Download Therapeutic Recreation

Biofeedback: A New Frontier for
Recreation Therapy
West Virginia Therapeutic Recreation Association
Annual Conference – Cacapon State Park
November 5-7, 2008
Michael Duquette, CTRS, BCIAC, CCDC
Lead Therapist
National Institutes of Health
Bethesda, Maryland
Benedict Stover
Recreation Therapy Intern
National Institutes of Health
Bethesda, Maryland
Outline
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
X.
XI.
Definitions
Biofeedback Clips
Certification Process
Stress/Autonomic Nervous System
Operant Conditioning
Relaxation Response
Biofeedback Modalities
Stress Test
Guided Imagery Assisted Biofeedback
Heart Rate Variability Biofeedback
Questions
Body → Mind
 Physiological Psychology – How changes in the body
(e.g., drinking, drugs, stress hormones) affect the way
people think and feel.

Physiological psychologists manipulate physiology, then
observe behavioral results.
Mind → Body
 Psychophysiology – How changes in the mind (e.g.
observations, thoughts, attitudes, emotions) affect the
way the body responds to the environment.

Psychophysiologists manage, guide, and obstruct human
psychological variables, then observe physiological
effects.
Complementary Alternative
Medicine (CAM)
 The term “alternative medicine”, encompasses
any healing practice "that does not fall within the
realm of conventional medicine."
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Chiropractic
Meditation
Yoga
Biofeedback
Hypnosis
Acupuncture
Prayer
Applied Biofeedback
a) A group of therapeutic procedures…
b) utilizing electronic instruments…
c) to accurately measure, process, and ‘feedback’
to persons information…
d) with reinforcing properties…
e) about their neuromuscular and autonomic
activity, both normal and abnormal…
f) in the form of analog or binary, auditory, and/or
visual feedback signals.
Applied Biofeedback Cont.

Best achieved with a competent biofeedback
professional
The objectives are to help patients:

1.
2.
3.
Develop greater awareness and voluntary control
over their physiological processes that are
otherwise outside awareness and/or under less
voluntary control (ANS)
By first controlling the external signal
And then with the internal psycho-physiological
cues
Biofeedback Videos
 ECU Biofeedback
 Pediatric Biofeedback
BCIA Certification in General
Biofeedback
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Bachelor or higher degree in a BCIA approved health care related field
Human Anatomy/Physiology
Didactic Biofeedback Education (48 hrs)
Practical Biofeedback Training - 20 contact hours with a BCIA approved
mentor
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The 20 contact are used hours to review:
·10 sessions of personal biofeedback, demonstrating self-regulation.
·50 sessions of patient/client treatment as follows: 10 sessions each of
Thermal, EMG, and GSR. The remaining 20 sessions are to include any
combination of EMG, Thermal, GSR, EEG, HRV, and respiration training.
·10 case conference presentations.
*Sessions are a minimum of 20 minutes.
Written Examination
BCIA Information
Reasons for Medical Visits to Primary Providers
Others
Chest pain, dyspnea,
etc.
Functional GI
Colds, Flu, etc.
Panic, insomnia,
anxiety, etc.
Headaches, back
pain, fibromyalgia,
etc.
Stress Related Disorders
Stress
 Acute



MOST common form of
stress.
Comes from demands
and pressures of the
recent past and
anticipated demands and
pressures of the near
future.
Can be thrilling and
exciting in small doses,
but too much is
exhausting.
 Chronic



Comes when a person
never sees a way out of
a miserable situation.
Insistent demands and
pressures for seemingly
interminable periods of
time.
With no hope, the
individual gives up
searching for solutions.
Autonomic Nervous System
1) Central Nervous System (CNS)
2) Peripheral Nervous System (PNS)

