Game-based biofeedback for paediatric anxiety and depression.

Twenty-four children and adolescents aged 9-17 who were referred for treatment for anxiety were assigned to either a game-based biofeedback group or a waiting list comparison group. The eight-session biofeedback intervention included psychoeducation, identification of triggers and signs of anxiety, and in vivo practice. The intervention used computer-based gaming technology to teach and practise relaxation. Analyses using ANCOVA revealed significant differences in post-test scores of anxiety and depression measures between the two groups. The intervention group reduced anxiety and depression scores on standardised tests. Findings suggest that biofeedback-assisted relaxation training can be useful in decreasing anxiety and depressive symptoms in anxious youths.

Psychological and physiological factors associated with tilt table testing for neurally mediated syncopal syndromes.

This study investigated psychological and physiological factors in two groups of patients who had tilt table testing for autonomic dysfunction. The first group of 61 patients completed assessments of depression, anxiety, and symptom effects on lifestyle. The 25 patients identified as tilt positive were younger (30.5 years) and had higher mean depression scores (7.6) compared to the tilt-negative response group (n = 36); the latter averaged 40 years of age and had mean depression scores of 4.6. These differences were statistically significant. Women testing tilt positive were significantly more depressed than tilt-negative women (P = 0.02). More severe depressive symptoms were associated with lower blood pressure (BP) (P < 0.05). A second group of 52 patients was monitored during tilt for BP, heart rate (HR), skin temperature (TEMP), skin conductance level (SCL), and forehead muscle tension (EMG). Twenty-seven tested positive and 23 were negative. There were statistically significant group differences in systolic BP and diastolic BP (P < 0.05). There was a significant interaction between tilt status (positive or negative) and time (P = 0.03) in HR. TEMP increased 2 degrees over time in both groups (P < 0.05). The decrease in SCL from 13.7 to 10.4 mu omega in the tilt-positive response group compared to the slight increase in the tilt-negative group was significantly different (P < 0.05). Identification of psychological factors correlated with BP and physiological changes that accompany decreases in BP in tilt-positive response patients could guide management of patients with autonomic dysfunction.

The effects of massage therapy alone and in combination with other complementary therapies on immune system measures and quality of life in human immunodeficiency virus.

OBJECTIVES: Determine effects of massage therapy alone and in combination with exercise or stress management-biofeedback treatment on enumerative immune measures, and quality of life in moderately immunocompromised human immunodeficiency virus (HIV) subjects. DESIGN: Randomized prospective controlled trial with 42 subjects randomly assigned to one of three treatment groups or a control group receiving standard care and intervention over a 12-week period. SETTING: Academic medical center. SUBJECTS: Forty-two (42) subjects with HIV infection (40 males; 2 females; aged 27-50 years) met eligibility requirements of CD4+ lymphocyte cell count greater than 200 cells per microliter; no present or recent signs or symptoms of acquired immunodeficiency syndrome (AIDS), and were not hospitalized. INTERVENTIONS: A 45-minute overall body massage once per week; similar massage and supervised aerobic exercise 2 other days per week; similar massage and biofeedback stress management once per week; control receiving standard treatment. OUTCOME MEASURES: Changes in peripheral blood levels of CD4+ lymphocytes, CD8+ lymphocytes, CD4+/CD8+ lymphocyte ratio and natural killer cells; six dimension quality-of-life assessment. RESULTS: No significant changes (p > 0.05) were found in any enumerative immune measure. Significant (p < 0.05) differences for quality-of-life assessment were in health care utilization and health perceptions, favoring massage and stress management compared to massage only and controls. CONCLUSIONS: Massage administered once per week to HIV-infected persons does not enhance immune measures. Massage combined with stress management favorably alters health perceptions and leads to less utilization of health care resources. This suggests that HIV-infected persons receiving massage and stress management would tend to not overutilize health care services, thus possibly reducing health care costs.

Asthma severity, psychophysiological indicators of arousal, and immune function in asthma patients undergoing biofeedback-assisted relaxation.

Asthma is characterized by airway hyper-responsiveness, inflammation, and reversible obstruction. Respiratory tract infection, allergies, air pollution, and psychosocial factors impact the severity and frequency of asthma symptoms. Pharmacotherapy and self-care are the major components in the management of asthma, but behavioral interventions also have the potential to affect asthma morbidity. We conducted a small, randomized controlled study, examining the effects of biofeedback-assisted relaxation in 16 nonsmokers with nonsteroid-dependent mild asthma. Data were collected on asthma symptoms, pulmonary function, indicators of arousal, and cellular immune factors. The trained group evidenced a decrease in forehead muscle tension in comparison to the controls, but no changes in peripheral skin temperature. Decreases in asthma severity and bronchodilator medication usage for the experimental group were observed. Pulmonary function testing revealed a significant difference between groups in FEV1/FVC at posttest, with the E group having a higher ratio than the controls. The cellular immune data showed no significant group differences in total white blood cell or lymphocyte counts, but decreases over time were observed. Significant differences were observed in the numbers of neutrophils and basophils in the trained group compared to controls, which supports the concept of decreased inflammation. Results of delayed-type hypersensitivity skin testing suggested enhanced function, but they were not conclusive. These findings, though limited by size of population, suggest a positive effect of biofeedback-assisted relaxation in young, nonsteroid-dependent asthmatics. The mechanisms underlying linkages between psychological, behavioral, and immune responses in asthma require further study.

