The Biofeedback Association of South Africa
Biofeedback is a form of self-regulation where the aim is to enhance and bring awareness to the way in which the mind/thoughts may trigger or influence physiological processes within the body.
The body constantly adjusts to the environment by either “speeding up” or “slowing down” in order to maintain balance and homeostasis and attend to the demands of the environment. When the Autonomic Nervous System (ANS) gets stuck and speeds up and does not slow down when appropriate, detrimental health effects can result.
The Autonomic Nervous System consists of two main branches:
1. Sympathetic Nervous System (SNS)
The SNS controls our “fight / flight / freeze” response and increases our heart rate, breathing and blood flow to muscles when required. The role of the SNS is to quickly activate the body’s endocrine system to attend to short-term stressors. However, the SNS ignores the long-term health consequences of continued nervous system overactivation on the body.
2. Parasympathetic Nervous System (PNS)
PNS is our “rest and digest” or recovery response and decreases our heart rate when needed.
This assists with physical reparation in the body and conserves energy within physiological systems for optimal functioning.
Biofeedback is the practice of making these physiological processes measurable and visible to the client. The client gains insight into how the body adjusts and responds to internal physiological processes and its stress response to daily events.
Biofeedback is an effective training modality for developing self-awareness thereby promoting mindfulness of the moment-to-moment responses to life’s challenges (stress). Biofeedback is primarily used to treat high blood pressure and to lower anxiety responses. It is also used for tension headaches, migraine headaches, chronic pain and urinary incontinence. Further utilization includes Peak Performance Training with top athletes, artists and executives.
Electrodes or sensors placed on the body measure physiological responses, for example, the tension in particular muscle groups, blood pressure or hand temperature. These real-time measurements are displayed on a monitor for the client to observe, learn from and consciously alter.
With assistance from a biofeedback therapist, the client learns techniques to regulate their breathing, heart rate or blood pressure. At first, the monitor is used to track progress. Eventually, the client will be able to achieve success without a monitor or electrodes and generalise this improvement to daily life.
DESCRIPTION OF MODALITIES:
1. Skin Temperature
During the fight/flight response that gets triggered during high stress levels, the peripheral nervous system will divert blood away from one’s extremities to more important organs like the brain, lungs and heart for survival and to manage acute stress optimally. This leads to cold and clammy hands.
Warm peripheral skin temperature is an indication of better homeostasis in the body. Migraine and chronic headache sufferers, as well as people suffering from hypertension and Raynaud’s Disease, benefit from this training.
2. Electrodermal Activity – Galvanic skin response
This involves the measurement of conductance of moisture/sweat on the skin surface of the hand. It is an accurate measure of eccrine sweat gland activity that is triggered when one becomes anxious or aroused. The speed of small electrical currents are measured. (This forms a common part of “lie-detector“tests). Biofeedback practitioners teach clients to lower the skin conductance response to ameliorate depression, sleep disorders, anger, overall stress and facilitate mind-body awareness.
3. Surface Electromyography (SEMG) - Muscle tension or Neuromuscular re-education
The monitoring of bio-electrical activity produced by the muscle when it contracts is a good indicator of muscle tension in various muscle groups in the body. These contractions are intended to last only a moment, with the muscle then returning to baseline “ready position” immediately after. However, when the fight/flight or freeze response is triggered, incorrect muscle firing patterns can develop, for example, SMA (sensory motor amnesia - muscles forget to relax). During and after periods of stress, body tension has shown how posture can be negatively affected and how pain patterns can emerge. Contracted muscles that are responding to high neural firing rates for extended periods of time show fatigue, cramping and pain patterns. EMG biofeedback training is used for symptom reduction in cases of tension headaches, bruxism, TMJ complaints, hypertension, stress, chronic pain, repetitive strain injuries and Carpal Tunnel syndrome.
4. HEART RATE VARIABILITY
HRV measures and trains coherence or synchrony between breathing and heartbeat. Higher HRV resonance has been shown to result in improvement in the ability to mediate life’s stressors. HRV is efficacious in the reduction of stress, depression, PTSD, sleep disorders, hypertension and improves mind-body awareness.
The body is a finely integrated operating system involving the interaction of
These systems do not work independently of one another but are interdependent.
