Biofeedback: A New Frontier for Recreation Therapy

1. Biofeedback: A New Frontier for Recreation Therapy West Virginia Therapeutic Recreation Association Annual Conference – Cacapon State Park November 5-7, 2008 Michael Duquette, CTRS, BCIAC, CCDC Lead Therapist National Institutes of Health Bethesda, Maryland Benedict Stover Recreation Therapy Intern National Institutes of Health Bethesda, Maryland

2. Outline • Definitions • Biofeedback Clips • Certification Process • Stress/Autonomic Nervous System • Operant Conditioning • Relaxation Response • Biofeedback Modalities • Stress Test • Guided Imagery Assisted Biofeedback • Heart Rate Variability Biofeedback • Questions

3. Body → Mind • Physiological Psychology – How changes in the body (e.g., drinking, drugs, stress hormones) affect the way people think and feel. • Physiological psychologists manipulate physiology, then observe behavioral results. Mind → Body • Psychophysiology – How changes in the mind (e.g. observations, thoughts, attitudes, emotions) affect the way the body responds to the environment. • Psychophysiologists manage, guide, and obstruct human psychological variables, then observe physiological effects.

4. Complementary Alternative Medicine (CAM) • The term “alternative medicine”, encompasses any healing practice "that does not fall within the realm of conventional medicine." • Chiropractic • Meditation • Yoga • Biofeedback • Hypnosis • Acupuncture • Prayer

5. Applied Biofeedback • A group of therapeutic procedures… • utilizing electronic instruments… • to accurately measure, process, and ‘feedback’ to persons information… • with reinforcing properties… • about their neuromuscular and autonomic activity, both normal and abnormal… • in the form of analog or binary, auditory, and/or visual feedback signals.

6. Applied Biofeedback Cont. • Best achieved with a competent biofeedback professional • The objectives are to help patients: • Develop greater awareness and voluntary control over their physiological processes that are otherwise outside awareness and/or under less voluntary control (ANS) • By first controlling the external signal • And then with the internal psycho-physiological cues

7. Biofeedback Videos • ECU Biofeedback • Pediatric Biofeedback

8. BCIA Certification in General Biofeedback • Bachelor or higher degree in a BCIA approved health care related field • Human Anatomy/Physiology • Didactic Biofeedback Education (48 hrs) • Practical Biofeedback Training - 20 contact hours with a BCIA approved mentor • The 20 contact are used hours to review: • ·10 sessions of personal biofeedback, demonstrating self-regulation. • ·50 sessions of patient/client treatment as follows: 10 sessions each of Thermal, EMG, and GSR. The remaining 20 sessions are to include any combination of EMG, Thermal, GSR, EEG, HRV, and respiration training. • ·10 case conference presentations. • *Sessions are a minimum of 20 minutes. • Written Examination • BCIA Information

9. Reasons for Medical Visits to Primary Providers Stress Related Disorders

10. Stress • Acute • MOST common form of stress. • Comes from demands and pressures of the recent past and anticipated demands and pressures of the near future. • Can be thrilling and exciting in small doses, but too much is exhausting. • Chronic • Comes when a person never sees a way out of a miserable situation. • Insistent demands and pressures for seemingly interminable periods of time. • With no hope, the individual gives up searching for solutions.

11. Autonomic Nervous System • Central Nervous System (CNS) • Peripheral Nervous System (PNS) • Sensory – Afferent Division • Motor – Efferent Division • Somatic – Skeletal Muscles – Voluntary • Autonomic Nervous System (ANS) – Involuntary • Sympathetic - Parasympathetic • Smooth Muscle (stomach, bladder, blood vessels) • Cardiac Muscle • Glands (tear, sweat, salivary, adrenal)