Role of mood in outcome of biofeedback assisted relaxation therapy in insulin dependent diabetes mellitus.

Stressful life events and negative mood have been associated with elevated blood glucose and poor self-care in individuals with diabetes. The purpose of this controlled study was to determine the effect of mood state, specifically depression, anxiety, and daily hassles on the outcome of biofeedback assisted relaxation in insulin dependent diabetes mellitus. Eighteen subjects completed the study, nine in biofeedback assisted relaxation and nine in the control group. There were no significant group differences in blood glucose between those receiving biofeedback assisted relaxation and the subjects continuing usual care. Five of the nine experimental subjects and one of the nine control subjects were identified as succeeders according to an arbitrary criterion. Treatment failures were more depressed, more anxious, and took longer to complete the protocol than succeeders. Statistically significant correlations were found between high scores on inventories measuring depression, anxiety, and hassles intensity and higher blood glucose levels and smaller changes in blood glucose as a result of treatment. It is suggested that mood has an important impact on the response to biofeedback assisted relaxation. Further research is necessary to determine whether assessment of anxiety and depression followed by appropriate treatment where necessary should precede biofeedback assisted relaxation in insulin dependent diabetes.

Application of the high risk model of threat perception to a primary care patient population.

This study was designed to test the hypothesis that patients with a tendency to somatize psychological distress into physical symptoms could be differentiated from patients who do not somatize on the basis of specific predisposing factors defined by the High Risk Model of Threat Perception. Patients in a family practice were assessed for the tendency to somatize by the Diagnostic Interview Schedule (DIS) and by physician rating. Twenty-seven percent of the patients were positive for tendency to somatize by physician rating. These patients had relatively high negative affect, absorption, catastrophizing, self-reported pain and stress, and greater utilization of services. None of the patients assessed by the DIS met criteria for somatization disorder, but 28% were positive for somatoform pain disorder. These patients also scored higher on the negative affect questionnaire, tended to have higher absorption scores, reported greater pain and stress, and utilized more services. Results of this study are partially supportive of the High Risk Model of Threat Perception, because two of the predisposer factors were associated both with tendency to somatize by physician rating and with somatoform pain disorder by interview. The higher utilization of services in the somatizing patients has cost and service ramifications. Treatment of patients with tendencies to somatize within a family practice setting are discussed.

Outcome of biofeedback-assisted relaxation for neurocardiogenic syncope and headache: a clinical replication series.

Preliminary evidence exists through single case reports that psychophysiological interventions may be useful in the treatment of syncope (fainting). To explore this possibility, a case series of ten patients with histories of recurrent unexplained syncope or near syncope, headache, and a poor response to or tolerance for medication was performed. All patients were treated with electromyographic, thermal, biofeedback as well as progressive and autogenic relaxation. Six of the ten patients showed a major decrease in symptoms at the end of treatment. Descriptive comparisons between the improved and unimproved group were made and a detailed case study of one improved patient is presented. The results suggested that biofeedback-assisted relaxation treatment was most effective in younger patients whose syncope was associated with a strong psychophysiological response and whose headaches were intermittent, not daily occurrences.

Good news--bad press: applied psychophysiology in cardiovascular disorders.

Dysregulation in blood pressure control can occur as a result of psychological stress in either the hypertensive or hypotensive direction. Applied psychophysiological techniques incorporating biofeedback and relaxation have been shown to be efficacious in controlled studies of hypertensive patients. Electromyograph, thermal, skin conductance and direct blood pressure feedback have been utilized alone or in combination with relaxation, blood pressure monitoring, and medication. Prediction models are proposed to define what type of hypertensive is most likely to respond with significant blood pressure decrease. Neurocardiogenic syncope is a cardiovascular disorder which manifests itself as lightheadedness, dizziness, syncope, and often migraine-type headache. Preliminary indications suggest that biofeedback-assisted relaxation may also prove beneficial to patients with this syndrome.

Racial and gender effects on the relaxation response: implications for the development of hypertension.

