Long-term efficacy of biobehavioral treatment of temporomandibular disorders.

This study evaluated the relative long-term efficacy of biofeedback, cognitive-behavioral skills training (CBST), combined biofeedback and CBST (Combined), and no-treatment comparison groups in 108 patients suffering from chronic temporomandibular disorder (TMD). After an initial evaluation, patients were assigned to one of the four treatment conditions. The three biobehavioral treatment interventions consisted of 12 standardized sessions. Patients were reevaluated 1 year after completing treatment. Results demonstrated that patients who received the biobehavioral treatments reported significant improvement in subjective pain, pain-related disability, and mandibular functioning 1 year after receiving treatment. The no-treatment comparison group did not demonstrate such improvements. The combined biofeedback and CBST treatment produced the most comprehensive improvements across all outcome measures. These results again demonstrate the heuristic value of adopting a biopsychosocial perspective to the assessment and treatment of chronic medical/dental disorders such as TMD.

Complementary and alternative medicine: applications and implications for cognitive functioning in elderly populations.

OBJECTIVE: Aged populations in the United States are growing in numbers, and stand to be affected most by the changing shape of healthcare delivery. Within these elderly populations, the problem of decreased cognitive functioning due to dementing disorders is rising. Recent compelling research on complementary and alternative medicine interventions targeted at cognitive deficits in the elderly is reviewed in this survey. DATA SOURCES: A literature review was undertaken to identify original clinical research studies, review articles, chapters, and books on treating cognitive deficits in the elderly. Contact with complementary and alternative medicine researchers provided additional information concerning developments in this field. STUDY SELECTION: Research studies that were methodologically sound were selected for review. More purely clinical studies also were included to provide a thorough overview of the limited amount of accumulated knowledge in this field. DATA SYNTHESIS: A qualitative synthesis of the above data was used to comprehensively present all information accumulated to date in this field. CONCLUSIONS: Although still in the preliminary stages of development, clinical research exploring the benefits of complementary and alternative therapies for cognitive deficits among the elderly shows a significant level of promise that warrants a further investment of resources.

The relative efficacy of three cognitive-behavioral treatment approaches to temporomandibular disorders.

The purpose of this study was to evaluate the relative efficacy of different biopsychosocial treatment conditions on patients with chronic temporomandibular disorder. Ninety-four patients with chronic temporomandibular disorder were assigned to either a biofeedback treatment group, a cognitive-behavioral skills training (CBST) treatment group, a combined (combination of biofeedback/CBST) treatment group, or a no-treatment control group. Pain scores were analyzed pretreatment and posttreatment to determine group and within-subjects treatment effects. Results demonstrated that, in terms of a self-reported pain score, all three treatment groups had significantly decreased pain scores from pretreatment to posttreatment, while the no-treatment group did not. Moreover, patients in the biofeedback group were the most significantly improved compared to the no-treatment group. Finally, participants in the three treatment groups displayed significant improvement in mood states.

Percutaneous electrical nerve stimulation for low back pain: a randomized crossover study.

CONTEXT: Low back pain (LBP) contributes to considerable disability and lost wages in the United States. Commonly used opioid and nonopioid analgesic drugs produce adverse effects and are of limited long-term benefit in the management of this patient population. OBJECTIVE: To compare the effectiveness of a novel nonpharmacologic pain therapy, percutaneous electrical nerve stimulation (PENS), with transcutaneous electrical nerve stimulation (TENS) and flexion-extension exercise therapies in patients with long-term LBP. DESIGN: A randomized, single-blinded, sham-controlled, crossover study from March 1997 to December 1997. SETTING: An ambulatory pain management center at a university medical center. PATIENTS: Twenty-nine men and 31 women with LBP secondary to degenerative disk disease. INTERVENTIONS: Four therapeutic modalities (sham-PENS, PENS, TENS, and exercise therapies) were each administered for a period of 30 minutes 3 times a week for 3 weeks. MAIN OUTCOME MEASURES: Pretreatment and posttreatment visual analog scale (VAS) scores for pain, physical activity, and quality of sleep; daily analgesic medication usage; a global patient assessment questionnaire; and Health Status Survey Short Form (SF-36). RESULTS: PENS was significantly more effective in decreasing VAS pain scores after each treatment than sham-PENS, TENS, and exercise therapies (after-treatment mean +/- SD VAS for pain, 3.4+/-1.4 cm, 5.5+/-1.9 cm, 5.6+/-1.9 cm, and 6.4+/-1.9 cm, respectively). The average +/- SD daily oral intake of nonopioid analgesics (2.6+/-1.4 pills per day) was decreased to 1.3+/-1.0 pills per day with PENS (P<.008) compared with 2.5+/-1.1, 2.2+/-1.0, and 2.6+/-1.2 pills per day with sham-PENS, TENS, and exercise, respectively. Compared with the other 3 modalities, 91 % of the patients reported that PENS was the most effective in decreasing their LBP. The PENS therapy was also significantly more effective in improving physical activity, quality of sleep, and sense of well-being (P<.05 for each). The SF-36 survey confirmed that PENS improved posttreatment function more than sham-PENS, TENS, and exercise. CONCLUSIONS: In this sham-controlled study, PENS was more effective than TENS or exercise therapy in providing short-term pain relief and improved physical function in patients with long-term LBP.