One such system is the Autonomic Nervous system (ANS) which regulates body systems on an unconscious level. Blood pressure, blood glucose levels, levels of stress hormones, digestion, heart rate and others are regulated without conscious awareness during wakefulness and sleep.
Basic Heart Rate Variability (HRV) measurements are the changes seen in time between successive heartbeats called inter-beat-intervals (see diagram below).
Mean heart rate variability has become an indicator of fitness as well as a predictor of enhanced vitality and health. These measurements have been shown to indicate a direct link to the Autonomic Nervous System providing insight into the nervous system’s response to stress and its ability to recover.
The body constantly adjusts to the environment by either “speeding up” or “slowing down” in order to maintain balance and homeostasis and attend to the demands of the environment. When the Autonomic Nervous System gets stuck and speeds up and does not slow down when appropriate, detrimental health effects can result.
FIGURE 1. A typical HRV biofeedback screen showing the transition from normal breathing to 7 breaths per minute breathing.
In the Psychophysiological research field, HRV originally focused on balancing of the Autonomic Nervous System. The medical field continues to focus on HRV as the indicator of adaptability and Baroreflex sensitivity. Researchers have investigated the impact of HRV on vagus nerve activity in various disorders such as asthma, chronic pain and anxiety disorders.
Many research projects are underway to look at the effect of the heart on the brain / CNS. Research shows that there is a stronger impact of the heart on the brain than vice versa.
The procedure of HRV training consists of feeding back beat by beat heart rate data during slow breathing manoeuvres.
RSA is the heart pattern that occurs when heart rate increases during inhalation and decreases during exhalation - as can be seen in Figure 1
During this slower breathing the participant tries to maximize their Respiratory Sinus Arrhythmia (RSA) and create a sine-wave-like curve of peaks and valleys, and match RSA to heart rate patterns.
The participant uses feedback or a breath pacing device to produce the characteristic maximized RSA.
Breathing at your Resonant Breathing Rate increases HRV
HRV training is an evidence-based training modality (Biofeedback) used to increase the active control over the body’s response to stress. It creates the bridge between the heart and the brain / nervous system, bringing into consciousness the processes that get influenced by the ANS.
Biofeedback training allows accurate feedback mirroring what your heart is communicating to the rest of your nervous system, in time learning to gain better control over how your body reacts to the stress stimuli and building on your resilience to such stress stimuli. Combining HRV with other modalities like With Together with Psychotherapy, CBT and stress management strategies your clients enable themselves to better self-regulate in day to day situations. HRV Biofeedback training teaches clients to access some of the following benefits:
Enhanced cardiac health
Reduction in anxiety and performance anxiety symptoms
Reduced muscle tension
Improvement in general energy and mood
Clearer cognitive abilities
Calmness and faster reaction times
Improved hormone balance
Improved immune system activity
Improve on recovery rate after intense physical training
Gevirtz (2013) recently reviewed all of the available literature on the outcomes of HRVB. He looked at the following application categories: asthma, COPD, IBS, cyclic vomiting, recurrent abdominal pain, fibromyalgia, cardiac rehabilitation, hypertension, chronic muscle pain, and pregnancy induced hypertension, depression, anxiety, PTSD, insomnia, and performance. While few areas have extensive support by way of controlled studies, the overall picture seems to be very promising for this intervention. As can be seen, the applications are quite varied. We have begun to explore what physiological and/or psychological mechanisms might be contributing to these positive outcomes.
Stress Profile and Stress reduction training
A Combination of all of the above sensors or measurements are used to compile a measured outcome of a client’s physiological response to simulated stress (Stress profile).
This provides the clinician with a clear path for training with their client. The aim is to establish a more regulated neuro-physiological response pattern of the nervous system - which results in a feeling of internal balance.
Neurofeedback is a specific form of biofeedback, providing feedback to the brain so that functioning can be optimized.
Extensive research has shown that neurofeedback is an effective option for children and adults with difficulties such as concentration problems, hyperactivity, depression, anxiety, and sleep disorders and other disorders of the central nervous system. It is a non-invasive method of training the brain to optimize the intricate interplay of brainwaves that determine our behaviour, emotions, thoughts and attention. Computer software provides the client with real-time, instantaneous visual and auditory feedback regarding what is happening in the brain. It enhances flexibility, thereby improving the brain’s ability to respond with healthy patterns of functioning.