Sensory – Afferent Division

Motor – Efferent Division

Somatic – Skeletal Muscles – Voluntary

Autonomic Nervous System (ANS) – Involuntary

Sympathetic - Parasympathetic
a) Smooth Muscle (stomach, bladder, blood vessels)
b) Cardiac Muscle
c) Glands (tear, sweat, salivary, adrenal)
Spinal Nerves
T1-12 & L1, L2
Cranial
NervesIII,VII,IX,X
Spinal Nerves S1, S2
Sympathetic
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The “fight or flight” subdivision of the Autonomic Nervous System
Involves activation of the adrenal medulla
Postganglionic axons secrete noradrenaline
Includes spinal nerves from T1 → L2
 stimulates heartbeat
 raises blood pressure
 dilates the pupils
 dilates the trachea and bronchi
 stimulates the conversion of liver glycogen into glucose
 shunts blood away from the skin and viscera to the skeletal muscles, brain, and heart
 inhibits peristalsis in the gastrointestinal (GI) tract
 inhibits contraction of the bladder and rectum
Parasympathetic
 Postganglionic axons secrete acetylcholine
 Involves Cranial Nerves III, VII, IX, X, and Spinal Nerves S2 →S4
 MOST active when the body is at rest
 slows down of the heartbeat
 lowers blood pressure
 constricts the pupils
 increases blood flow to the skin and viscera
 allows peristalsis of the GI tract
 relaxes the bladder and rectum
The Autonomic Nervous System
Structure
Sympathetic Stimulation
Parasympathetic Stimulation
Iris (eye)
Pupil Dilation
Pupil Constriction
Heart
Heart rate and force increased
Decreased stroke volume
Heart rate and force decreased
Increased stroke volume
Lung
Bronchial muscle relaxed
Bronchial muscle contracted
Small Intestine
Motility reduced
Digestion increased
Kidney
Decreased urine secretion
Increased urine secretion
Adrenal medulla
Norepinephrine and
epinephrine secreted
Bladder
Wall relaxed
Sphincter closed
Wall contracted
Sphincter relaxed
Stress Pathways
Acute Stress
 Sympathetic-Adrenal-Medullary (SAM)
Chronic Stress
 Hypothalmus-Pituitary-Adrenal (HPA)
Sympathetic-Adrenal-Medullary
(SAM)
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“Flight or Flight” – Walter B. Cannon
Primary Pathway – autonomic nervous System
Fast acting
Brain→ Spinal Cord →Adrenal Medulla
Epinephrine →Released in bloodstream
Norepinephrine →Nerve Cells →Glands & Muscles
↑Heart Rate
↑Blood Pressure
Dilates Pupils
↑Metabolism Dilates Bronchi
↑Saliva Flow
Converts Glycogen to Glucose
Inhibits Bladder
HPA Axis
 Involved in long term stress response
 ↑ amount of energy to places most needed
 Hypothalamus
↓
Pituitary
↓
Adrenal
The Brain’s Stress Response
Brain
Structure
Chemical
Fear
Freeze
Amygdala
Hypothalmus
Emotion
Corticotropin
Releasing
Hormone (CRF)
Increase blood
glucose
level
Decrease
inflammation
Reduce pain
Flush
Pituitary
Gland
Adrenal
Cortex
ACTH
(adrenocorticotrophic
Hormone)
Flight/
Flight
Faint
Cortisol
Resist long
term stress
Parasympathetic
Sympathetic
Operant Conditioning
 Operant conditioning
forms an association
between a behavior
and a consequence
1.
 There are four
possible consequences to any
behavior. They are:
3.
2.
4.
Something Good can start or
be presented, so behavior
increases = Positive
Reinforcement (R+)
Something Good can end or
be taken away, so behavior
decreases = Negative
Punishment (P-)
Something Bad can start or
be presented, so behavior
decreases = Positive
Punishment (P+)
Something Bad can end or
be taken away, so behavior
increases = Negative
Reinforcement (R-)
The Relaxation Response
Diaphragmatic breathing is a basic tool
in developing awareness, modulating
stress and enhancing a healthy mindbody balance (Benson, 1994)
Benson’s Basic Components to
Promote the Relaxation Response
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A Quiet Environment
Something to “dwell” on
A passive attitude
A Comfortable Position
The Relaxation Response
 The Relaxation Response is an integrated
hypothalamic response which results in
generalized decreases in sympathetic
nervous system activity.
 It is the physiologic antithesis of the flightor-fight response.
(Benson, 1975, 1992)
Benson’s Basic Components to
Promote the Relaxation Response
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A Quiet Environment
Something to “dwell” on
A passive attitude
A Comfortable Position
Mindfulness
 Being aware of, and paying attention
to, the moment in which we find
ourselves.
 Our past is gone, our future is not yet
here… so what exist between them is
the present moment.
Mindfulness YouTube Clip 23-27min
General Biofeedback Modalities