Clinical outcome research in complementary and alternative medicine: an overview of experimental design and analysis.

This article serves as a primer for those beginning clinical research in complementary and alternative medicine. The authors provide a basic overview of important experimental design and statistical issues, of which clinical researchers in the area of complementary and alternative medicine must be aware when attempting to demonstrate the effectiveness of particular treatment modalities. As the article suggests, science is an inferential process, and experimental investigations can vary greatly in methodological integrity. Key concepts in clinical outcome research such as internal validity, statistical conclusion validity, and the appropriate measurement and operational definitions of outcomes are discussed. New scientific approaches that are evolving because of paradigm shifts in science (e.g., chaos theory) are also reviewed. Suggestions are provided to further develop an understanding of clinical outcome research methodology.

Comparative efficacy of behavioral stress management versus propranolol in reducing psychophysiological reactivity in post-myocardial infarction patients.

The present study compared the relative efficacy of a behavioral stress-management procedure versus a pharmacologic method (the beta-blocker propranolol) in reducing psychophysiological reactivity in post-myocardial infarction (MI) patients. A pretreatment-posttreatment assessment design was used, with 10 patients participating in six separate sessions. The first session involved evaluating psychophysiological reactivity to an emotional stressor (a public-speaking task). The subsequent five sessions involved the administration of the respective treatments, either stress management or drug. The patients were randomly assigned to each treatment group. The public-speaking stressor was readministered after the last treatment session. Results demonstrated that behavioral stress management reduced psychophysiological reactivity to public speaking to the same level seen with propranolol. The findings suggest that this nonpharmacological approach could be of use when beta-blocker therapy is not desired, not practical, or medically contraindicated.

Acupuncture relief of chronic pain syndrome correlates with increased plasma met-enkephalin concentrations.

In twenty patients with chronic pain syndrome, acupuncture treatment resulted in significant improvement of both pain and psychiatric symptoms and higher plasma concentrations of metenkephalin. Plasma beta-endorphin concentrations were unchanged. The degree of symptom relief was correlated with the increase in plasma met-enkephalin.

Psychophysiological and cognitive characteristics of ulcer and rheumatoid arthritis patients.

This study examined differences in the physiological and cognitive response patterns among peptic ulcer, rheumatoid arthritis, and healthy group subjects to two types of stressors-slides of autopsies and imagined scenes involving conflicts and attitudes proposed to be associated with the two psychosomatic disorders. Ten subjects were assessed in each group. Results indicated that the ulcer patients demonstrated a heart rate accelerative trend, while arthritic and normal subjects showed significant deceleration, in response to the aversive slides of autopsies. Ulcer patients also reported paying less attention to the slides, and experiencing more anxiety when viewing them, relative to the other subjects. In response to the imagined scenes, the arthritic patients responded with more heart rate acceleration, apparently because of the greater emotional imagery produced by the scenes in these subjects. Finally, self-report and interview data did not lend support to a derivative of the specificity-of-attitude model of psychosomatic disorders.

The comparative effectiveness of heart rate biofeedback, speech skills training, and a combination of both in treating public-speaking anxiety.

Forty-two speech-anxious undergraduate students (21 female, 21 male) were administered either heart rate biofeedback training, speech skills training, or a combination of both to aid in the alleviation of speech anxiety. Physiological (heart rate, tonic skin conductance level, systolic blood pressure, and diastolic blood pressure), overt motor, and self-report measures of anxiety were assessed during a pretreatment speech and two posttreatment speeches. Results indicated that all treatments were effective in lowering overt motor and self-report components of anxiety. However, only the biofeedback and combined group subjects demonstrated significantly less heart rate increase while speaking before an audience during the posttreatment assessment. Two individual difference variables examined in this study--cognitive/autonomic focus of anxiety and subjective confidence in treatment--were not found to significantly influence treatment effectiveness. Finally, factor analyses of the physiological data suggested that heart rate changes play a large role in the physiological component of anxiety.

