Biofeedback in medical practice Now that the tempest in a teapot over a-brainwave biofeedback is over, serious biofeedback clinicians are coming forward again. Made timorous by the untoward publicity of the early 1970s, this new breed of specialists in behavioural medicine is cautiously expanding its efforts. Investigations and clinical applications are becoming widespread, especially in the United States. Deliberate control over one's hidden neural and psychosomatic mechanisms is now known to be possible, with the help of adequate artificial feedback signals from one's effector organs the skeletal muscles, smooth muscles, and exocrine and endocrine glands. Although skeletal muscle is under the control of the voluntary nervous system, this control becomes so automatic and unconscious that humans rarely or barely perceive their motor functions; certainly they have little awareness of the mechanisms that maintain muscular tone or produce a normal skilled act. Humans just "do it" normally until the tensions of modem life ("stress") tie them up in knots or until a neural catastrophe strikes them down. Because smooth muscle and glands are controlled by the autonomic nervous system, professionals in medical science have agreed that they cannot be consciously activated or deactivated. This parsimonious view has been proven to be erroneous. With electronic biofeedback devices that display their responses, both healthy and unhealthy persons have been trained to raise and lower their blood pressure, to change substantially (he temperature of their extremities, and even to alter the flow of both gastric secretion and sweat. That the use of biofeedback is effective in the laboratory is beyond question, but what can be done with this fact in the practice of medicine? The heaviest clinical investment in time and money has been in obtaining striated-muscle control. Our early fundamental studies at Queen's University in Kingston, Ont. demonstrated the ability of humans to control individual spinal motor neurons.1" The resulting clinical applications split into two main streams in the
1960s. The first was medical rehabilitation of various types of upper motor neuron disturbance, especially the paresis and spasticity of the postacute stages of such disorders as stroke, cerebral palsy and dyskinesias (e.g., spasmodic torticollis). The results in alleviating specific symptoms in patients with these discouraging conditions have sometimes been dramatic; for example, several clinical research studies have shown that in most cases footdrop was markedly improved by a short course of biofeedback training;3'4 many patients could walk without braces for the first time in months or years. The underlying physiology is obscure; apparently the artificial proprioception provided by biofeedback subserves new or dormant cognitive loops that permit patients to activate "paralyzed" muscles consciously; later, many patients learn the new control to the point of making it automatic. The other main stream of striatedmuscle biofeedback has been relaxation training. As unexciting as this training might appear, it has stimulated thousands of clinicians - mostly psychologists and psychiatrists in several continents to apply myoelectric biofeedback to the relief of various symptoms of stress. Tension headache, chronic back problems and anxiety are prime targets, and the literature on their management with biofeedback relaxation is expanding rapidly, as evidenced by the many articles in a new journal (Bicfeedback and Self-Regulation, Plenum Press, New York). The main problem in this area is confusion about "placebo effects", always a bugbear in psychosomatic medicine. Nevertheless, many patients have received substantial benefit when all earlier treatments proved ineffective. Volumes 1 and 2 of the new journal have reported long-term success rates that are more than double the short-term placebo rates of 32% cynically cited by critics for all novel treatments. Readers are referred to the Brief Coinniunicatlons section of this issue of the Journal for two ..ertinent ar tides, beginning on pages 45 and 48.