Different speeds of brainwaves should be dominant when we sleep compared to when we need to focus on a complex maths problem. The goal of neurofeedback is to help an individual move from one brain state to another to accommodate each new task, therefore improving academic performance, mood, behaviour, and thought processing. Neurofeedback meets the criteria specified by the American Psychological Association to be classified as an evidence-based intervention. At its core, Neurofeedback embodies a process of neuronal self-regulation and re-education, leading the brain to find new and beneficial states and ways of processing new information and feeling. (T. Collura)
Power training is also known as amplitude training. Amplitude training is the earliest type of neurofeedback and is still used by most neurofeedback practitioners.
Power training can be single channel, two channel or multichannel training.
In one channel training an active electrode is placed on a certain position on the scalp based on the 10-20 placement system depending on the symptoms and the protocol decision of the clinician.
The clinician specifies the frequency bands to be rewarded and the frequency bands to be inhibited. The amplitudes of the specified frequency bands are influenced in this training process. The amplitude of a particular frequency band indicates the amount of power contained in a signal. There may be either an excess or a deficit of an amplitude within a frequency range. A unidirectional increase or decrease in the amplitudes of selected frequency bands is the objective of this type of neurofeedback training.
Amplitude training is considered to be a reliable and conservative approach. Research has clearly established the efficacy of this paradigm.
Coherence is a connectivity measure. This type of training can help different brain areas to efficiently connect with one another. Coherence training can be a two/ four or multi-channel training that focus on connectivity between brain regions. Coherence training makes use of a comparative database for training reference.
This new form of training that utilizes a mathematical equation where information from surface electrodes is used to observe and to train the deeper/subcortical brain structures. The source of the EEG activity deeper within the cortex is triangulated by referencing 19 electrodes on the scalp by means of Standardized Low Resolution Standardized Electromagnetic Tomography which is an inverse mathematical algorithm.s-LORETA and can be combined with live z-score training.
Also one of the earlier training modalities, this is used to calm the brain and to assist with assessing deeper inner states leading to changes in awareness. The Penniston research clearly showed the efficacy of this training with clients that struggle with High Beta dominance that leads to higher anxiety levels. Clients that struggle with addiction and have learnt to use Alpha-Theta state training, show fewer relapse episodes during recovery.
Live Z-score Training
The use of z-scores implements the concept of a normal distribution. The brain receives information pertaining to the increase and decrease of amplitudes in all the frequency bands relative to persons of the same age. Z score training also impacts the training of coherence, phase and asymmetry thus stabilizing inefficient networks in the brain
Infra-Slow (ISF) Training is a recent development. It focuses on the lowest energy that the brain produces (<0.1Hz). Research indicates that it regulates autonomic functioning.
WHAT HAPPENS IN A NEUROFEEDBACK SESSION ?
Electrodes are placed on the client’s head with paste to hold them in place and to conduct the electrical signal. One or two of these are also placed on the earlobe. These sensors measure the electrical activity coming from the brain at the specific sites being monitored. No electric current is passed into the brain. This information is fed into a computer for analysis and is converted into game-like displays on the client’s screen. The better the client’s performance, the more stimulating the feedback. The client is constantly fed information regarding the state of their brain with auditory and visual signals. After practicing this over a period of time, the changes are usually long lasting.
Bio-/neurofeedback equipment allows clinicians to monitor underlying dynamic physiological processes occurring in the body, such as EEG, heart rate, blood pressure, peripheral temperature and arousal levels.
Bio-/neurofeedback equipment accurately measures and records specific physiological functions. The information is then relayed to the client and the biofeedback practitioner by means of real-time auditory and visual display systems. It is important to note that bio-/neurofeedback does not send signals or impulses to any physiological process in the body but only receives input from these systems. Bio-/neurofeedback is a tool that clinicians can use in combination with other techniques to evaluate EEG, stress response, anxiety, breathing efficiency and heart rate variability, and to train clients to alter these processes to improve functioning.
FREQUENTLY ASKED QUESTIONS
Which equipment should I purchase?
It is important to know beforehand exactly what you would like to do with the bio-/neurofeedback equipment, how it will be incorporated into your practice or, if for research purposes, what the equipment should be able to measure and train. Equipment can be very expensive and takes a great deal of time to set up according to your needs. Receiving training on the use of new equipment as well as mentoring are costs that should be considered.
