resonant frequencies.
ing events. Experiential and applied exercises will be done, and treatment man-
Neurofeedback Fundamentals for Successful Assessment and uals and applications to autonomic and emotional dysfunction will
Training Presented by Lynda Thompson, Ph.D. assisted by be discussed.What you will learn:o To identify the various known
Michael Thompson, MD oscillations in heart rate, their link with breathing, and known
This workshop covers the basic science behind neurofeedback physiological mediators.o To examine the theoretical links between
and provides practical pointers for how to assess and improve func- the body's homeostatic capacity and both the complexity and
tioning in clients with a variety of problems: ADHD, learning dis- amplitude of these oscillations.o To recognize the differing resonant
abilities, Asperger's syndrome, seizure disorders, anxiety, movement frequencies for heart rate and blood pressure, and implications for
disorders (Tourette's, Parkinson's) and depression. Participants will studying and training baroreflex activity.
learn about quantitative EEG profiles (single channel and 19-chan- You will also have the opportunity to advance your education
nel) and how they differ according to symptoms. A logical and sharpen your professional skills by participating in any one of 5
approach to moving from assessment information to decisions panels, 4 keynote presentations and 18 outstanding short courses.
about which frequencies and electrode placements to use is given. Workshops, short courses, keynotes and panels on the Heart rate
There will be tips on how to set up training programs that combine variability and EEG biofeedback will cover the latest research on
neurofeedback and biofeedback. Included are methods for helping the Heart and Mind. A special luncheon panel on Ambulatory
generalization of the training to home, school and work environ- Physiological Monitoring will be sure to bring new ideas to
ments. The course will also mention how to use these techniques to biofeedback and continuous monitoring of physiological stress lev-
optimize the performance of executives and athletes.What you will els. This year we are expecting more student involvement with a
learn:o Recognize EEG patters that are typical for anumber of dis- poster presentation session. Join us for an in-depth examination at
orders;o Understand one and two channel EEG assessments and the latest biofeedback hardware and software by spending time at a
describe the procedurd for applying electrodes, collecting, and arti- dedicated available for demonstrations and teachings. A special
facting EEG datao Develop a ration intervention based on assess- workshop from a new member coming from Mexico City will help
ment data, and conbine elements of neurofeedback, biofeedback to teach us how to work with children from Mexico.
and cognitive strategies for an individualized training programThis Outstanding speakers include: Michael and Lynda Thompson,
course is suitable for those new to the field of neurofeedback as well Paul Lehrer, Peter Litchfield, Rob Kall, Dick Gevirtz, Larry
as to experienced clinicians who want to review the most effective Jammer, Shari St. Martin (Mexico City, Mexico), Naras Bhat, and
practices in our field and the science that underlies EEG work. Eric Peper.
Cardiovascular Resonant Frequency Biofeedback, Presented by Contact BSC at (800) 272-6966 or (714) 848-0022
Paul Lehrer, Ph.D. for more information, or see
This workshop will introduce participants to cardiac variability, http://www.biofeedbackcalifornia.org/2003%20Conference.htm.
the complex patterns of oscillation that comprise it, interpretation
of various rhythms, and effects of biofeedback for amplifying respi-

Summer 2003 Biofeedback 33


Dear colleagues:

ISNR and AAPB are co-sponsoring a one day workshop on the "Fundamentals of General Biofeedback" on September 17 at the
ISNR conference in Houston. Knowledge and skills in general biofeedback can broaden the kinds and numbers of referrals which your
neurofeedback practice can accept. You will be able to address more diagnoses and disorders, help more people, and recruit referrals
from a larger market. General biofeedback is also an excellent tool to prepare patients for neurofeedback. Learning simple physiological
control assists the individual to gain a stronger internal locus of control. Neurofeedback often proceeds faster when interspersed with
such basic biofeedback modalities as thermal biofeedback and respiratory biofeedback.

Two experienced clinicians and teachers, Drs. Fred Shaffer and Don Moss, will be teaching this workshop, which will cover the fol-
lowing objectives: 1) introduce the students to the basic modalities of peripheral biofeedback, 2) review the common well-documented
applications of peripheral biofeedback, 3) review autonomic nervous system physiology relevant to biofeedback, 4) review ANS medi-
ated biofeedback treatment interventions, and 5) review conceptual models for the efficacy of biofeedback therapies, including general
stress theory, operant conditioning, the stress-diathesis model, and non-specific therapeutic effects.

This workshop will also provide eight didactic hours toward BCIA certification, and will include demonstrations with several general
biofeedback modalities. The workshop will be taught at the introductory level.