8 CMA JOURNAL/JULY 8, 1978/VOL. 119
Autonomic nervous system controls, clearly demonstrated in the laboratory, have not had the same lasting success rate in clinical practice. Patients with moderate essential hypertension have become rapidly but temporarily normotensive with biofeedback training. Some medical investigators have succeeded in making the training effect carry over into daily living;5 others have reported both success and failure.6 Too parochial an approach to hypertension by noncardiologists seems to be the problem, yet the fact remains that patients can be taught to relate to a machine that displays their blood pressure and to manipulate their cardiovascular controls by consciously changing the instant readings on the machine. This surely offers us a great lesson. Alteration of peripheral blood flow (usually monitored from exquisitely sensitive thermistors on a fingertip) has been applied most widely to the treatment of migraine. Again the exact mechanism of vascular readjustments is unclear, but some of the reported success rates are exciting;7 again they go well beyond those of the placebo effect. Raynaud's phenomenon has also been attacked by thermal feedback, with good early results in several clinics;8 however, long-term results are lacking. While this editorial is not meant to be a review, neither is it an apologia. Clinical biofeedback based on scientific principles and basic science has emerged, and it will form an important part of the new discipline of behavioural medicine. The correction of somatic and emotional disturbances by the judicious application of behavioural techniques that employ self-regulation principles should make a real contribution. Biofeedback provides windows for the patient through which to see the previously hidden somatic responses; then, through an effort of will reinforced by the trained clinician, the patient should learn to change an increasing number of those somatic responses into healthier responses. This is the sober promise of clinical biofeedback that deserves careful
nurture by all who believe that behavioural medicine is soon to be an important part of clinical investigation and practice. J.V. BASMAJIAN, MD, FACA
Director, rehabilitation centre Chedoke Hospitals Hamilton, Ont.
References 1. BASMAJIAN JV: Muscles Alive: Their Functions Revealed by Electromycgraphy, 3rd ed, Williams & Wilkins, Baltimore, 1974, pp 114-39 2. Idem: Control and training of individual motor units. Science 141: 440, 1963 3. JOHNSON HE, GARTON WH: Muscle re-education in hemiplegia by use of electromyographic device. Arch Phys Med Rehabil 54: 320, 1973
Historical notes - plague Throughout "the Golden Age" of Rome periodic epidemics of plague occurred. At one point plague almost exterminated the Roman army. Malaria and plague were as much the conquerers of Rome as the Goths and Vandals. In 542 AD an epidemic of plague in lower Egypt spread up the Nile and into Asia Minor, reaching Constantinople; at its height it killed 5000 to 10000 people daily. Plague recurred frequently during the Middle Ages but was quiescent to 1345, when it became epidemic in Africa and Asia. Two years later it spread to Constantinople, then to Greece and Italy, and finally throughout Europe. During this epidemic, which killed 25 million people, plague was named the Black Death because of the black extravasated blood around the petechiae. In the 14th century plague killed an estimated one fourth of the population of Europe and perhaps one half of the population of England. Medieval physicians protected themselves against plague by wearing leather suits and gauntlets, and masks with glass coverings for the eyes and a long snout filled with fumigants. They lit fires and burned aromatic substances to purify the air, sprinkled perfumed water in the room and on their clothing, and recommended the following for avoiding plague: Go quick, go far and return late. Plague was almost continuously present in London, England until late
4. BASMAJIAN JV, KUKULKA CG, NARAYAN MG, et al: Biofeedback treatment of foot-drop after stroke compared with standard rehabilitation technique: effects of voluntary control and strength. Arch Phys Med Rehabil 56: 231, 1975 5. PATEL C: 12-month follow-up of yoga and bio-feedback in the management of hypertension. Lancet 1: 62, 1975 6. SHAPIRO AP, SCHWARTZ GE, FERGU-
SON DC, et al: Behavioral methods in the treatment of hypertension. A review of their clinical status. Ann intern Med 86: 626, 1977 7. GREEN EE, GREEN AE: Beyond Bio-
feedback, Delacorte Pr, New York, 1977 8. TAUB E: Self-regulation of human tissue temperature, in Biofeedback Theory and Research, SCHWARTZ GE, BEATTY J (eds), Acad Pr, New York, 1977