The role of biofeedback in the operant modification of human heart rate.

The recent literature on the role played by biofeedback in the modification of human heart rate is reviewed. Emphasis is placed on research pertinent to the issue of whether biofeedback is more productively conceived as a reinforcer of an operant response or as a source of information enabling the development of a voluntary motor skill. Criticisms of the operant paradigm are answered, and limitations of the motor skills analogy are discussed. It is concluded that the operant conditioning paradigm best accounts for most available data on the role of biofeedback in heart rate control, and that it is superior to the motor skills model because it is more parsimonious and makes fewer untestable assumptions.

The production and generalization of large-magnitude heart rate deceleration by contingently faded biofeedback.

Eight subjects were taught to decrease their heart rates via biofeedback training. Four of these received contingently faded, beat-by-beat analogue feedback and contingent reinforcement each time their performance met a specified and adjusting criterion. The other four received continuous, beat-by-beat analogue feedback, but not the contingent reinforcement. Subjects in the two groups were yoked to ensure equal densities of reinforcement. Subjects in the first group were asked to decrease heart rates 15% from baseline and were then trained using only 75%, 50% and 25% of beat-by-beat feedback. It was hypothesized that the immediate reinforcement of appropriate behavior and the contingent fading (following mastery) of feedback would aid in the generalization of the response. Following completion of all criterion steps or 10 training sessions, whichever came first, all subjects were tested with no feedback and no contingent reinforcement. The group receiving contingently faded feedback training showed a significantly greater heart rate decrease in the training sessions and also the test session. These results were interpreted as indicating that biofeedback can be conceptualized as an operant conditioning paradigm, and that the use of operant techniques may help subjects produce clinically significant changes.

Effectiveness of two procedures for reducing dental fear: group-administered desensitization and group education and discussion.

Self-control desensitization and education and discussion groups improved the behavior of subjects who were extremely anxious about dental treatment. These two treatment procedures can be used effectively on a group basis in the community by dentists who receive some basic training in administration.

Development of physiological response patterns concomitant with the learning of voluntary heart rate control.

Thirty-six male undergraduate students were instructed to raise or lower heart rate in a multiple-session biofeedback experiment. Systolic and diastolic blood pressure, frontalis electromyographic activity, and skin conductance level were simultaneously recorded throughout biofeedback training. Principal axes factor analyses showed that physiological response patterning concomitant with the development of heart rate control was different early in training (Training Session 1) than it was late in training (Training Session 4) for both speeding and slowing conditions. These results indicate that different heart rate control strategies were used by the subjects early and late in training. The factor patterns also indicated a tendency for greater heart rate response specificity as training progressed for both speeding and slowing. Heart rate speeding sessions were also found to be associated with a significant increase in perceived state anxiety as measured by the State-Trait Anxiety Inventory. No significant change in perceived anxiety state, however, was associated with heart rate slowing.

Physiological response patterning in short--and long--term heart rate control training.

The present investigation assessed the physiological response patterns which accompany heart-rate control performance, both early and late in training. Six subjects were employed who received six heart-rate control training sessions, half of which were speeding sessions and half of which were slowing. Heart rate, skin resistance, frontalis EMG, systolic and diastolic blood pressure, and respiration rate were continuously recorded throughout all training sessions. Results indicated that the physiological response topography during heart-rate control performance changes from early to late training. Moreover, the changes are different for speeding and slowing performance, suggesting the involvement of different underlying physiological mechanisms in the two tasks.

The effect of voluntary control of heart rate deceleration on skin conductance level: an example of response fractionation.

Twenty-four undergraduate male volunteers participated in an experimental designed to assess the effect of voluntary control of heart rate deceleration on skin conductance level. One group of subjects received heart rate feedback training and a second group performed a tracking task. Because heart-rate feedback was presented via a visual display, the tracking task group was included to control for display monitoring influences on heart rate. Results demonstrated feedback mediated acquisition of learned control of heart rate slowing. More importantly, the heart-rate slowing performance was accompanied by increases in skin conductance level. This 'fractionation' of physiological responding suggests the presence of a physiological response pattern which may counter initial attempts to produce greater magnitude slowing effects.