The effects of stress, anxiety, and outdoor temperature on the frequency and severity of Raynaud's attacks: the Raynaud's Treatment Study.

It was expected that stress and anxiety would be related to Raynaud's phenomenon (RP) attack characteristics when mild outdoor temperatures produced partial or no digital vasoconstriction. Hypotheses were that in warmer temperature categories, compared to those below 40 degrees F, higher stress or anxiety would be associated with more frequent, severe, and painful attacks. The Raynaud's Treatment Study recruited 313 participants with primary RP. Outcomes were attack rate, severity, and pain. Predictors were average daily outdoor temperature, stress, anxiety, age, gender, and a stress-by-temperature or an anxiety-by-temperature interaction. Outcomes were tested separately in multiple linear regression models. Stress and anxiety were tested in separate models. Stress was not a significant predictor of RP attack characteristics. Higher anxiety was related to more frequent attacks above 60 degrees F. It was also related to greater attack severity at all temperatures, and to greater pain above 60 degrees F and between 40 degrees and 49.9 degrees F.

The Raynaud's Treatment Study: biofeedback protocols and acquisition of temperature biofeedback skills.

The Raynaud's Treatment Study (RTS) compared temperature biofeedback training and a behavioral control procedure (frontalis EMG biofeedback) with nifedipine-XL and a medication placebo for treatment of primary Raynaud's phenomenon (RP) in a large (N = 313) multicenter trial. The present study describes the RTS biofeedback protocols and presents data on the acquisition of digital skin temperature and frontalis EMG responses in the RTS. The findings point to substantial problems with acquisition of physiological self-regulation skills in the RTS. Only 34.6% of the Temperature Biofeedback group (N = 81) and 55.4% of the EMG Biofeedback group (N = 74) successfully learned the desired physiological response. In contrast, 67.4% of a Normal Temperature Biofeedback group (N = 46) learned hand warming. Multivariate analysis found that coping strategies, anxiety, gender, and clinic site predicted acquisition of hand-warming skills whereas variables related to RP disease severity did not. Physiological data showed vasoconstriction in response to the onset of biofeedback and also found that performance in the initial sessions was critical for successful acquisition. These findings indicate that attention to the emotional and cognitive aspects of biofeedback training, and a degree of success in the initial biofeedback sessions, are important for acquisition.

Applied psychophysiology: commentary from a rehabilitation perspective.

This commentary endorses a broad definition of applied psychophysiology that can accommodate professionals from many different disciplines, including rehabilitation. As we adopt and implement a definition, we need to be alert to outmoded terminology suggesting that applied psychophysiology procedures are primarily for functional and stress-related disorders.

Age as a factor in admission to chronic pain rehabilitation.

OBJECTIVE: To examine access to multidisciplinary pain rehabilitation programs for older patients. DESIGN: Telephone and written surveys of pain programs accredited by Commission on Accreditation of Rehabilitation Facilities. Visual Analog Scale (VAS) ratings of patient vignettes in which older patients were alternatively assigned their true age or a younger age. PARTICIPANTS: Health care professionals at pain programs. MAIN OUTCOME MEASURES: Telephone survey of admission policies and treatment services. VAS ratings of patient vignettes. RESULTS: No program excludes older pain patients by age. However, 28% of programs had admitted only the youngest old (< 70 years). Age-related criteria, such as presence of concurrent medical diagnoses that are more likely to exclude older patients, are common. In addition, VAS ratings of patient vignettes indicated an age bias: the same patients were rated as 14.8% less likely to be admitted (p < .001) and 12.5% less likely to succeed if admitted (p < .001) when their true, older age was given than when a false younger age was provided. CONCLUSION: Pain program admission policies do not exclude older patients by age but frequently include age-related criteria that disproportionately exclude the elderly. There is also evidence of an age bias in which age per se reduces perceived suitability for pain program admission.

Psychogenic cough treated with biofeedback and psychotherapy. A review and case report.

Psychogenic cough is a barking or honking cough, which is persistent and disruptive to normal activity. The cough may be a debilitating condition that interferes with work and social relationships. Although the frequency of this condition is low, it is not rare. The majority of cases reported involve pediatric or adolescent patients. Surprisingly, there are scant data describing this condition in the adult population and no reports of biofeedback being used to treat this syndrome. We present a case report of an adult patient with psychogenic cough and review the available pediatric and adult literature. A 41-yr-old obese female presented with a complex 7-yr history of intractable, nonproductive, chronic cough. She had been avoiding social activities because of embarrassment by her repeated episodes of coughing. Extensive diagnostic work-up failed to find an organic etiology. Numerous medical and surgical treatments had failed. The patient was treated with a combination of biofeedback-assisted relaxation training, psychotherapy, and physical therapy. Review of the literature revealed only one report on adults, in which three of four patients were successfully treated with a combination of speech therapy, relaxation techniques, breathing exercises, and psychotherapy. Our success suggests a possible future use of this treatment protocol for cases of psychogenic cough.

