Evaluation of Clinical Biofeedback PDF
Preview Evaluation of Clinical Biofeedback
Evaluation of Clinical Biofeedback Evaluation of Clinical Biofeedback William J. Ray, James M. Raczynski, Todd Rogers, and William H. Kimball The Pennsylvania State University University Park, Pennsylvania Plenum Press New York and London LibraI)' of Congress Cataloging in Publication Data Main entry under title: Evaluation of clinical biofeedback. Bibliography: p. Includes index. 1. Medicine, Psychosomatic. 2. Biofeedback training. I. Ray, William I., 1945- (DNLM: 1. Biofeedback (psychology) WLl03 En] RC49.E95 616.08 79-310 ISBN 918-1-4684-3526-9 ISBN 978-1-4684-3524-5 (eBook) DOl 10.1007/978-1-4684-3524-5 Cl1919 Plenum Press, New York Softcover reprint of the hardcover 1st edition 1979 A Division of Plenum Publishing Corporation 221 West 17th Street, New York, N.Y. 10011 All rights reserved No pari of this book may-be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microrllming, recording, or otherwise, without written permission from the Publisher Acknowledgments The impetus for this book came from Dr. Morris ParI off, Chief of the Clinical Research Branch of NIMH, and initial support was provided by a contract from the National Institute of Mental Health (PLD-07841-77SH). We appreciate and acknowledge the assistance of all the researchers in the field who were willing to spend time talking with us and supplied us with their clinical research reports. Finally, we are indebted to Ms. Esther Strause and Ms. Joy Creeger, who typed and retyped the manuscript in various phases of its development. We are especially appreciative of the record time in which Ms. Creeger completed the final copy of the lengthy appendix. v Foreword This comprehensive survey will be useful for anyone who seriously wants to learn more about the current therapeutic status of biofeedback-therapists, physicians considering a referral, well-educated prospective patients, teachers, students, and research workers. But readers with different needs should use it in different ways. For a quick overview of a large field, one should tum to the Introduction and Summary and Conclusions sections. The reader interested in a specific disease should look for the proper section in the Table of Contents and then tum to the overall summary at the end of that section and also the briefer summaries that are given in the last paragraph of many subsections, whenever sufficient data are available. The reader who wants more information should read the entire chapter. The serious student or research worker, for whom the book will be most valuable, will want to read more of the main volume and at least to sample the Appendix to see the kinds of information that can be mined from it. When patients are satisfied with a new treatment and seem to be improved by it, why bother with any additional evaluation? The reason is that history has shown over and over again that new forms of treatment initially can be used enthusiastically for many conditions with apparent success, only to have the pendulum swing in the opposite direction from overenthusiasm to com plete disillusionment. In some cases, such treatments are abandoned as worth less; in others, there is a gradual recovery from disillusionment to find that the treatment is of some real benefit in specific types of conditions. Often a treatment, such as bloodletting or strong purges, that is widely used with enthusiasm is later found actually to have been harmful. Today we are discov ering that even excellent drugs like the antibiotics can be used for conditions that they do not help and that such misuse is producing two undesirable results: the development of resistant strains of bacteria, and allergies that prevent some patients from using that antibiotic when they really need it. Finally, an ineffective treatment can be harmful if it prevents a patient from seeking a more adequate one. Thus, it is important to evaluate a treatment for the good of both the patient who receives it and the public which pays an increasing percentage of the cost. As more of the cost is being paid by third parties-insurance companies or the federal government-there is an increas ing demand for the rigorous evaluation of therapeutic techniques. Thus, if a type of treatment is effective, evaluation will have cash value for the therapist who uses it. vii viii Foreword There are at least three reasons why therapists and patients are likely to overestimate the effectiveness of a new type of treatment. First, the body has a wonderful natural tendency to heal itself; many acute afflictions get better without, or even in spite of, treatment. Second, many chronic conditions fluctuate; the patient is likely to come for treatment when he is feeling much worse than usual and to be discharged as cured when he is feeling better than usual. Finally, there is a powerful placebo effect. lf the patient believes that something important is being done for him, he is likely to feel and even to be better, at least for a while, even though the treatment