in the 17th century; epidemics broke out periodically. Some doctors prescribed smoking to ward off the disease. In 1666 the great fire of London destroyed the infected rats and arrested the epidemic. A subsequent outbreak in Europe lasted 20 years. The last epidemic began in China in 1867 and spread to Hong Kong, where in 1894 Yersin and Kitasato described the causal bacillus. In 1900 plague was introduced into San Francisco. Public health authorities did not admit that the problem existed. Before 1 million rats were killed the disease had spread to ground squirrels, 20 million of which were killed to eradicate the disease. In 1906-07 plague was prevalent on the Canadian Pacific Coast. People were paid to take rats to the provincial laboratory for examination in a concrete building erected for the purpose. In 1919 two fatal cases of plague occurred on a ship travelling from Montreal to Bristol that had sailed originally from Alexandria (Heagerty JJ: "Four Centuries of Medical History in Canada", Macmillan, Toronto, 1928). Plague remains endemic, especially in the southern United States, where isolated cases occur, mainly among hunters exposed to rat fleas from ground squirrels or prairie dogs. Plague must be considered in persons with fever, lymphadenopathy and recent contact with wild rodents or rabbits if secondary plague pneumonia is to be avoided among contacts.E
10 OMA JOURNAL/JULY 8, 1978/VOL. 119
meTamuat Prescribing Information INDICATIONS: For the relief of chronic, atonic, spastic and rectal constipation and for the constipation accompanying pregnancy, convalescence and advanced age. For use in special diets lacking in residue and as adjunctive therapy in the constipation of mucous and ulceralive colilis and diverliculitis. Also useful in the managementof hemorrhoids and following anorectal surgery. CONTRAINDICATIONS: Presence of nausea, vomiting, abdominal pain or symptoms of an acute abdomen or fecal impaction. Metamucil Instant Mix is contraindicated in patients who must severely resirict their dietary sodium intake. PRECAUTIONS: For patients, such as those suffenng from diabetes mellilus, where ngid dietary calone conirol is required: Powder-I dose furnishes 14 calones. Instant Mix- I dose furnishes 3 calories. DOSAGE:Powdr-one rounded teaspeonful of pawder Ito 3 times daily depending on the condition being treated, its severity and mdividual respansiveness. The teaspeonful of pawder is stirred into an 8 oz. glass of cool water or other suitable liquid and should be token immediately. Instant Mix-one packet I to 3 times daily depending on the condition being treated, its severity and indMdual respansiveness. The contents of the packetare paured into an 8 oz. glasstowhich cool wateris then siowly added. The resulting effervescent mixlure should be taken immediately. SUPPUED: Powdr-a refined, purified and concentrated vegetable mucilloid, prepared ftom the mucilaginous parlion of Plantogo ovata,combinedwithdexhose as a dispersing agent Each rounded teaspeonful contains approximately 3.1 g of psyllium hydrophilic mucilloid per dose, a negligible amount of sodium, and furnishes 14 calories. Available in 6 and 12 oz. plastic baffles. Instant Mix-premeasured unit-dose packets. Each unit-dose packet contains 3.6 g of psyllium hydrophilic mucilloid with eftervescent and flavouring excipients, 0.25 g of sodium as bicarbonate, and furnishes 3 calories. Available in boxes of 15 unit-dose packets.
Natural bowel management that benefits many kinds of patients. Complete prescribing information available on request (or consult ORS.).
Searle Pharmaceuticals Oakville, Ontario L61-l 1M5
1960s. The first was medical rehabilitation of various types of upper motor neuron disturbance, especially the paresis and spasticity of the postacute stages of such disorders as stroke, cerebral palsy and dyskinesias (e.g., spasmodic torticollis). The results in alleviating specific symptoms in patients with these discouraging conditions have sometimes been dramatic; for example, several clinical research studies have shown that in most cases footdrop was markedly improved by a short course of biofeedback training;3'4 many patients could walk without braces for the first time in months or years. The underlying physiology is obscure; apparently the artificial proprioception provided by biofeedback subserves new or dormant cognitive loops that permit patients to activate "paralyzed" muscles consciously; later, many patients learn the new control to the point of making it automatic. The other main stream of striatedmuscle biofeedback has been relaxation training. As unexciting as this training might appear, it has stimulated thousands of clinicians - mostly psychologists and psychiatrists in several continents to apply myoelectric biofeedback to the relief of various symptoms of stress. Tension headache, chronic back problems and anxiety are prime targets, and the literature on their management with biofeedback relaxation is expanding rapidly, as evidenced by the many articles in a new journal (Bicfeedback and Self-Regulation, Plenum Press, New York). The main problem in this area is confusion about "placebo effects", always a bugbear in psychosomatic medicine. Nevertheless, many patients have received substantial benefit when all earlier treatments proved ineffective. Volumes 1 and 2 of the new journal have reported long-term success rates that are more than double the short-term placebo rates of 32% cynically cited by critics for all novel treatments. Readers are referred to the Brief Coinniunicatlons section of this issue of the Journal for two ..ertinent ar tides, beginning on pages 45 and 48.