Chronic-pain medications: equivalence levels and method of quantifying usage.

Medication use is an important consideration in chronic-pain rehabilitation programs (CPRPs). However, it is difficult to quantify this aspect of chronic-pain treatment, because patients often take multiple medications that can differ by pharmacological class as well as dosage level. The Medication Quantification Scale (MQS) provides a method for quantifying medication use in patients with chronic, nonmalignant pain. Scores are calculated for each medication based on weights assigned by medication class and dosage level, and these scores are summed to provide a quantitative index of total medication usage suitable for statistical analysis. The method for calculating MQS scores is illustrated, and research data on MQS reliability and validity are presented. Interrater reliability was rho = 0.985 (p less than 0.0001) for 30 MQS scores calculated by two clinicians. MQS scores for 88 patients correlated well with the clinical judgment of 12 health care professionals (mean rho = 0.755, p less than 0.0001). The MQS scores for 60 chronic-pain patients (30 treated in a CPRP and 30 untreated) were obtained at two time points: evaluation and 1-year follow-up. A two (groups) by two (time points) analysis of variance yielded a significant group-by-time interaction (F = 8.82, p less than 0.0043). Treated patients decreased their medication intake significantly (p less than 0.0001), whereas untreated patients did not (p greater than 0.57). The MQS offers a reliable and valid method for quantifying medication usage in chronic-pain patients.

Biofeedback-assisted relaxation training for the aging chronic pain patient.

The older segments of the U.S. population are expanding rapidly and account for a disproportionate amount of health care, including treatment for pain-related musculoskeletal disorders. In a prospective study with objective measures and one-year follow-up, Middaugh et al. (1988) found that older patients (55-78 yr; N = 17, 76% success) treated in a multidisciplinary chronic pain rehabilitation program enjoyed a success rate equal to that of younger patients (29-48 yr, N = 20, 70% success). The current study presents additional data on these two groups of patients to compare their ability to learn the physiological self-regulation skills taught in the biofeedback/relaxation component of the multimodal program. This component included progressive muscle relaxation training, diaphragmatic breathing instruction, and EMG biofeedback. Repeated measures ANOVA showed significant increases in digital skin temperature (peripheral vasodilation) and decreases in respiration rate both within and across training sessions (p values = .04 to .0001) with no differences between age groups (p greater than .05). EMG measures for the upper trapezius ms in patients with cervical pain showed similar deficits in muscle control at evaluation and similar improvements with biofeedback training for the two age groups. These findings indicate that older pain patients responded well to the biofeedback/relaxation training component of the multimodal pain program.

Self-reported depression profiles in chronic pain and family practice patients.

This study examined profiles of self-reported depressive symptoms in chronic pain patients (n = 51), family practice outpatients (n = 52), and controls (n = 53) who were receiving neither psychological nor medical treatment and were pain free. Subjects in the three groups were matched for age and sex. The short form of the Multiscore Depression Inventory (SMDI) was used. Chronic pain and family practice groups had similar SMDI profiles, with significant elevations on Low Energy, Pessimism, Sad Mood, and Low Self-Esteem subscales compared with controls. Although both groups of medical patients were depressed compared with control subjects, their SMDI profiles were different from those previously reported for psychiatric inpatients with a diagnosis of depression.

On clinical efficacy: why biofeedback does--and does not--work.

Questions of clinical efficacy are becoming more prominent in this era of diminishing funds for research and clinical care, and new treatment procedures, in particular, are being rigorously scrutinized. This presents a challenge for the relatively recent field of biofeedback and applied psychophysiology. This field has a strong scientific orientation and a rapidly expanding research base, which includes many well-controlled clinical outcome studies. The point is raised, and illustrated with data from current clinical outcome studies, that it is time for a shift in emphasis away from simply piling study upon study and toward more thoughtful interpretation of experimental and clinical findings and the development of a clearer conceptual framework for biofeedback therapy and research.

Biofeedback in treatment of urinary incontinence in stroke patients.