12. Cranial NervesIII,VII,IX,X Spinal Nerves S1, S2 Spinal Nerves T1-12 & L1, L2

13. Sympathetic • The “fight or flight” subdivision of the Autonomic Nervous System • Involves activation of the adrenal medulla • Postganglionic axons secrete noradrenaline • Includes spinal nerves from T1 → L2 • stimulates heartbeat • raises blood pressure • dilatesthe pupils • dilates the trachea and bronchi • stimulatesthe conversion of liver glycogen into glucose • shunts blood away from the skin and viscera to the skeletal muscles, brain, and heart • inhibits peristalsis in the gastrointestinal (GI) tract • inhibitscontraction of the bladder and rectum

14. Parasympathetic • Postganglionic axons secrete acetylcholine • Involves Cranial Nerves III, VII, IX, X, and Spinal Nerves S2 →S4 • MOST active when the body is at rest • slows down of the heartbeat • lowers blood pressure • constricts the pupils • increases blood flow to the skin and viscera • allows peristalsis of the GI tract • relaxes the bladder and rectum

15. The Autonomic Nervous System StructureSympathetic StimulationParasympathetic Stimulation Iris (eye) Pupil Dilation Pupil Constriction Heart Heart rate and force increased Heart rate and force decreased Decreased stroke volume Increased stroke volume Lung Bronchial muscle relaxed Bronchial muscle contracted Small Intestine Motility reduced Digestion increased Kidney Decreased urine secretion Increased urine secretion Adrenal medulla Norepinephrine and epinephrine secreted Bladder Wall relaxed Wall contracted Sphincter closed Sphincter relaxed

16. Stress Pathways Acute Stress • Sympathetic-Adrenal-Medullary (SAM)Chronic Stress • Hypothalmus-Pituitary-Adrenal (HPA)

17. Sympathetic-Adrenal-Medullary(SAM) • “Flight or Flight” – Walter B. Cannon • Primary Pathway – autonomic nervous System • Fast acting • Brain→ Spinal Cord →Adrenal Medulla • Epinephrine →Released in bloodstream • Norepinephrine →Nerve Cells →Glands & Muscles • ↑Heart Rate ↑Blood Pressure Dilates Pupils • ↑Metabolism Dilates Bronchi ↑Saliva Flow • Converts Glycogen to Glucose Inhibits Bladder

18. HPA Axis • Involved in long term stress response • ↑ amount of energy to places most needed • Hypothalamus ↓ Pituitary ↓ Adrenal

19. The Brain’s Stress Response Brain Structure Chemical Emotion Amygdala Fear Freeze Increase blood glucose level Decrease inflammation Reduce pain Resist long term stress Corticotropin Releasing Hormone (CRF) Hypothalmus Flush Flight/ Flight Faint Pituitary Gland ACTH (adrenocorticotrophic Hormone) Adrenal Cortex Cortisol

20. Parasympathetic Sympathetic

21. Operant conditioning forms an association between a behavior and a consequence There are four possible conse-quences to any behavior. They are: Something Good can start or be presented, so behavior increases = Positive Reinforcement (R+) Something Good can end or be taken away, so behavior decreases = Negative Punishment (P-) Something Bad can start or be presented, so behavior decreases = Positive Punishment (P+) Something Bad can end or be taken away, so behavior increases = Negative Reinforcement (R-) Operant Conditioning

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

23. Benson’s Basic Components to Promote the Relaxation Response • A Quiet Environment • Something to “dwell” on • A passive attitude • A Comfortable Position

24. The Relaxation Response • The Relaxation Response is an integrated hypothalamic response which results in generalized decreases in sympathetic nervous system activity. • It is the physiologic antithesis of the flight-or-fight response. (Benson, 1975, 1992)

25. Benson’s Basic Components to Promote the Relaxation Response • A Quiet Environment • Something to “dwell” on • A passive attitude • A Comfortable Position

26. Mindfulness • Being aware of, and paying attention to, the moment in which we find ourselves. • Our past is gone, our future is not yet here… so what exist between them is the present moment. Mindfulness YouTube Clip 23-27min

