Biofeedback and Cardiac Coherence Training

1. Biofeedback and Cardiac Coherence Training Ronald Glick, MD Medical Director—Center for Integrative Medicine at UPMC Shadyside

2. Impact of Stress • Lazarus and Folkman—External pressure exceeds one’s perceived ability to cope • Associated with both psychological and physiological changes

3. Relaxation Response • Herbert Benson—A physical state of deep rest that changes the physical and emotional responses to stress • Associated with i Metabolism i HR, BP, RR Muscles relax Change in brain wave activity Change in immunity

4. Mind-Body Approaches • Meditation • Guided imagery • Rhythmic breathing • Hypnosis • Autogenic training • Yoga • Biofeedback • QiGong

5. Biofeedback • A process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. • Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. • These instruments rapidly and accurately "feed back" information to the user. • The presentation of this information — often in conjunction with changes in thinking, emotions, and behavior — supports desired physiological changes. • Over time, these changes can endure without continued use of an instrument.   BCIA, AAPB, ISNR

6. Goals of Biofeedback • Education regarding connections between symptoms & physiology • Skills training in changing biofeedback signals corresponding to specific physiologic processes • Development of awareness of the internal states linked to arousal and relaxation • Development of carry-over in recognizing and modifying internal states without the aid of instrumentation • Development of an overall sense of self-efficacy and empowerment for contributing to one’s health and well-being, regardless of the extent to which the presenting problem has been resolved

7. Advantages of Biofeedback • Fun/Gimmicky—Tends to engage people who might not otherwise be interested • Can help to engage someone who isn’t “psychologically-minded” • Depending on modality, doesn’t require quiet room with closed eyes—may be more acceptable to patients who have concerns with loss of control or those somewhat energetic or restless • Can tie in with other phenomena besides relaxation response

8. Autonomic Physiology 101 • Like the Criminal Justice System, the Autonomic Nervous System is represented by 2 separate yet equally important groups • Extensive connections going both ways between the heart and the brain/brainstem

9. Sympathetic System • Excitatory • Chemically mediated by adrenals • Ass’d with epinephrine/norepi • Result in cortisol release • Associated with fight or flight response

10. Parasympathetic System • Braking or dampening system • Vagally mediated • Associated with relaxation response

14. How do you pick a modality for Bioveedback? • What you’re measuring is beyond conscious awareness • It’s tied in with a useful physiologic function/system—eg sympathetic/parasympathetic tone • The measure can be altered via awareness and exercises • Altering the measure results in improvement of some symptom

15. Level of Evidence (Glick & Greco) • Migraines & TTH A • AD/HD A • Urinary Incontinence A • Anxiety D/O B • FS/MPS B • Heart Dz/HTN B • COPD/Asthma

16. Targets for Biofeedback-EMG • Uses surface electrodes to read out muscle activity • Especially helpful for headaches and myofascial pain • Also can be used for pelvic pain and urinary incontinence • Exercises can be direct—eg PMR vs indirect eg breathing, imagery, autogenics • Some connection with autonomics

17. Targets for Biofeedback-GSR • Skin conductance related to autonomics/ stress levels—think sweaty palms • Unlike muscles, no direct imagery so relies on other indirect methods

18. Targets for Biofeedback-Thermal • Simplest—both in terms of technology and to learn—simple forms bio-dot and mood rings • Cool hands are ass’d with stress • For migraines rationale is that HA ass’d with dilatation of cerebral vessels—may be offset by peripheral dilatation • May also help for Raynaud’s • May tie in with visual and sensory imagery

19. Targets for Biofeedback-EEG • Neurofeedback—uses computer algorithm to form Quantitative EEG and analyzes for predominant frequency • Most commonly used/studied for AD/HD Protocols include: Decrease theta/Increase beta Increase slow cortical potentials • Also may help for Asperger’s & Anxiety D/O’s

20. Heart Rate Variability • Initially described in perinatology with changes associated with fetal distress • Provides a barometer of autonomic balance • Can be described in terms of frequency components • Sorry but a short lesson in Fourier Analysis follows:

22. High Frequency HRV • Mediated by parasympathetic system/vagus • i associated with Anxiety Depression Heart disease • h associated with relaxation response and cognitive focus • Elicited by mind-body approaches & exercise

23. Respiratory Sinus Arrhythmia • Physiologic process—HR h with inspiration & i with expiration • Reflects balance between sympathetic & parasympathetic systems • Considered to be vagally mediated

24. Mayer Wave • Describes a similar cyclic phenomenon to RSA • Relatively consistent frequency • Oscillations in blood pressure—ass’d with baroreceptor reflex • Occurs at around 6 cycles/min slower with athletes & meditators faster in kids and older adults

25. Resonance • The increase in amplitude of oscillation of a system exposed to a periodic force whose frequency is equal or very close to the natural un-damped frequency of the system • Occurs when the respiratory frequency (RSA) overlaps with baroreceptor frequency (Mayer’s wave) • Explains why much of yogic breathing is practiced at 6 breaths/min

26. Chaos vs. Coherence • Chaos—random pattern from 1 point to the next • Coherence—predictable pattern; from 1 point to the next you can make a pretty good guess as to where it’s heading

28. Emotional Awareness/Mastery • Positive emotion fg Negative emotion • Low arousal fg High arousal

29. Emotional Awareness/Mastery High Arousal Creativity Anger Joy Agitated Depression Focus + Emotions - Emotions Contentment Depression Creativity Passivity Low Arousal

30. HRV Biofeedback • Typically relies on infrared probe (ear or finger), picking up on change in skin color with systole • Programs have an algorithm that defines coherence vs chaos & feeds-back info to help a person shift to a coherent pattern • Cues that are used are paced breathing and imagery

31. HeartMath Emwave • HeartMath Institute has done extensive research, writing of books and monographs, and training • Has developed very engaging software for kids & adults • Has a PC or Mac based system as well as a handheld unit • Focus on heart-centered imagery and positive emotion

32. Resonant Frequency Biofeedback • Focus is on achieving resonance of RSA & Mayer’s wave • As the Mayer’s wave frequency varies from person to person, the ideal respiratory rate varies as well • Can be determined by having the patient breathe at various frequencies & see which elicits the greatest spike in HRV amplitude & in the amplitude on the frequency plot • Typically between 4-6 breaths per minute • Has been used for hypertension, asthma, anxiety, and depression

41. References Glick RM, Greco CM. Biofeedback and primary care. Primary Care: Clinics in Office Practice. 37(1): 91-103. 2010 March. Childe, D. & Martin, H. : The HeartMath Solution, Harper, San Francisco, 1999. Lehrer PM, Vaschillo E, Vaschillo B. Resonant frequency biofeedback training to increase cardiac variability: rationale and manual for training. Applied Psychophysiology & Biofeedback. 25(3):177-91, 2000 Sep. AndrasikF. Biofeedback in headache: an overview of approaches and evidence.  Cleveland Clinic Journal of Medicine. 77 Suppl 3:S72-6, 2010 Jul.