This study was designed to explore the effect of race and gender on the forehead muscle tension and finger temperature response to biofeedback-assisted relaxation training in individuals with normal blood pressure. Forty-five subjects-18 Black and 27 White, 25 males and 20 females-participated in eight sessions of autogenic relaxation training and thermal biofeedback. Multivariate analysis of variance of the variables measured at baseline (systolic BP diastolic BP sodium excretion, anxiety) was significant for gender Univariate analysis showed males different from females in DBP Na(+) excretion, and trait anxiety. Pretest values of muscle tension were similar by gender, but pretest temperatures were lower in males than females. Repeated measures ANOVA for muscle tension showed a significant effect of period. For temperature a significant effect of period, gender and gender x period was observed. Males increased temperature more than females. There was no effect of history of hypertension on the relaxation response. Multiple regression performed on change in muscle tension and change in temperature showed that pretest muscle tension predicted change in muscle tension. Four variables contributed to the variance in change in temperature: pretest temperature, sodium excretion, and state and trait anxiety.

Biofeedback-assisted relaxation in insulin-dependent diabetes: A replication and extension study.

The effects of twelve sessions of biofeedback-assisted relaxation on blood glucose were tested in a controlled trial of 16 patients with insulin-dependent diabetes mellitus. Treatment consisted of electromyograph biofeedback, thermal biofeedback, relaxation therapy, and diabetes education. The controls received only diabetes education. All patients monitored blood glucose daily. The treated group improved on average blood glucose, percent of values above 200 mg/dl, and number of values at target. Two biologic indicators of blood glucose were used as correlates of self-reported blood glucose. Fructosamine and glycosylated hemoglobin were significantly correlated with values determined by self-monitoring of blood glucose at pretest. Fructosamine was a better index of short-term change than glycosylated hemoglobin. These results, though limited by size of population and reliance on self-reported blood glucose, support our earlier study and are promising for biofeedback-assisted relaxation as an adjunct to conventional therapy of insulin-dependent diabetes.

A provisional model to predict blood pressure response to biofeedback-assisted relaxation.

Blood pressure (BP) response to biofeedback-assisted relaxation is not uniform among hypertensive individuals. The purpose of this exploratory study was to determine if selected psychophysiological variables could be used to identify individuals able to lower blood pressure using biofeedback-assisted relaxation. Responders were defined using a preset criterion of 5 mm Hg or greater decrease in mean arterial pressure. A logistic regression model derived from five variables (heart rate, finger temperature, forehead muscle tension, plasma renin response to furosemide, and mean arterial pressure response to furosemide) provided significant predictive power for BP response, exhibiting a sensitivity of 84.6% and a specificity of 80.0%. With future validation, the proposed model may provide useful information to identify patients likely to benefit from biofeedback-assisted relaxation.

Changes in cerebral blood flow velocity associated with biofeedback-assisted relaxation treatment of migraine headaches are specific for the middle cerebral artery.

Twenty-five patients with diagnosed migraine headaches were randomly assigned to a biofeedback-assisted relaxation therapy group or to a group who relaxed on their own. This study confirmed that the biofeedback trained group significantly decreased pain and medication more than the self-relax group. The best responders were those with the more elevated initial cerebral blood flow values and the changes in cerebral blood flow were specific for the middle cerebral artery.

Complex, humanitarian emergencies : III. Measures of effectiveness

Complex humanitarian emergencies lack a mechanism to coordinate, communicate, assess, and evaluate response and outcome for the major participants (United Nations, International Committee of the Red Cross, nobgovernmental organization and military forces). Success in these emergencies will depend on the ability to accomplish agreed upon measures of effectiveness (MOEs). A recent civil-military humanitarian exercise demonstrated the ability of participants to develop consensus-driven MOEs.(AU)

Effect of biofeedback-assisted relaxation on migraine headache and changes in cerebral blood flow velocity in the middle cerebral artery.

Twenty-three patients with diagnosed migraine headaches were randomly assigned to a biofeedback-assisted relaxation therapy group or to a group who relaxed on their own. The biofeedback trained group decreased pain and medication more than the self relax group. Cerebral blood flow velocity was measured in the middle cerebral artery with transcranial doppler (TCD). The trained group significantly reduced systolic and mean cerebral blood flow velocity on the side with the highest velocity.

Effects of group relaxation training and thermal biofeedback on blood pressure and related physiological and psychological variables in essential hypertension.

