Biofeedback
Marion Good
Jaclene A. Zauszniewski
This chapter provides an overview of biofeedback, its scientific basis, health conditions in which it is useful, and a technique that can be used by nurses trained in its practice.
DEFINITION
Biofeedback is based on holistic self-care perspectives in which the mind and body are not separated, and people can learn ways to improve their health and performance. Biofeedback therapists use instruments and teach self-regulation strategies to help individuals to increase voluntary control over their internal physiological and mental processes. Biofeedback instruments measure physiological activity such as muscle tension, skin temperature, cardiac activity, and brainwaves, and then provide immediate and real-time feedback to the people in the form of visual and/or auditory signals that increase their awareness of internal processes. The biofeedback therapist then teaches individuals to change these signals and to take a more active role in maintaining the health of their minds and bodies. The holistic and self-care philosophies underlying biofeedback and its focus on helping subjects gain more control over personal functioning make the intervention an appropriate one for nurses to use. Over time, a person can learn to maintain these changes without continued use of an instrument (Biofeedback Certification International Alliance, 2012).
SCIENTIFIC BASIS
The following data provide the basis for the use of biofeedback:
Biofeedback originated from research in the fields of psychophysiology, learning theory, and behavioral theory. It has been used by nurses for decades and is consistent with self-care nursing theories.
For centuries it was believed that responses such as heart rate were beyond the individual’s control. In the 1960s scientists found that the autonomic nervous system (ANS) had an afferent as well as a motor system, and control of ANS functioning was possible with instrumentation and conditioning.
Heart rate variability (HRV) biofeedback was first studied by Soviet scientists in the 1980s. HRV is the amount of fluctuation from the mean heart rate. It represents the interaction between sympathetic and parasympathetic systems and specifically targets autonomic reactivity. HRV biofeedback is based on the premise that slowed breathing will increase the HRV amplitude, strengthen baroreflexes, and improve ANS functioning (McKee, 2008). HRV biofeedback is easy to learn and can be used with inexpensive, user-friendly devices, some of which can be used independently in the home.
Neurofeedback uses electroencephalogram (EEG) feedback that shows people their real-time patterns in cortical functioning (Yucha & Montgomery, 2008).
The model for biofeedback is a skills-acquisition model in which individuals determine the relationship between ANS functioning and their voluntary muscle or cognitive/affective activities. They learn skills to control these activities, which are then reinforced by a visual and/or auditory display on the biofeedback instrument. The display informs the person whether control has been achieved, reinforcing learning.
Behavioral strategies, such as relaxation or muscle strengthening, are often part of biofeedback treatment to modify physiological activity.
Biofeedback with relaxation strategies can be used to control autonomic responses that affect brain waves, peripheral vascular activity, heart rate, blood glucose, and skin conductance.
Biofeedback combined with exercise can strengthen muscles weakened by conditions such as chronic pulmonary disease, knee surgery, or age.
INTERVENTION
Nurses are ideal professionals to provide biofeedback because of their knowledge of physiology, psychology, and health and illness states. However, to use biofeedback they need to acquire special information, skills, and equipment. It is recommended that information be gained
from classes and workshops available in many locations in the United States, a few other countries, and online. Nurses using biofeedback should become certified by the Biofeedback Certification International Alliance (BCIA, www.bcia.org), which offers certifications in general biofeedback, neurofeedback, and pelvic muscle dysfunction biofeedback. People in the following countries have received BICA certificates: Australia, Austria, Brazil, Canada, China, Egypt, El Salvador, Germany, Greece, Ireland, Israel, Jamaica, Japan, Mexico, the Netherlands, Poland, Republic of Korea, Republic of Singapore, Slovakia, South Africa, Taiwan, Turkey, the United Kingdom, the United States , and Venezuela. The Association for Applied Psychophysiology and Biofeedback (AAPB) (303-422-8436, www.aapb.org) is also an excellent resource for information and can be contacted at 10200 W. 44th Avenue, Wheat Ridge, CO 80033.
from classes and workshops available in many locations in the United States, a few other countries, and online. Nurses using biofeedback should become certified by the Biofeedback Certification International Alliance (BCIA, www.bcia.org), which offers certifications in general biofeedback, neurofeedback, and pelvic muscle dysfunction biofeedback. People in the following countries have received BICA certificates: Australia, Austria, Brazil, Canada, China, Egypt, El Salvador, Germany, Greece, Ireland, Israel, Jamaica, Japan, Mexico, the Netherlands, Poland, Republic of Korea, Republic of Singapore, Slovakia, South Africa, Taiwan, Turkey, the United Kingdom, the United States , and Venezuela. The Association for Applied Psychophysiology and Biofeedback (AAPB) (303-422-8436, www.aapb.org) is also an excellent resource for information and can be contacted at 10200 W. 44th Avenue, Wheat Ridge, CO 80033.
For professionals in Europe, North and South America, Asia, and Africa, the Biofeedback Foundation of Europe (BFE) sponsors education, training, and research activities in biofeedback. On their website (www.bfe.org) BFE lists these opportunities in the form of conferences, workshops, Internet courses, courseware, and other materials. Both AAPB and BFE recommend a book that can be used for teaching and self-directed learning (Peper, Tylova, Gibney, Harvey, & Combatalade, 2009). Biofeedback Resources International (BRI), (www.biofeedbackinternational.com/smart/smart0.html), another company, offers self-directed online courses that meet the didactic requirements for BCIA certification and also offers software, books, and compact disks (CDs) of biofeedback treatment programs for anxiety, addiction, anger, and pain. Face-to-face training programs with hands-on training and mentoring, however, are strongly recommended, and biofeedback equipment for sale can be found on the AAPB and the BRI websites.