8 CMA JOURNAL/JULY 8, 1978/VOL. 119
Autonomic nervous system controls, clearly demonstrated in the laboratory, have not had the same lasting success rate in clinical practice. Patients with moderate essential hypertension have become rapidly but temporarily normotensive with biofeedback training. Some medical investigators have succeeded in making the training effect carry over into daily living;5 others have reported both success and failure.6 Too parochial an approach to hypertension by noncardiologists seems to be the problem, yet the fact remains that patients can be taught to relate to a machine that displays their blood pressure and to manipulate their cardiovascular controls by consciously changing the instant readings on the machine. This surely offers us a great lesson. Alteration of peripheral blood flow (usually monitored from exquisitely sensitive thermistors on a fingertip) has been applied most widely to the treatment of migraine. Again the exact mechanism of vascular readjustments is unclear, but some of the reported success rates are exciting;7 again they go well beyond those of the placebo effect. Raynaud's phenomenon has also been attacked by thermal feedback, with good early results in several clinics;8 however, long-term results are lacking. While this editorial is not meant to be a review, neither is it an apologia. Clinical biofeedback based on scientific principles and basic science has emerged, and it will form an important part of the new discipline of behavioural medicine. The correction of somatic and emotional disturbances by the judicious application of behavioural techniques that employ self-regulation principles should make a real contribution. Biofeedback provides windows for the patient through which to see the previously hidden somatic responses; then, through an effort of will reinforced by the trained clinician, the patient should learn to change an increasing number of those somatic responses into healthier responses. This is the sober promise of clinical biofeedback that deserves careful
nurture by all who believe that behavioural medicine is soon to be an important part of clinical investigation and practice. J.V. BASMAJIAN, MD, FACA
Director, rehabilitation centre Chedoke Hospitals Hamilton, Ont.
References 1. BASMAJIAN JV: Muscles Alive: Their Functions Revealed by Electromycgraphy, 3rd ed, Williams & Wilkins, Baltimore, 1974, pp 114-39 2. Idem: Control and training of individual motor units. Science 141: 440, 1963 3. JOHNSON HE, GARTON WH: Muscle re-education in hemiplegia by use of electromyographic device. Arch Phys Med Rehabil 54: 320, 1973
Historical notes - plague Throughout "the Golden Age" of Rome periodic epidemics of plague occurred. At one point plague almost exterminated the Roman army. Malaria and plague were as much the conquerers of Rome as the Goths and Vandals. In 542 AD an epidemic of plague in lower Egypt spread up the Nile and into Asia Minor, reaching Constantinople; at its height it killed 5000 to 10000 people daily. Plague recurred frequently during the Middle Ages but was quiescent to 1345, when it became epidemic in Africa and Asia. Two years later it spread to Constantinople, then to Greece and Italy, and finally throughout Europe. During this epidemic, which killed 25 million people, plague was named the Black Death because of the black extravasated blood around the petechiae. In the 14th century plague killed an estimated one fourth of the population of Europe and perhaps one half of the population of England. Medieval physicians protected themselves against plague by wearing leather suits and gauntlets, and masks with glass coverings for the eyes and a long snout filled with fumigants. They lit fires and burned aromatic substances to purify the air, sprinkled perfumed water in the room and on their clothing, and recommended the following for avoiding plague: Go quick, go far and return late. Plague was almost continuously present in London, England until late