has no specific effect on the disease. The latter two factors are discussed in more detail in this book. At a recent meeting, one of the more enthusiastic promoters of biofeedback received applause for criticizing investigators who are so compulsive about evaluation that they force a form of treatment into a Procrustean experimental design that distorts it so much that any possibility for benefit is eliminated, and then announce that they have failed to find any therapeutic effect. Actually, the reader of this book will find that most of the serious doubts are raised not by any failure to find a therapeutic effect in the experimental group given biofeedback but by finding an equal improvement in a control group that is given a different or supposedly ineffective type of treatment-for example, hand cooling instead of the hand warming that is supposed to cure migraine headaches. I have emphasized the cautions because biofeedback has been oversold. The reader will find that it is still an experimental technique that has not yet been thoroughly evaluated. Unfortunately, a considerable number of other widely used forms of treatment, for example, certain types of surgery, also have not yet been adequately evaluated. With a number of conditions, how ever, enough encouraging results have been secured with biofeedback to merit, indeed to demand, the investment of the time and effort necessary to conduct more rigorous tests of its therapeutic value. Fortunately, more rigorous eval uative studies are beginning to appear, but the number of cases involved in such studies is still too small to yield a definitive result. Finally, the reader will find that, for certain conditions for which there is no treatment that has been proved to be effective, the encouraging but not yet definitive results make it worthwhile to try biofeedback. The purpose of this book is to evaluate the current evidence for the ther apeutic effectiveness of biofeedback. It achieves this goal. Another, different, need is to improve the effectiveness of biofeedback. One way of doing this is through research aimed at a better understanding of the mechanisms involved. For example, we need to determine whether the patient learns the skill of directly controlling the response, such as heart rate, that is being measured, or whether the feedback of information about his heart rate helps him to acquire the skill of controlling some other response such as hyperventilation (breathing too much) or muscle tension, that has a prompt effect on heart rate. In the latter case, it might be more effective to teach him the skill by giving feedback directly about the response (breathing and/or muscle tension) that is causing the trouble. In yet other cases, the primary problem may be controlling Foreword ix some response, such as fear (also called anxiety) that may be producing delayed symptoms, such as gastrointestinal disturbances. It is difficult to measure fear directly, but it is conceivable that it may be controlled indirectly by teaching the patient the skill of controlling a pattern of responses, such as muscle relaxation, peripheral vasodilatation, and increased skin resistance, that is correlated with moment-to-moment changes in fear. Basic research on all of the foregoing possibilities is needed. Finally, basic research on the laws of learning the difficult types of responses involved in the therapeutic applications of biofeedback should help us to produce more efficient learning of larger responses. If larger effects can be produced, it will be easier to evaluate them. The promise of biofeedback, as indicated by a considerable number of the more than 200 studies summarized in this book, thoroughly justifies further research. Neal E. Miller The Rockefeller University December, 1978 Contents Introduction 1 Cardiovascular Disorders 15 Raynaud's Disease 27 Migraine Headaches 29 Tension Headaches 33 Gastrointestinal Disorders 36 Asthma 39 Speech, Hearing, and Reading Disorders 42 Anxiety, Insomnia, and Addiction 48 Sexual Disorders 52 Biofeedback and Psychotherapy 55 Chronic Pain 56 Epilepsy 58 Hyperactive and Learning-Disabled Children 63 Dental Disorders 66 Neuromuscular Disorders 73 Summary and Conclusions 85 Appendix: Clinical Biofeedback Studies 91 References 307 Author Index 321 Subject Index 327 xi Introduction The first decade of biofeedback research and practice has ended. During this period there has been an enormous growth in the field. Studies of biofeedback as a research technique have appeared in the major journals in fields ranging from psychology through physiology and medicine to dentistry. Two profes sional societies, the Biofeedback Society of America and the Society of Bio feedback Clinicians, have been formed, and a specialized journal for the field, Biofeedback and Self-Regulation, has come into being. The primary goal of biofeedback has been to promote the acquisition of self-control of physiological processes. In the literature, terms like voluntary control, intentional control, and self-control have all been used to refer