The International Society for Neurofeedback and Research (ISNR) is a nonprofit member organization for health professionals, researchers, educators and other individuals who are interested in the promotion of self-regulation of brain activity for healthier functioning. The major goal of the Society is “to promote excellence in clinical practice, educational applications, and research in applied neuroscience in order to better understand and enhance brain function.” Although it is based in McLean, Virginia, Society members gather from around the globe for their annual scientific meetings.
Technique
A biofeedback unit consists of a sensor that monitors the patient’s physiological activity and a transducer that converts what is measured into an electronic visual or auditory display. Frequently measured physiological parameters include muscle depolarization, which is monitored by electromyelogram (EMG) and peripheral temperature.
Biofeedback provides information about changes in a physiological parameter when behavioral treatments such as relaxation or strengthening exercises are used for a health problem. For example, a relaxation tape helps patients relax muscles, whereas the EMG biofeedback instrument informs the learner of progress (i.e., reduced tension in the muscle). Temperature feedback is also used with relaxation treatments. As muscles relax, circulation improves and the fingers and toes become warmer. When exercises are used to strengthen perineal muscles in preventing urinary incontinence, success in contracting the correct muscles may be monitored by a pressure sensor inserted into the vagina. In health conditions exacerbated by stress, biofeedback is often combined with stress-management counseling.
Biofeedback is most frequently used in an office or clinic setting in eight to twelve 30-minute training sessions (McKee, 2008). Prior to beginning training at the initial session, the therapist and patient should decide on the number of sessions. If the patient has not achieved mastery or control of a function by the end of the agreed-upon number of sessions, the reasons and the need for further sessions should be discussed. Both the behavioral and feedback aspects of the therapy should be identified to patients.
The first session is devoted to assessing the patient, choosing the appropriate mode of feedback, discussing the roles of the nurse and the patient, and obtaining baseline measurements. Measuring several parameters helps in getting valid baseline data. Because success will be determined by changes from baseline, it is essential that these are accurate and reflect the true status of the parameter being used. The first session will be longer than subsequent ones, perhaps lasting 1 to 2 hours. Behavioral exercises are provided.
The therapist plays a key role in the success of biofeedback. It is helpful for the nurse to have advanced training in relaxation, imagery, and stress-management counseling. Because practice of the behavioral techniques is vital, the nurse who succeeds in motivating patients to practice at home is most likely to have patients who achieve their goals.
The final sessions focus on integration of the learning into the person’s life. The patient is connected to the machine, but does not receive feedback while practicing the technique; the nurse monitors the degree of control achieved. Descriptions of stressful situations are provided, and the person is asked to practice the procedure as if in those situations. Final measurements are taken. Follow-up sessions at 1 month and 6 months are advocated.
Guidelines for Biofeedback-Assisted Relaxation
A protocol for using biofeedback with cognitive-behavioral interventions for relaxation and stress management is found in Exhibit 10.1. This technique could be used for hypertension, anxiety, asthma, headache, or pain because muscle relaxation improves these conditions. The protocol should be tailored to the patient, condition, and type of feedback.
Exhibit 10.1. Biofeedback Protocol
1. Before first session
Determine health problem for which biofeedback treatment is sought.
Ask for physician’s name so care can be coordinated. Give information on location, time commitment, and cost.
Request a 2-week patient log with medications and the frequency and severity of the health problem (e.g., number, intensity, and time of headaches).
Answer questions.
2. First session
Interview patient for a health history; include the specific health condition.
Assess abilities for carrying out current medical regimen and behavioral intervention. Assess cultural preferences for behavioral treatments.
Discuss rationale for biofeedback, type of feedback, and behavioral intervention.
Explain that the role of the nurse is to provide ten 50-minute sessions once a week, using the biofeedback instrument to supply physiological information.
Explain that the patient is the major factor in the successful use of biofeedback and that it is important to continue to keep a log of the health problem, including home practice sessions. The patient should consult the physician if other health problems occur.
Explain the procedure. If using frontal muscle tension feedback, apply three sensors to the forehead after cleaning the skin with soap and water and applying gel. Set the biofeedback machine and operate according to instructions.
Obtain baseline EMG readings of frontal muscle tension for 5 minutes while the patient sits quietly with closed eyes.
Instruct the patient to practice taped relaxation instructions for 20 minutes while the EMG sensors are on the forehead. Ask the patient to watch the biofeedback display for information on the decreasing level of muscle tension.
Review the 2-week record of the health problem and set mutual goals.
Give a tape or compact disc and instructions for practicing relaxation at home. Provide a log to record practice and responses. Discuss timing, frequency, length, and setting for practice.
Discuss self-care for any possible side effects to the behavioral intervention.
3. Subsequent sessions
Open the session with a 20-minute review of the health-problem log, stressors, and ways used for coping in the past week; provide counseling for adaptive coping.
Apply sensors and earphones and let the patient practice relaxation for 20 minutes while watching the display. Quietly leave the room after the patient masters the technique.
Vary relaxation techniques to maintain interest and increase skill.
Give instructions for incremental integration of relaxation into daily life. For example, add 30-second mini-relaxation exercises for busy times of the day (e.g., touch thumbs to middle fingers, close eyes, and feel relaxation spreading through the body).
4. Final session
Conduct the session as above; obtain final EMG readings.
Discuss a plan for ongoing practice and stress management after treatment ends.
Various types of relaxation exercises, such as autogenic phases or systematic relaxation, may be used. To increase patient awareness of the relaxed state versus the state of tension, progressive muscle relaxation with alternate contraction and relaxation may be helpful. Imagery may relax patients by distracting the mind and reducing negative or stressful thoughts. Hypnosis and self-hypnosis also produce an alternative state of mind. Soft music relaxes and distracts and may be used with relaxation or imagery.
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