For more information on the workshop, see the following prospectus. To register for the ISNR conference and this workshop, please
go to http://www.isnr.org/2003/main2003.htm

Sincerely,

Lynda Kirk, MA
President, AAPB

800-488-3867
office@isnr.org
www.isnr.org

Make your plans now to join us in HOUSTON on SEPTEMBER 18 – 21, 2003


for the 11th Annual ISNR Conference!

Bring your string tie and fancy boots. Rustle on over to the Westin Oaks where the rates aren’t Texas
sized, but the discounts ARE - $99 per night – single or double occupancy! We continue the tradition of good
science and good times!
Our conference highlights some of the most prominent neuroscientists and clinicians in the world. Our
Keynote and Invited speakers include Donald Bars (Switzerland) Anat Barnea (Israel), John Gruzelier (Great
Britain), John Hughes, Wolfgang Klimesch (Austria), Juri Kropotov (Russia), Norman Moore (Australia),
Rolland Parker, Karl Pribram, Alan Scheflin, Barry Sterman, Gabriel Tan, Robert Thatcher, Lynda & Michael
Thompson (Canada), and Eran Zaidel.
As in previous years, the ISNR conference is the place to learn about the latest research and clinical
techniques that are being applied in the field of EEG Biofeedback. The presentations and workshops this year
include several basic introductory sessions for the beginner, diverse clinical applications (including LORETA)
with various patient populations for the clinicians, and several QEEG and ERP studies for the researchers in
our society. No matter what one’s interest is or level of expertise, there is something for everyone in this
exciting conference!
See our website, www.isnr.org
, for a list of pre- and post-conference workshops, and a
complete conference schedule! Don’t forget the registration form! See y’all there!

34 Biofeedback Summer 2003


Association for Applied Psychophysiology and Biofeedback Canadian Non-Profit Org.
Publication U.S. POSTAGE
10200 W 44th Ave Suite 304,
Agreement PAID
Wheat Ridge CO 80033-2840
#1583581 PERMIT NO. 66
Wheat Ridge, CO

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aapb News
& Events
FROM THE PRESIDENT

“Build It and They Will Come”


Lynda Kirk, MA, LPC, BCIA-C, QEEGT

I want to tell you all how truly honored I and wonders of nature, mathematics, and sion to use biofeedback to reduce their
am to serve as your president. I have a science, and in our longing for connection symptoms and their need for medication
strong love for this field and for AAPB. You to the Absolute. simultaneously. You and I have very many
are my friends and colleagues, and you have And in our more recent history, from the patients who go back to their referring
mentored me, nurtured me, and taught me Greens’ early work at Menninger and the physicians and thank them dearly for sug-
much. I promise to do my very best to help work of many other biofeedback pioneers gesting biofeedback.
this organization and our field to grow and such as Kamiya and Basmajian to our cur- Complaints more often categorized as
thrive so that we can reach the many, many rent biofeedback applications, we have seen “medical” where biofeedback can improve
people who need what we do. Now perhaps stunning successes in transforming and function are myriad: chronic pain, migraine
more than at any time in our history, what healing mind, body, and spirit. and tension headaches, myofascial pain dis-
we have to offer is really important. In the St. Augustine said, “Miracles do not hap- order, fibromyalgia, chronic fatigue, auto-
next several paragraphs, I want to take you pen in contradiction to nature, but only in immune disorders, asthma, irritable bowel
on a brief journey from our past to our contradiction to that which is known to us syndrome, TMJ syndrome, hypertension,
present to a vision of our future. What we about nature.” Our current technologies Raynaud’s, epilepsy, brain injury, cardiac
do greatly affects the future of this field. It’s allow us ever-increasing knowledge about arrhythmias, coronary disease, gastrointesti-
up to us. We have much important work to nature. We can now map the human brain nal problems, acid reflux, esophageal spasm,
do. and map the human genome. We have chronic constipation, urinary incontinence,
As I did research preparing my talk for technologies to map both inner and outer dysfunctional voiding, interstitial cystitis,
AAPB’s 34th Annual Meeting, I was awed space. Our tools of technology have become vulvodynia, vaginismus, muscle spasm, dys-
by the length of time we human beings powerful tools of transformation. tonias, and more. Patients with these pre-
have been on a quest for tools of transfor- Our current biofeedback tools allow us to sentations are the ones who were
mation. Since the beginning of human his- guide people from states of dysfunction to historically referred to biofeedback as a last
tory, there is plenty of evidence that our function all the way to optimal function. As resort. I am thankful that this is no longer
ancestors attempted to understand and you know, biofeedback can help people the case. Yet, even though biofeedback is
influence the internal and external “powers- with the following dysfunctional states considered mainstream, we’re not reaching
that-be.” become more functional: anxiety disorders, enough people.
From the prehistoric cave drawings, to panic disorders, OCD, sleep disorders, Biofeedback technologies are also an inte-
the great pyramids in ancient Egypt almost stress disorders, depression and mood disor- gral part of optimal function training,
5000 years ago; to megaliths such as ders, PTSD, ADHD, pervasive develop- whether the application is to health and
Stonehenge, to shamans and healers down mental disorder, Tourette’s, conduct wellness, to sports and athletics, to business,
through the ages, we humans have sought disorder, addictions, learning disabilities, to education, to performing and fine arts,
tools of transformation. We have continued and more. It is nothing less than transfor- or to life. The common thread in all these
this quest in explorations of the mysteries mative for a patient with anxiety or depres- applications is self regulation.