4. BASMAJIAN JV, KUKULKA CG, NARAYAN MG, et al: Biofeedback treatment of foot-drop after stroke compared with standard rehabilitation technique: effects of voluntary control and strength. Arch Phys Med Rehabil 56: 231, 1975 5. PATEL C: 12-month follow-up of yoga and bio-feedback in the management of hypertension. Lancet 1: 62, 1975 6. SHAPIRO AP, SCHWARTZ GE, FERGU-
SON DC, et al: Behavioral methods in the treatment of hypertension. A review of their clinical status. Ann intern Med 86: 626, 1977 7. GREEN EE, GREEN AE: Beyond Bio-
feedback, Delacorte Pr, New York, 1977 8. TAUB E: Self-regulation of human tissue temperature, in Biofeedback Theory and Research, SCHWARTZ GE, BEATTY J (eds), Acad Pr, New York, 1977
in the 17th century; epidemics broke out periodically. Some doctors prescribed smoking to ward off the disease. In 1666 the great fire of London destroyed the infected rats and arrested the epidemic. A subsequent outbreak in Europe lasted 20 years. The last epidemic began in China in 1867 and spread to Hong Kong, where in 1894 Yersin and Kitasato described the causal bacillus. In 1900 plague was introduced into San Francisco. Public health authorities did not admit that the problem existed. Before 1 million rats were killed the disease had spread to ground squirrels, 20 million of which were killed to eradicate the disease. In 1906-07 plague was prevalent on the Canadian Pacific Coast. People were paid to take rats to the provincial laboratory for examination in a concrete building erected for the purpose. In 1919 two fatal cases of plague occurred on a ship travelling from Montreal to Bristol that had sailed originally from Alexandria (Heagerty JJ: "Four Centuries of Medical History in Canada", Macmillan, Toronto, 1928). Plague remains endemic, especially in the southern United States, where isolated cases occur, mainly among hunters exposed to rat fleas from ground squirrels or prairie dogs. Plague must be considered in persons with fever, lymphadenopathy and recent contact with wild rodents or rabbits if secondary plague pneumonia is to be avoided among contacts.E
10 OMA JOURNAL/JULY 8, 1978/VOL. 119
meTamuat Prescribing Information INDICATIONS: For the relief of chronic, atonic, spastic and rectal constipation and for the constipation accompanying pregnancy, convalescence and advanced age. For use in special diets lacking in residue and as adjunctive therapy in the constipation of mucous and ulceralive colilis and diverliculitis. Also useful in the managementof hemorrhoids and following anorectal surgery. CONTRAINDICATIONS: Presence of nausea, vomiting, abdominal pain or symptoms of an acute abdomen or fecal impaction. Metamucil Instant Mix is contraindicated in patients who must severely resirict their dietary sodium intake. PRECAUTIONS: For patients, such as those suffenng from diabetes mellilus, where ngid dietary calone conirol is required: Powder-I dose furnishes 14 calones. Instant Mix- I dose furnishes 3 calories. DOSAGE:Powdr-one rounded teaspeonful of pawder Ito 3 times daily depending on the condition being treated, its severity and mdividual respansiveness. The teaspeonful of pawder is stirred into an 8 oz. glass of cool water or other suitable liquid and should be token immediately. Instant Mix-one packet I to 3 times daily depending on the condition being treated, its severity and indMdual respansiveness. The contents of the packetare paured into an 8 oz. glasstowhich cool wateris then siowly added. The resulting effervescent mixlure should be taken immediately. SUPPUED: Powdr-a refined, purified and concentrated vegetable mucilloid, prepared ftom the mucilaginous parlion of Plantogo ovata,combinedwithdexhose as a dispersing agent Each rounded teaspeonful contains approximately 3.1 g of psyllium hydrophilic mucilloid per dose, a negligible amount of sodium, and furnishes 14 calories. Available in 6 and 12 oz. plastic baffles. Instant Mix-premeasured unit-dose packets. Each unit-dose packet contains 3.6 g of psyllium hydrophilic mucilloid with eftervescent and flavouring excipients, 0.25 g of sodium as bicarbonate, and furnishes 3 calories. Available in boxes of 15 unit-dose packets.
Natural bowel management that benefits many kinds of patients. Complete prescribing information available on request (or consult ORS.).
Searle Pharmaceuticals Oakville, Ontario L61-l 1M5
