There are intuitive physiological rationales for incorporating biofeedback in treatment plans for the diverse disorders described in this unit. In arthritis and edema, temperature biofeedback may increase local circulation, removing inflammatory agents and accumulated fluid. In irritable bowel syndrome (IBS), biofeedback may be part of a stress management package that helps patients control the stressors that trigger alternating episodes of diarrhea and constipation. In diabetic neuropathy and foot ulcers, temperature biofeedback for the feet may increase circulation through temperature increases. Finally, in hyperhidrosis, electrodermal biofeedback for the hands or feet may dampen sympathetic overactivity, reducing excessive perspiration. The evidence of biofeedback's clinical efficacy is modest for all of these applications. Irritable bowel syndrome (IBS) and foot ulcers have the strongest support, which is level 2, "possibly efficacious."

This unit covers the Pathophysiology, biofeedback modalities, and treatment protocols for specific ANS biofeedback applications (IV-D).
Students completing this unit will be able to discuss:

  1. Pathophysiology, biofeedback modalities, and treatment protocols for specific ANS biofeedback
    A. Arthritis
    B. Edema
    C. Irritable bowel syndrome
    E. Diabetic neuropathy
    F. Foot ulcers
    G. Hyperhidrosis

Below is a BioTrace+ / NeXus-10 screen that displays several of the modalities that could be used to treat autonomic disorders like arthritis.

Arthritis is a subtype of rheumatism in which inflammation produces painful joint swelling and stiffness. In rheumatoid arthritis, the immune system bilaterally attacks cartilage and joint linings, resulting in a thickened synovial membrane and swollen joint. In osteoarthritis, aging, irritation, and "wear-and-tear" progressively destroy cartilage in the synovial joints, especially those that bear weight (Tortora & Derrickson, 2006).

The prevalence of rheumatoid arthritis (RA) in the United States is about 1% and the male-to-female ratio is 1 to 3. While RA can occur at any age, the age of onset is usually between 25 and 50, and prevalence peaks in the 40s and 50s. Juvenile rheumatoid arthritis (JRA) appears before the 16 years (King & Worthington, 2005).

About 80-90% of patients over 65 present with primary osteoarthritis. In those over 55, osteoarthritis is more prevalent among women and targets the distal interphalangeal joints of the fingers and knee joints. However, men disproportionately experience osteoarthritis of the hip. Under 45, osteoarthritis is more prevalent among men than women. The prevalence of osteoarthritis increases nonlinearly with age and accelerates after age 50 (Stacy & Basu, 2005).

Temperature biofeedback may increase clearance of inflammatory cytokines (IL6, IL8 and GM-CSF), prostaglandins, and protease enzymes, reducing arthritis pain.

Flor, Haag, Turk, and Koehler (1983) compared SEMG biofeedback, a credible pseudotherapy, and conventional medical treatment for 24 patients diagnosed with chronic rheumatic back pain. Patients were treated for 4 weeks as inpatients and then evaluated at 4-month follow-up. Only the SEMG biofeedback group showed significant SEMG reduction and improvement in back pain duration, intensity, and quality.

Lavigne and colleagues (1992) evaluated the efficacy of a six-session treatment protocol that included relaxation training, SEMG biofeedback, and thermal biofeedback for children diagnosed with juvenile rheumatoid arthritis, and training to help mothers manage physical therapy and school attendance.

Visual inspection of the multiple baseline data for four children who received immediate treatment showed modest evidence of reduction in child and parent ratings of pain intensity, and in parent ratings of the frequency of pain behaviors at the end of treatment and at 6-month follow-up. There was no reduction in the physical therapistís rating of pain during evaluation.

Edema is swelling due to the abnormal accumulation of interstitial fluid produced by excessive capillary filtration or inadequate fluid reabsorption. In cases of inflammation and allergic reactions, temperature biofeedback may help remove accumulated fluid from the edematose region by dilating peripheral arteries.

Preeclampsia or pregnancy-induced hypertension (PIH) affects about 5% of pregnancies in the United States. Preeclampsia is a major cause of perinatal morbidity and mortality, and is responsible for about 35-300 deaths per 1000 births. While the risk of preeclampsia is highest for pregnant women in the youngest and oldest age ranges, women under 20 are at greatest risk (Brooks, 2005).