One hundred and one patients, 70 experimental and 31 controls, with a diagnosis of essential hypertension, were examined for the effects of group relaxation training and thermal biofeedback on blood pressure and on other psychophysiologic measures: heart rate, forehead muscle tension, finger temperature, depression, anxiety, plasma aldosterone, plasma renin activity, and plasma and urinary cortisol. Eighty percent of the participants were medicated. Treatment yielded a short-term success rate, defined as a decrease in mean arterial pressure of 5 mm Hg, of 49% in the experimental group. Other significant short-term changes included a reduction of forehead muscle tension, state anxiety, plasma aldosterone, and increased finger temperature. Follow-up measurements were made approximately 10 months after treatment in 36 patients, 51% of the treatment completers. Twenty of the 36 were short-term treatment failures, while 16 were treatment succeeders. Thirty-seven percent of the short-term succeeders continued to meet blood pressure criterion at follow-up. In short-term succeeders, continued practice of relaxation may influence long-term maintenance of decreased blood pressure. It is suggested that group relaxation training can be beneficial for short-term and long-term adjunctive treatment of essential hypertension in selected individuals.

The effects of biofeedback-assisted relaxation on cell-mediated immunity, cortisol, and white blood cell count in healthy adult subjects.

The effect of biofeedback-assisted relaxation on cell-mediated immunity, cortisol, and white blood cell count was investigated in healthy adults under low-stress conditions. Fourteen subjects were trained with biofeedback-assisted relaxation for 4 weeks, while 17 subjects were controls. The group trained in relaxation techniques showed increased blastogenesis, decreased white blood cell count, due to decreased neutrophils, and no change in cortisol in comparison to the control group. Subjects with lower initial anxiety scores and forehead muscle tension levels showed larger increases in blastogenesis and larger decreases in neutrophils than subjects with higher initial anxiety and muscle tension levels.

Interaction of biofeedback-assisted relaxation and diuretic in treatment of essential hypertension.

Thirty patients with essential hypertension participated in a study designed to compare two treatments: diuretic medication alone (n = 10) and biofeedback assisted relaxation combined with diuretic (n = 20). One of 10 patients lowered BP with diuretic alone and 11 of 20 patients lowered BP with diuretic combined with biofeedback-assisted relaxation. The addition of the behavioral intervention to the diuretic therapy produced a decrease in blood pressure beyond that associated with the diuretic alone. The decrease in BP mediated by diuretic were related to high entry levels of BP, low anxiety, forehead muscle tension, anger expression and plasma renin activity. The BP decrease mediated by combined diuretic and biofeedback-assisted relaxation was associated with high pretreatment BP, anger controlled, low finger temperature and high/normal plasma renin activity.

Racial differences in the relaxation response of hypertensives.

Racial differences in the relaxation response of hypertensives maintained on diuretic were investigated by comparing blood pressure, muscle tension, and hand temperature changes occurring with biofeedback assisted relaxation. Resting blood pressures were not different in blacks compared with whites. Both black and white subjects decreased diastolic blood pressure significantly from baseline values, but only whites significantly decreased systolic blood pressure. Though both blacks and whites significantly decreased forehead muscle tension, black subjects showed no changes in finger temperature while whites increased temperature significantly. The lack of change in finger temperature in blacks may be a reflection of the increased peripheral resistance previously associated with the greater incidence of hypertension in the American black population.

Sustained effects of biofeedback-assisted relaxation therapy in essential hypertension.

The usefulness of biofeedback-assisted relaxation as an adjunct or substitute for pharmacotherapy in essential hypertension can be enhanced if the effects are shown to persist after formal treatment has ended. Patients with essential hypertension successfully treated with biofeedback-assisted relaxation were recalled for follow-up yearly after the termination of treatment. Twenty-six of 40 patients met the BP criterion for success. At one-, two-, and three-year follow-up, 31%, 38%, and 27% of the successful completers continued to meet the criterion for success. The pretreatment-posttreatment decreases in BP were accompanied by decreases in forehead muscle tension and urinary cortisol. Forehead muscle tension, urinary cortisol, and anxiety levels were significantly lower than pretreatment one year after the end of treatment. Self-report data were used to assess continued relaxation practice. No relationship was found between practice and any other dependent measure. It appears that some patients trained in biofeedback-assisted relaxation can maintain lowered blood pressure, muscle tension, anxiety, and cortisol levels over the long term; however, the role of relaxation practice in maintaining these lowered levels remains unclear.

Controlled study of biofeedback-assisted relaxation in type I diabetes.

OBJECTIVE: The effect of biofeedback-assisted relaxation was tested in a randomized trial in 18 adults with insulin-dependent (type I) diabetes. RESEARCH DESIGN AND METHODS: Pretreatment and posttreatment blood glucose values and insulin dosages in the group trained for 10 wk in biofeedback-assisted relaxation were compared with those in the untrained group. RESULTS: Significantly lower average blood glucose levels, percentage of fasting blood glucose levels at target, and percentage of glucose values greater than 11.2 mM were observed in the trained group at posttest compared with the untrained group. CONCLUSIONS: These differences could not be explained by increases in insulin. It is suggested that stress management be considered as an adjunct to the medical management of people with type I diabetes.