Finger Temperature (FT)

Respiration

Skin Conductance (SC)

Electromyography (EMG)

Blood Pulse Volume (BVP)
Surface Electromyography (SEMG)

Three Fold Purpose:
1.
2.
3.
Receive the electrical
signal
Separate this electrical
output from other energy
on skin and amplify it
greatly
Convert the amplified
EMG signal into useful
forms of information
(Biofeedback)
Surface Electromyography (SEMG)
Microvolts
A
 An electrical correlate of
muscle contraction
 EMG is measured in
microvolts (millionths of a
volt)
 The strength of
contraction is directly
proportional to the signal
level
 EMG is derived from 2
active electrodes and a
ground/reference
B
0
5
Seconds
A – Bicep
B - Tricep
Skin Conductance (SC)
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Electrodermal Response (EDR) or Galvanic Skin
Response (GSR)
Measurement of skin response to a small electrical
current being passed through it.
Changes in resistance of skin to an electrical current
due to opening and closing of sweat glands.
Electrodes attach to the volar surface of finger tips or
palm of hand.
The more emotionally aroused you are, the more
active your sweat glands are and the greater the
electrical conductivity of your skin.
Indication of sympathetic arousal; quick to activate,
slow to recover.

Effective in treating: phobias, anxiety, excessive
sweating, and, at times, stuttering since these emotions
will affect your skin's conductivity.
Thermal Feedback
 A device that monitors vasodilatation (↑ blood volume and
vasoconstriction (↓ blood volume).
 Usually, to the middle or small finger of your dominant hand.
 When you are tense or anxious, your skin temperature drops
as blood is redirected inward to muscles and internal organs,
(sympathetic nervous system).
 Like monitoring muscle tension, measuring skin temperature
is a useful tool in learning how to manage stress, (↑ in skin
temperature-activation of parasympathetic nervous system).
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↓ 85F = Aroused, Distressed
85-89.9F = Anxious, Nervous
90-92.9 = Normal Range
93-94.9 = Calm, Quiet
Above 95 = Deeply Relaxed
Guided Imagery Treatment
Guided Imagery Audio
Heart Rate
Variability
Biofeedback
Oscillations
Tides
Breathing
Respiratory Sinus Arrhythmia
(RSA)
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Respiratory = Breath
Arrhythmia = Heart Rate Changes
Sinus = Oscillations
RSA triggers very powerful
cardio-vascular reflexes that
help to balance the autonomic
nervous system to include the
Bainbridge Reflex (blood
volume) and the Baroreceptor
Reflex, (blood pressure).
Exhale

Oscillations
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In healthy individuals, a degree of
interaction between activity of SNS and
PSNS allows more effective responses to
demands.
This interaction produces variability in HR.
Oscillations in HR interact with other
oscillating systems (hormones, blood
pressure, respiration, emotion, etc).
Oscillations-Heart Rate Variability
Breathing
Heart Rate
Blood
Pressure
Blood
Volume
Vaschillo’s Resonant
Frequency
Theory
Ordinary Breathing produces
three HR frequencies,
HF,LF,&VLF
Progression to
approx. 6 BPM,
(Diaphragmatically) in
experienced breathers
produces single summated
peak at about .1hz:
RESONANT FREQUENCY
Daily practice in this
state increases
homeostatic reflexes
HR and BP Oscillations Elicited by the Stimulus of
Respiration at Resonant Frequency
Blood Pressure
Time
Delay~ 5 sec
Heart Rate
Time
Respiration
Time
Inhale
Exhale
Sympathetic
Para-sympathetic
Diaphragm
Breathing Video
Diaphragmatic Breathing - Sitting
Resources
 Biofeedback Institute of America

www.bcia.org
 Association for Psychophysiology and Biofeedback

www.aapg.org
 Biofeedback Foundation of Europe

www.bfe.org
(this is where you can download the breathing
pacer, EZ-Air)
ECU Biofeedback Lab

www.ecu.edu/rcls/biofeedback/
Stens Biofeedback

www.stens-biofeedback.com
Thought Technology

www.thoughttechnology.com