Ronald Glick, MD

Medical Director—Center for

Integrative Medicine at UPMC
Shadyside
 Lazarus and Folkman—External pressure exceeds
one’s perceived ability to cope
 Associated with both psychological and physiological
changes
 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
 Meditation
 Guided imagery
 Rhythmic breathing
 Hypnosis
 Autogenic training
 Yoga
 Biofeedback
 QiGong
 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
 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
 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
 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
 Excitatory
 Chemically mediated by adrenals
 Ass’d with epinephrine/norepi
 Result in cortisol release
 Associated with fight or flight response
 Braking or dampening system
 Vagally mediated
 Associated with relaxation response
 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
 Migraines & TTH A
 AD/HD A
 Urinary Incontinence A
 Anxiety D/O B
 FS/MPS B
 Heart Dz/HTN B
 COPD/Asthma
 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
 Skin conductance related to autonomics/
stress levels—think sweaty palms
 Unlike muscles, no direct imagery so relies on
other indirect methods
 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
 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
 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:
 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
 Physiologic process—HR h with inspiration
& i with expiration
 Reflects balance between sympathetic &
parasympathetic systems
 Considered to be vagally mediated
 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
 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
 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
 Positive emotion fg Negative emotion
 Low arousal fg High arousal
 High Arousal
Creativity Anger
Joy Agitated Depression
Focus

+ Emotions - Emotions
Contentment Depression
Creativity Passivity

Low Arousal
 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
 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
 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
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.
Andrasik F. Biofeedback in headache: an overview of
approaches and evidence. Cleveland Clinic Journal of
Medicine. 77 Suppl 3:S72-6, 2010 Jul.