Summer 2003 Biofeedback 1A


With EEG biofeedback, we can now self- because that’s when I finished my biofeed- the sky is the limit. Consider what associate
regulate our brainwaves. Let’s use ADHD as back training.” editor neurologist Frank Duffy, MD wrote
an example. According to the American With biofeedback we can now self-regu- in his editorial in the journal Clinical EEG:
Academy of Pediatrics, ADHD is the most late our cognition, our intellect, and our “The literature, which lacks any negative
common neurobehavioral disorder of child- consciousness in ways that were not previ- study of substance, suggests that EEG
hood, with an estimated 6-9% of children ously possible. This unprecedented ability biofeedback therapy should play a major
in the U.S.A. having ADHD. There are a heralds a dramatic breakthrough in the shift therapeutic role in many difficult areas.
number of valid public health concerns of power to the individual. This is perhaps In my opinion, if any medication had
about medication treatment of ADHD. the most powerful thing we have to offer – demonstrated such a wide spectrum of
Medications fail to produce desired we can empower people – and shift their efficacy, it would be universally accepted and
improvements in 30-40% of patients. Gains locus of control from external to internal. widely used.”
from pharmacotherapy are state-dependent They can own the ability to self-regulate. “Build it and they will come.” We have
(i.e. they wear off ). 20-50% of patients William James said, “The greatest thing, the tools of transformation before us. What
experience side effects from medications. then, is to make the nervous system our ally we must build, my friends and colleagues, is
And there is well-documented potential for instead of our enemy.” Our transformation- increased awareness in the professional and
medication abuse. al tool of biofeedback has the potential to lay public about biofeedback and psy-
We have an excellent rationale for EEG shift our old paradigms of healthcare and chophysiological self-regulation. We MUST
biofeedback versus medication management healing and launch new paradigms of psy- get the word out and make biofeedback
for ADHD. As I tell the University of Texas chophysiological self-regulation. more widely available to a public that is
Medical School residents who cycle through We now have the potential to produce hungry for self-regulation. What we have to
my clinic during their Integrative and enormous social and economic changes lose by inaction on our part is the opportu-
Complementary Medicine rotation, EEG with biofeedback and psychophysiological nity to make a real impact on unnecessary
biofeedback can be an effective, drug-free self-regulation. Take seizures as an example. human pain and suffering. What we have to
alternative for patients who have side-effects The chance that a medically uncontrolled gain by building increased awareness of our
from medication, who have poor medica- candidate for temporal lobectomy can be powerful tools of transformation is quan-
tion response, who are concerned about saved with EEG biofeedback is estimated to tum leaps in health, creativity and human
medication’s long-term effects, or who sim- be about 50%. Surgery costs are between potential. The time is now. It’s up to us.
ply refuse to consider medication. $50,000 to $100,000. You figure the math
With biofeedback we can now self-regu- (not to mention the risks of surgery, infec-
late our physiology. As one of my patients tion, downtime and more). Yet how often is AAPB Foundation
told an Austin magazine, “I have no more
migraines and way less stress. I wish the
biofeedback considered an option?
If we look back at Gene Peniston’s work
Receives
doctor had made the suggestion to do with alcoholic veterans over 13 years ago, Recognition for
biofeedback earlier instead of wasting time subsequent hospitalizations were reduced by
and money on pills that don’t work.” 80%. Using fiscal projections from 10 years Ferguson
With biofeedback we can now self-regu- ago, the cost of hospitalization was over An anonymous donor has made a con-
late our emotions. Another of my patients $100,000 compared to the $3000 to tribution to the AAPB Foundation
who was interviewed in the newspaper stat- $5000 cost of the biofeedback Peniston Student Scholarship Fund in recognition
ed, “I don’t do depression anymore. I don’t used to get these results. This is yet another of AAPB member Elsie Ferguson. The
react angrily very often any more, and when example of biofeedback being the tools of award as made in honor of Dr. Elsie
I do I get over it real quick. I credit EEG transformation in the lives of these vets and Ferguson and in recognition of her
biofeedback for making it possible. I’ve got their families. unstinting commitment to teach and
a new appreciation of life. They say life What are the potentials and possibilities train her colleagues in the Mid-Atlantic
begins at 40. Well for me it began at 41 for us and our field? I propose to you that Society for Biofeedback and Behavioral
Medicine. Dr. Ferguson daily lives by and
We Encourage Submissions honors the clinical and scientific stan-
Send chapter meeting announcements, section and division meeting dards inherent in the scientist/practitioner
reports, and any non-commercial information regarding meetings, pre- paradigm. She is an inspiration to each of
sentations or publications which may be of interest to AAPB members. us. The funds were used to aid a student
Articles should generally not exceed 750 words. Remember to send infor- to attend the annual meeting through the
mation on dated events well in advance (we may be able to publicize Foundation’s student scholarship pro-
your event more than once if you get your calendar to us early enough). gram.
Francine Butler, PhD,
Send Word (.doc) or text files by e-mail to the News and Events Editor:
AAPB Executive Director
Ted LaVaque, PhD tlavaque@gbonline.com.