Are there any legal requirements?
It is advisable to utilize equipment that, if imported, is approved by the relevant authority. Equipment imported from America should be approved by the FDA and equipment imported from Europe should have CE conformity approval.
Ensure that the equipment you choose will fulfil your requirements
Ensure that the device you purchase will fulfil your requirements.
For example, if you intend to perform pelvic floor biofeedback with women suffering from urinary incontinence, it will not be necessary to purchase a multi-channel system capable of recording EEG.
If you only assist clients with one major group of disorders, such as stress-related breathing problems, for which you would like to use only a few biofeedback techniques, like heart rate variability and respiration, you will only need equipment with two channels that are able to record heart rate and respiration. You will not need to purchase complex software or hardware with additional capabilities. However, you should be certain that this is all you will require as two channels are not sufficient to perform a stress profile or for many other types of bio-/neurofeedback training.
In addition, the device you choose should be able to record the signals you need simultaneously. Some systems can record the signals you need but not at the same time. If possible, purchase equipment with additional capabilities in order to have the option of adding modalities to your repertoire at a later stage.
What are sensors?
Sensors are the leads and signal transformers that connect the amplifier to the client. Each sensor is usually specialized for specific signals and, because of the cost of each sensor, can increase the cost of a system significantly. Ensure that you know exactly which sensors you need for the tasks you want to perform in bio-/neurofeedback. Purchase only the necessary sensors and be sure that the software of the device can support the sensors you choose. For example, if you want to record respiration patterns from the chest and abdomen simultaneously for breathing assessments relative to stress, be certain that your software and hardware are able to record and display these measures simultaneously.
If you purchase sensors from a company other than the manufacturer, be sure that your software on the device is compatible with the sensors as well as the hardware.
Accessory equipment and consumables
Many small items can be required for bio-/neurofeedback training sessions, such as disposable pre-gelled SEMG sensor pads, breathable tape used to attach temperature leads, conductive gel for reducing impedance, and adhesive removal pads. Most of these can be purchased from local companies. Obtain quotes from more than one company once you are sure of what it is that you require. However, you will get what you pay for so do not trade quality for cost savings.
Do you need a specific computer to run bio-/neurofeedback software?
Most modern bio-/neurofeedback devices will run on any new laptop or desktop. Some practitioners prefer to display the feedback to the client on a separate screen. Most manufacturers of good quality bio-/neurofeedback devices provide similar computer specifications needed to run the device. If a company insists on you purchasing a computer supplied by the company, ensure that you understand the reason for this. If software cannot be easily installed on a generic computer, be sure that you are informed about the extra costs for repair and technical support before the purchase.
Device portability and durability
Bio-/neurofeedback devices are mostly used in clinicians’ offices or clinics and occasionally transported to other locations. Almost all current bio-/neurofeedback devices can run on modern laptops which ensures portability. Many of the sensors are fragile and do not perform well while recording rapidly moving subjects, such as runners. If you intend to use the device for active sports applications, it is advisable to explore a system that transmits data from the sensor to the bio-/neurofeedback device and then from the device to a computer via a non-wired telemetry system.
Ease of use of software
It is important to make use of the software of the device before purchase. Some devices require considerable time to learn while others are easier to operate. However, there may be a significant tradeoff between ease of use and flexibility. Many practitioners prefer to be able to alter the feedback display screens to accommodate his/her needs. However, some bio-/neurofeedback systems do not have this capability.
Some standalone devices do not display feedback screens that are useful to the clinician nor the client. Ensure that the device you choose has the capabilities that meet your requirements.
Is training necessary, accessible and affordable?
Do you have the appropriate professional training and accreditation for application of the device?
Is there a good tutorial with “live” examples built into the software?
Is there adequate technical support available at an affordable cost?
Are the warranty, service and repair specifications adequate for my needs?
The pelvic floor muscles mediate bowel, bladder and sexual activity. The role of the pelvic floor muscles is to help to preserve these activities. Biofeedback of the pelvic floor has been proven to assist in improving these activities and / or assisting in correcting them if there are pelvic floor disorders.