to the same procedure. This procedure, which we will refer to as biofeedback, is deceptively simple, and this simplicity may account for the rapid rise in its popularity. Kamiya (1971) suggested that there are three requirements for biofeedback training. First, the physiological function to be brought under control must be continuously monitored with sufficient sensitivity to detect moment-by-moment changes. Second, changes in the physiological measure must be reflected immediately to the person attempting to control the process. Third, the person must be motivated t~ learn to-effect the physiological changes uncier.study. For example, if a person was motivated to learn heart rate control, information concerning heart rate would be "fed back" to him or her in the form of visual (e.g., light display) or auditory (e.g., loudness and pitch of a tone) feedback. The basic premise of biofeedback is that through the immediate feedback of the response under study an individual can gain control over physiogical processes. Although the majority of early biofeedback studies were aimed at deter mining the parameters and theoretical models of the self-control of physiol ogical functioning, a considerable clinical focus has also developed. As a re flection of the growth of this area, there has been an increase from fewer than ten clinical research articles published before 1968 to over two hundred pub lished during the following ten years. These clinical reports represent the application of biofeedback procedures to such varied physiological processes as the functioning of the cardiovascular system, the electrical activity of the cortex, and the movement of the peripheral musculature. Disorders treated with biofeedback have likewise been varied, and have included cardiac ar rhythmias, hypertension, epilepsy, headaches, asthma, anxiety, and various forms of neuromuscular disorders. The goal of the clinical focus has in each 1 2 Introduction case been the elimination or reduction of a physiological disorder through the development of physiological self-regulation or control. It is toward the eval uation of this goal that the present review directs itself. In this volume, we will examine and outline every published clinical study reported during the period 1967-1977. Our review will be presented in both descriptive and evaluative terms and will be divided into two sections. In the first section we will discuss published papers and give an overview of the field by specific disorders, which will be grouped according to the various phy siological systems under study, such as the cardiovascular and neuromuscular systems. In this initial narrative, we will present the current clinical research in the light of a scientific evaluation. This section will be representative of the present literature in clinical biofeedback but will not be exhaustive. In the Appendix to this volume, we will present each study published during the period 1967-1977. These studies will be presented in an outline form based on evaluative criteria that are developed in this Introduction. The criteria for inclusion of a study in this review were that it 1. Be presented in the form of a published article that appeared in print before 1978. 2. Utilize a clinical population. 3. Direct itself toward the elimination or reduction of a clinical disorder. The only exceptions that were made to these criteria were cases in which we considered information presented in other formats (e.g., convention presen tations that significantly added to the understanding of biofeedback), and recent exemplary studies that clearly advanced the field or modified our original conclusions. Evaluation of Biofeedback Therapy One of the difficulties in the evaluation of biofeedback therapy is arriving at a satisfactory definition of biofeedback beyond a simple procedural one. Before asking whether biofeedback works for a specific clinical disorder, one must create a model or paradigm for directing which specific evaluative ques tions will be posed. At present there is no one model universally accepted by those who research and practice biofeedback therapy. For evaluative purposes, there is not one biofeedback therapy any more than there is one psychotherapy or one form of education or even one form of religion. There are actually a number of different and distinct modes of treatment that are curtently being considered under the single rubric of biofeedback therapy. It is just as logical to consider all therapies, either physical or psychological, that utilize vocal feed back (Le., those in which the therapist talks to the patient or client) as similar as it is to consider biofeedback as a single form of therapy. Currently, there are two distinct models presented as rationales for clinical biofeedback work. These are the learning theory model and the relaxation model. The first model of biofeedback is based on the learning theory paradigm and is often presented as a skills training analogue (cf. Miller, 1978). This
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