2A Biofeedback Summer 2003


At the AAPB awards and recognition breakfast in
Jacksonville on March 30, 2003 the following individu-
als were honored. The presentations were made by
President Paul Lehrer and the following comments are
from his presentation.
The first two recognitions go to pioneers in our
field-- Marjorie and Hershel Toomim. These two folks
have been true pioneers in biofeedback, in clinical prac-
tice, in training and in the development of instrumen-
tation. They have given years to our field and we President Lehrer Presents Donald Moss with
recognize their contributions with a plaque. Congratulations Marjorie and Hershel. Adler Service Award
The next presentation goes to an old friend, a colleague, a teacher and a mentor – Dr.
David Shapiro. Dave was also a pioneer in this field who inspired many of his students to
follow a science career in the study of applied psychophysiology.
This year we honor Dr. Donald Moss as the recipient of the Sheila Adler Service Award
for AAPB. The Awards Committee selected Donald P. Moss PhD for his major contribu-
tions to AAPB and to the field. As Editor of our magazine, Biofeedback, he turned the
newsletter into a first class magazine of which the membership can be proud. As chair of
the primary care interest group, he nurtured its growth into an active section of AAPB. He
served as chair of several AAPB committees and completed his term as president of AAPB a
year ago. As editor of his new book, Mind Body Medicine for Primary Care, he led the effort
to present the best clinical applications to the national and international primary care audi-
ence. President Lehrer Honors Marjorie and Herschel
The second recognition goes to Edward B. Blanchard PhD as the recipient of the AAPB Toomim
Distinguished Scientist Award. His outstanding research over many years has garnered
recognition and grant support by NIH and by numerous scientific journals that have pub-
lished his work. His research has been highly influential in advancing science and practice
in the areas of headache, hypertension, irritable bowel syndrome and post traumatic stress
disorder. He has shared his vision and his expertise with his graduate students, who have
gone onto independent careers at academic institutions, and with his colleagues in AAPB,
who have been educated and inspired by his work. . AAPB is proud to confer the
Distinguished Scientist Award to Dr. Ed Blanchard.
I turn to my close friend and colleague, Richard Sherman who chaired this yearís Annual
Meeting Committee. You did a wonderful job. This plaque can only symbolize my endur-
ing thanks.
The Presidential Recognition Award is presented to an individual or organization who
On the left, Past-President Paul Lehrer, center,
provides outstanding service to AAPB and to applied psychophysiology as recognized by
President Lynda Kirk, on the right, President Elect
the President. This year we want to recognize Larry Klein and Hal Myers the founders of Steve Baskin
Thought Technology Ltd. They too are pioneers in our field who helped develop and nur-
ture its growth. Over the years they have been strong supporters of AAPB, helping promote
our meeting, our programs and membership development. Their contributions have
included advertising our programs in the printed materials, contribution of complete
instrumentation systems to qualified students and sponsorship of meeting eventsónote your
wonderful tote-bags. Thank you for being our friends and partners.
In our enduring relationship with corporate members, we thank you for your support
this past year. Without your development and new products, our field would not progress.
Although your plaque was presented to you at your booth, I would like these company rep-
resentatives to stand up and be recognized: Bio-Medical Instruments, Inc.; Heritage
Medical Services; Stens Corporation, and Thought Technology, Ltd.
This yearís student scholarship awards recipients were: Elizabeth Bigham, Ashley Burden,
President Lehrer Honors Hal Meyers and
Continued on page 4A Lawrence Klein of Thought Technology, Limited