It is important to mention that biofeedback needs to be used in conjunction with prescribed medical treatment and behavior modifications.
Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) causes abdominal pain, bloating and alternating constipation and / or diarrhoea. The cause is often unknown. However, factors such as dysfunctional pelvic floor muscles, emotional stress, infection and some foods can aggravate the condition. Treatment options include dietary modifications and stress management. A mixture of a few small controlled studies, a moderate number of small clinical studies, and many clinical case studies provide reasonably convincing evidence that biofeedback can effectively reduce or cure this problem.
Constipation & Other Elimination Disorders
The normal range for bowel movement frequency is from three times per day to three times per week. Generally, chronic constipation is having fewer than three bowel movements per week on a regular basis. Excessive straining, incomplete evacuation, and hard stools usually accompany the infrequent bowel movements. Many people experience constipation from time to time, but chronic (ongoing, unrelenting) constipation, indicates disease, trauma, post-surgery, or age-related changes in the body which may interrupt our ability to command this crucial body function and affects up to 34% of the population. (Rome III diagnostic criteria & Bristol stool scale).
Overview & Efficacy
Several comparative and controlled studies and numerous clinical studies have shown that muscle tension and pneumatic biofeedback can be highly effective for the treatment of most types of fecal incontinence (as long as the nerve paths are intact), and constipation is due to malfunctioning anal muscles (as opposed to dehydration).
Why biofeedback would help this problem
The muscles of the pelvic floor (including those controlling the anus) can become weakened due to overall loss of conditioning with age, stretching during delivery, etc. These muscles may be in good shape but they may have to resist more pressure than they can handle during a cough or jump. Many people do not have a good sense of when they need to defecate and are either fooled by sensations that are just warnings or miss the warnings entirely. Most people tense or relax the wrong muscles when they are trying to avoid leaking.
Biofeedback is a neuromuscular re-education tool used by therapists that can be used to tell if certain processes in our bodies are working correctly. Biofeedback therapy may be used to treat several bowel disorders such as constipation, elimination, and painful anal spasms of the pelvic floor muscles.
Incontinence is a term that describes any accidental or involuntary loss of urine from the bladder (urinary incontinence) or bowel motion, faeces or wind from the bowel (faecal or bowel incontinence). Incontinence is a widespread condition that ranges in severity from just a small leak to complete loss of bladder or bowel control.
People with poor bowel control or faecal incontinence have difficulty controlling their bowels. This may mean the passing of faeces or stools at the wrong time or in the wrong place. In addition, wind may be passed involuntarily,or there may be staining of underwear.
About one in 20 people experience poor bowel control. It is more commonin older people, but a lot of young people also have poor bowel control. Many people with poor bowel control also have poor bladder control (wetting or soiling themselves). Faecal incontinence can have a number of possible causes.
The following are the most common: weak back passage muscles due to childbirth, age, some types of surgery or radiation therapy, constipation or severe diarrhoea.
Urinary incontinence or underactive/overactive bladder control is a common condition that is frequently associated with pregnancy, childbirth, menopause or a range of chronic conditions such as asthma, diabetes and arthritis.
Poor bladder control can range from the occasional leak when you laugh, cough or exercise to the complete inability to control your bladder, which may cause you to wet yourself. Other symptoms you may experience include the constant need to urgently or frequently visit the toilet. This may be associated with ‘accidents’.
There are different types of incontinence with a number of possible causes. The following are the most common: stress incontinence, urge incontinence,,incontinence associated with chronic retention and
Urinary incontinence may be caused by many factors, but it can be treated, better managed and in many cases cured. For this reason, it is important to talk to your doctor or a continence advisor about your symptoms, in order to get on top of the actual problem. Delete?
Vulvar vestibulitis syndrome (VVS), vestibulodynia, or simply vulvar vestibulitis, is vulvodynia ??? localized to the vulvar region. It tends to be associated with a highly localized “burning” or “cutting” type of pain. Until recently, “vulvar vestibulitis” was the term used for localized vulvar pain: the suffix “-itis” would normally imply inflammation, but in fact there is little evidence to support an inflammatory process in the condition. “Vestibulodynia” is the term now recognized by the International Society for the Study of Vulvovaginal Disease.