27. General Biofeedback Modalities • Finger Temperature (FT) • Respiration • Skin Conductance (SC) • Electromyography (EMG) • Blood Pulse Volume (BVP)

28. Surface Electromyography (SEMG) • Three Fold Purpose: • Receive the electrical signal • Separate this electrical output from other energy on skin and amplify it greatly • Convert the amplified EMG signal into useful forms of information (Biofeedback)

29. Surface Electromyography (SEMG) Microvolts A • An electrical correlate of muscle contraction • EMG is measured in microvolts (millionths of a volt) • The strength of contraction is directly proportional to the signal level • EMG is derived from 2 active electrodes and a ground/reference B 0 5 Seconds A – Bicep B - Tricep

30. Skin Conductance (SC) • Electrodermal Response (EDR) or Galvanic Skin Response (GSR) • Measurement of skin response to a small electrical current being passed through it. • Changes in resistance of skin to an electrical current due to opening and closing of sweat glands. • Electrodes attach to the volar surface of finger tips or palm of hand. • The more emotionally aroused you are, the more active your sweat glands are and the greater the electrical conductivity of your skin. • Indication of sympathetic arousal; quick to activate, slow to recover. • Effective in treating: phobias, anxiety, excessive sweating, and, at times, stuttering since these emotions will affect your skin's conductivity.

31. Thermal Feedback • A device that monitors vasodilatation (↑ blood volume and vasoconstriction (↓ blood volume). • Usually, to the middle or small finger of your dominant hand. • When you are tense or anxious, your skin temperature drops as blood is redirected inward to muscles and internal organs, (sympathetic nervous system). • Like monitoring muscle tension, measuring skin temperature is a useful tool in learning how to manage stress, (↑ in skin temperature-activation of parasympathetic nervous system). • ↓ 85F = Aroused, Distressed • 85-89.9F = Anxious, Nervous • 90-92.9 = Normal Range • 93-94.9 = Calm, Quiet • Above 95 = Deeply Relaxed

32. Guided Imagery Treatment Guided Imagery Audio

33. Heart Rate Variability Biofeedback

34. Tides Breathing Exhale Exhale Exhale Inhale Inhale Inhale Oscillations

35. Inhale Inhale Exhale Exhale Respiratory Sinus Arrhythmia(RSA) • Respiratory = Breath • Arrhythmia = Heart Rate Changes • Sinus = Oscillations RSA triggers very powerful cardio-vascular reflexes that help to balance the autonomic nervous system to include the Bainbridge Reflex (blood volume) and the Baroreceptor Reflex, (blood pressure).

36. Oscillations • In healthy individuals, a degree of interaction between activity of SNS and PSNS allows more effective responses to demands. • This interaction produces variability in HR. Oscillations in HR interact with other oscillating systems (hormones, blood pressure, respiration, emotion, etc).

37. Oscillations-Heart Rate Variability Breathing Heart Rate Blood Pressure Blood Volume

39. Vaschillo’s Resonant Frequency Theory Progression to approx. 6 BPM, (Diaphragmatically) in experienced breathers produces single summated peak at about .1hz: RESONANT FREQUENCY Ordinary Breathing produces three HR frequencies, HF,LF,&VLF Daily practice in this state increases homeostatic reflexes

40. HR and BP Oscillations Elicited by the Stimulus of Respiration at Resonant Frequency Blood Pressure Time Delay~ 5 sec Time Heart Rate Respiration Time

41. Inhale Sympathetic Exhale Para-sympathetic

43. Diaphragm Breathing Video

44. Diaphragmatic Breathing - Sitting

45. Resources • Biofeedback Institute of America • www.bcia.org • Association for Psychophysiology and Biofeedback • www.aapg.org • Biofeedback Foundation of Europe • www.bfe.org (this is where you can download the breathing pacer, EZ-Air) • ECU Biofeedback Lab • www.ecu.edu/rcls/biofeedback/ • Stens Biofeedback • www.stens-biofeedback.com • Thought Technology • www.thoughttechnology.com