Summer 2003 Biofeedback 3A


FROM THE PRESIDENT-ELECT

Finding a Professional Home:


President Elect’s Column
Steve Baskin, PhD

I started this column hoping to add my We had lunch, (Mark for the second time), California told me how much he was enjoy-
two cents on complementary and alterna- and talked about our work, families, health, ing the meeting and how he felt that it was
tive medicine. As I reflect back on our and Mark gave me a viewing of the won- provocative, stimulating and fun. He had a
Jacksonville annual meeting, I keep hearing derful new edition of his classic book. We plan to get more students involved in our
Jim Gordon’s words on mind-body medi- laughed a lot. We talked about being mem- association. He suggested that all the “sen-
cine. He emphasized the therapeutic benefit bers of other professional groups and how ior” members, which unfortunately, I think,
of groups to facilitate social support across AAPB is clearly our professional home. included me, should give 10 talks a year to
the spectrum of health care. In a sense, Then I ran into the Medical College of student groups, exposing them to our work
mobilizing the power of a supportive Ohio crowd; Angele McGrady, Tom Fine, and ideas and encouraging them to join.
“home-like” environment to empower and and Guillermo Bernal. Now I knew I was Ten might be a bit much, but I did one last
heal. home. Talking NCAA basketball with week at Yale, that bastion of seriousness. I
Let me digress. I travel a bit and in times Angele, “belly” laughs with Tom and did the necessary power point psychophysi-
of chaos, either personal or community- Guillermo, the kind where your eyes are ology of migraine talk. However, my mes-
wide, it is always a bit unnerving to leave tearing and your nose runs. We caught up, sage to them was to never join a
home. Leaving Connecticut for LaGuardia talked a little shop and we laughed and professional group, or any group for that
airport to attend our annual meeting, I felt laughed some more. These wonderful expe- matter, that’s spiritually constipating. I
a vague sense of disquiet. There was a war riences kept happening. The combination introduced them to AAPB; diverse,unique,
beginning, and at 6:30 AM on a weekday of the terrific scientific program, the vitality challenging but friendly, lots of innovation
morning, there was surprisingly little traffic of our membership and the warm welcom- and excitement, peppered with the ocas-
into NYC. When I got to the airport, I was ing environment made me feel at home. sional characters and renegades. My profes-
amazed at how empty it was. Close to 8 Kind of like the healing properties of sional home. Vital and full of strong
AM and I am the only person at a boarding groups, according to Dr. Gordon. opinions. I’ve always believed it’s easier to
pass machine. A lonely agent walked over I went to the Allied Health Professional lower the volume than to raise it. We need
and said, “Excuse me sir, thanks for flying section meeting and was impressed with to proselytize, a bit. Go forth “senior”
Delta, do you need some help.” The slight their ideas and energy. A student from members and bring in some new faces.
feeling of dread increased a bit when she
noticed my 3 one-way tickets and my lug-
gage was sent straight to radiology. I was Awards and Recognition
allowed to board and spent the flight study- continued from Page 3A
ing the program for the annual meeting.
Rich Sherman had put together an incredi- Ann Conboy, Tobias Egner, Kathryn Findley, Brian Freidenberg, Larry Honig, Bridget
ble group of speakers covering a large area Luebbering, Dorothy Marie Mandel, Stephanie Tiller Nevin, Kathryn Rumora, Melissa
of the biofeedback and applied psychophys- Schlereth, Jennifer Schwyhart, Leslie Sherlin, Shannon Warwick, Sandra Wolfe.
iology waterfront. I began thinking about One of the sad events at the end of the year is to see the term of good people on the
AAPB, the uniqueness and diversity, the Board come to an end. This year Christine Hovanitz concludes her service at this
wonderful friendships formed over the meeting. Also, Don Moss completes his term as Past President.
years. My unease was lifting. Woth the ending of a term also comes new beginnings and it is with pleasure that I
I did my usual at the Jacksonville airport; turn the gavel to Linda Kirk to start her term as President.
good intentions to save money and take the I would like to also announce that Steven Baskin was elected to serve as your
shuttle, but time-urgently walked straight to President-Elect and the newly elected Board member is Aubrey Ewing. We are not
the cab line. First impressions at meetings going to let go of Don Moss just yet however, as he has accepted an appointment to
are always powerful. As I walked into the serve the remaining one year term as treasurer while Steve moves to president-elect.
hotel lobby I saw past-president Mark
Schwartz holding court at the lunch table.

4A Biofeedback Summer 2003