Urinary incontinence can occur poststroke owing to weakness or incoordination of sphincter muscles, impaired bladder sensation, or hyperreflexic, neurogenic bladder. Four male subjects who had urinary incontinence associated with a stroke that had occurred 8 months to 10 years earlier, and who averaged 1.6 to 7.5 accidental voidings per week, participated in an outpatient study with a 4-week scheduled-voiding baseline, 2 to 5 sessions of biofeedback-assisted bladder retraining, and 6- to 12-month follow-up. Training sessions included stepwise filling of the bladder and manometric feedback display of bladder pressure, abdominal pressure, and external anal sphincter pressure. Training procedures were designed to teach subjects to attend to bladder sensations, inhibit bladder contractions, and improve voluntary sphincter muscle control. All four subjects achieved and maintained continence regardless of substantial differences in subject characteristics, including laterality of stroke, degree of sensory impairment, and independence in daily activities.

Chronic pain: its treatment in geriatric and younger patients.

The response of geriatric patients to a multidisciplinary chronic pain rehabilitation program was measured by comparing outcome data on 17 older patients (55 to 78 years) to data on 20 younger patients (29 to 48 years) treated in the same program. Pretreatment data were obtained at an initial evaluation, and posttreatment data were obtained at the most recent follow-up contact, usually at 12 months after treatment. Treatment outcome was assessed on the basis of eight quantitative measures: pain ratings; health care utilization; activity tolerance; daily "up time"; hours per week spent in paid employment, housework, volunteer work, or school; medication intake; SCL-90R somatization, depression, and anxiety scores; and an overall summary measure. Pretreatment data indicated that older and younger groups were similar on both demographic variables and clinical status. There was a larger percentage of women in the older group. The older patients were initially somewhat more impaired than the younger ones, with nearly four times the rate of health care utilization and almost two times higher medication intake. Both groups improved significantly from pretreatment to posttreatment on most of the eight measures. Older patients showed a greater decrease in health care utilization. Women and men did not respond differentially to treatment. The data indicated that geriatric patients can benefit from chronic pain rehabilitation programs at least as much as, if not more than, younger patients.

Electromyographic feedback: effects on voluntary muscle contractions in normal subjects.

To evaluate the efficacy and function of EMG feedback (FB) in muscle reeducation, voluntary muscle contractions with and without EMG FB were compared under controlled experimental conditions in normal human subjects (n=10). Each subject was instructed to produce 12 sustained, 30-second contractions of the left abductor hallucis muscle, 6 contractions in each of 2 sessions. For all subjects, EMG FB was provided in half of the trials, alternating with nonfeedback (NFB) trials. A ranking task was included to measure ability to discriminate contractions in the target muscle. EMG activity was significantly greater during muscle contractions attempted with EMG FB; this was due to increased motor unit recruitment early in the course of the trials, a positive response in normal subjects similar to that in paretic subjects in our previous study. Performance on the ranking task also indicated that subjects had little perceptual awareness of their muscle contractions. Our findings suggest that the positive response to EMG FB was due to the precise information it provided concerning small, poorly discriminated muscle contractions.

Electromyographic feedback: effect on voluntary muscle contractions in paretic subjects.

To evaluate the efficacy and function of emg feedback (emgFB) in muscle reeducation, skeletal muscle contractions with and without emgFB were compared under controlled experimental conditions in human subjects with paresis due to brain damage (n=6) or peripheral nervous system damage (n=6). Each subject was instructed to produce 12 sustained 30-second contractions of a muscle below functional strength, 6 contractions in each of 2 sessions. EmgFB was provided in half the trials, alternating with nonfeedback trials. Emg activity during each trial was quantitified and the data analyzed statistically. By the 2nd session, emg activity was significantly greater during voluntary muscle contractions attempted with emgFB for both subject categories. This differential developed over the 1st 10 seconds of the muscle contraction and remained relatively constant until the end of the 30-second trial period. Response to emgFB was not closely linked to type of injury, duration of injury, or age. These results indicated a substantial and positive response to such feedback.

EMG feedback as a muscle reeducation technique: a controlled study.

In an effort to evaluate the efficacy and function of EMG feedback in muscle reeducation, improvement of the abductor function of the abductor hallucis muscle was studied under three training conditions involving 1) EMG feedback, 2) sensory stimulation or 3) equal time for unassisted practice; and a fourth, control condition involving testing without training. Active range of motion was measured before and after training to assess ability to use the muscle as an abductor. EMG activity was quantified for a 1-minute test contraction to evaluate ability to maintain and maximize a voluntary contraction of the target muscle. The results indicated that EMG feedback was highly effective when subjects had little initial use of the target muscle. EMG feedback improved the ability of these subjects to maintain and maximize voluntary muscle contractions, as demonstrated on the EMG measure. EMG feedback did not add to the learning situation when only a relatively brief, phasic contraction was required, as on the range-of-motion measure; similar gains were made with equivalent practive without EMG feedback. When subjects already had considerable use of the target muscle prior to training, EMG feedback may have actually interfered with training; in this case unassisted practice was more effective.