Overview & Efficacy
Several small controlled studies have shown that muscle tension biofeedback from the pelvic floor is at least as effective as surgery and cognitive restructuring for improvements in sexual functioning and significantly reduced pain during intercourse (but not quite as much as surgery) among people with vulvar vestibulitis.
Why biofeedback would help this problem
The pelvic floor muscles do not behave normally when vulvar vestibulitis is present. There are more spasms and abnormal levels of tension. Psychophysiological recording techniques can record these patterns of muscle tension. Muscle tension biofeedback is used to show these patterns to the patient so the person can learn to recognize when patterns become abnormal and to normalize them. When the patterns of muscle activity become normal, symptoms are significantly reduced or eliminated.
Pelvic Pain & Chronic Pelvic Pain
Pelvic pain is pain in the lowest part of the abdomen and pelvis. In women, pelvic pain might refer to symptoms arising from the reproductive, urinary or digestive systems, or from musculoskeletal sources.
Depending on its source, pelvic pain can be dull or sharp; it might be constant or intermittent; and it might be mild, moderate or severe. Pelvic pain can sometimes radiate to the lower back, buttocks or thighs. Sometimes, pelvic pain may only be noted at certain times, such as during urination or sexual activity.
Pelvic pain can occur suddenly, sharply and briefly (acute) or over the long term (chronic). Chronic pelvic pain refers to any constant or intermittent pelvic pain that has been present for six months or more.
Chronic pelvic pain (CPP) is a common problem and presents a major challenge to health care providers because of its unclear etiology, complex natural history, and poor response to therapy.
Chronic pelvic pain is poorly understood and, consequently, poorly managed. This condition is best managed using a multidisciplinary approach. Management requires good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric systems.
Overview & Efficacy
A significant number of these patients may have various associated problems, including bladder or bowel dysfunction, sexual dysfunction, and other systemic or constitutional symptoms. Other associated problems, such as depression, anxiety, and drug addiction, may also co-exist. Hundreds of controlled and clinical studies of various sizes, some with multi-year follow-ups, show that biofeedback can help and / or eliminate chronic pain either by rectifying the underlying problem causing the pain or by reducing the stress magnifying it.
Why biofeedback would help this problem
There are many different causes of chronic pain. In many instances, there is a specific problem which can be identified. In others, the body has become over sensitive to stimulation. Anxiety can also magnify pain tremendously. Psychophysiological assessments can frequently identify causes of chronic pain not diagnosable through other techniques. For example, the interaction between various muscle groups in the lower back can be detected as well as abnormal amounts of muscle tension. The combination of these frequently causes low back pain. Biofeedback treatments aimed at rectifying specific problems such as abnormal muscle tension in pelvic floor muscles causing pelvic floor dysfunction (that can cause bladder, bowel or sexual dysfunction problems) remove can be highly successful. Biofeedback to help people control their anxiety and, thus, reduce the overall amount of pain felt, can also be very helpful.
What are the benefits of becoming a BFSA member ?
What are the different BFSA Membership Categories ?
BFSA MEMBERSHIP CATEGORIES
Full Membership will be granted to clinicians who are registered with the HPCSA or their own regulatory body (in Health or Allied Health fields) and have completed their BCIA accreditation process. Full membership will give you BFSA voting rights, negotiated membership discounts with International Biofeedback bodies, your details listed on the BFSA website and notification of the latest events, research and courses related to the field of biofeedback. (R650.00 / year)
Associate membership will be granted to clinicians who are registered with the HPCSA or their own regulatory body (in Health or Allied Health fields) and who can provide proof that they are in the process of obtaining their BCIA accreditation and are actively engaged in a mentor-ship program. Associate members will have BFSA voting rights, your details will be listed on the BFSA website (if in mentor-ship program), negotiated membership discounts with International biofeedback bodies and notification of the latest research, courses and events related to the field of biofeedback. (R450.00 / year)
This membership is for any clinician interested in the field of biofeedback and related research but who have not done any training to qualify as a Full Member. Affiliate members will be notified of the latest research, upcoming courses and events related to the field of Biofeedback. No voting rights. (R150.00/ year)
Any student interested in biofeedback that can show proof that they are currently registered as a student. Students are able to start their training in the field of Bio/Neurofeedback
Student members will be notified of the latest research and events related to the field of biofeedback. No voting rights. (R150.00 / year)