Somers, Gevirtz, Jasin, and Chin (1989) examined the efficacy of a biobehavioral intervention to help treat mild pregnancy-induced hypertension (PIH), which is characterized by the development of hypertension, proteinuria, and edema late in pregnancy. The researchers randomly assigned 45 women with symptoms of PIH to one of three treatment conditions: bed rest alone, bed rest with individualized compliance enhancement training, or a four-session biobehavioral treatment consisting of bed rest, compliance enhancement training, and individualized thermal biofeedback- assisted relaxation training.

Subjects in the biobehavioral group achieved significantly lower blood pressures than those in the bed rest or compliance enhancement conditions, whose pressures increased and risked both maternal and infant

Patients with irritable bowel syndrome (IBS) respond to stressors with alternating diarrhea and constipation, associated with abdominal pain, cramping, excessive mucus in the feces, flatulence, loss of appetite, and nausea.

IBS has an estimated prevalence of 10-20% and an incidence of 1-2% in the United States. About 10-20% of persons with IBS receive medical treatment for this disorder. In Western nations, women develop IBS three times more often than men. About 50% of IBS patients report onset of symptoms before age 35 (Lehrer & Lichtenstein, 2005).

Evidence-Based Practice in Biofeedback and Neurofeedback (2004) rates biofeedback for IBS at level 2 efficacy, possibly efficacious. The criteria for level 2 efficacy include "At least one study of sufficient statistical power with well identified outcome measures, but lacking randomized assignment to a control condition internal to the study" (pp. 26-27). A level 2 rating was awarded due to mixed findings.

While Schwartz, Taylor, Scharff, and Blanchard (1990) reported that biofeedback reduced IBS symptoms up to 4 years posttreatment, two controlled studies reported by Blanchard et al. (1992) found no advantage for an established multimodal program (cognitive therapy, relaxation, and temperature biofeedback) over attention-placebo or symptom monitoring control groups.

More recently, Leahy, Clayman, Mason, Lloyd, and Epstein (1998) reported that training with a computer-based biofeedback game that monitored electrodermal activity successfully reduced IBS symptoms.

An International Consensus Meeting for the Outpatient Management of Neuropathy described diabetic neuropathy as "the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes." Patients with diabetic neuropathy present with diverse sensory (numbness), motor (impaired fine coordination), and autonomic (sensitivity to bright light) symptoms (Soliman & Gellido, 2005).

Prevalence estimates of diabetic neuropathy vary widely due to discrepant diagnostic criteria, sampling, and evaluation procedures. From 10-65% of diabetics are diagnosed with peripheral neuropathy. There is a higher incidence of diabetic neuropathy in men than women. While diabetic neuropathy can occur at any age, its symptoms are most often detected in patients over 50 (Soliman & Gellido, 2005).

Fiero, Galper, Cox, Phillips, and Fryburg (2003) studied the effect of neuropathy on the acquisition of thermal biofeedback-trained foot-warming by 24 diabetics (5 type I and 19 type II). Training consisted of two hand-warming and four foot-warming sessions. Despite mild-to-moderate neuropathy, participants increased foot temperature an average 2.2o  F across six thermal biofeedback sessions. However, lower extremity sympathetic-autonomic and sensory neuropathies accounted for 41% of the variance in foot-warming and limited skill acquisition. This study's findings were weakened by the lack of a no-treatment control group.

The authors did not find a similar relationship between upper extremity neuropathy and hand-warming. They speculated that a ceiling effect--most patients approached the criterion temperature during their first session--prevented detection of any relationship between neuropathy and hand-warming success.

Diabetics risk foot ulcers due to neurologic and microvascular causes. Progressive damage to peripheral sensory nerves, called peripheral neuropathy, can reduce or eliminate sensation from the foot and/or leg so that patients are unaware of traumatic injuries for days or weeks. In Charcot foot deformity, loss of pressure information causes patients to place excessive stress on their feet, resulting in reduced tissue blood flow (ischemia), localized tissue death (necrosis), and microfractures in the bones of the feet (Fishman, 2004).

About 3-4% of diabetics have foot ulcers or deep infections and 15% will suffer foot ulcers. Foot ulcer raises the risk of amputation by a factor of 8. Two years after transtibial amputation, 36% will have died (Pinzur, 2004).

Rice, Kalker, Schindler, and Dixon (2001) reported that temperature biofeedback increased healing of chronic nonhealing foot ulcers in a randomized controlled study of 32 patients. Healing occurred in 87.5% of the temperature biofeedback group and 43.8% of the control group.

Evidence-Based Practice in Biofeedback and Neurofeedback (2004)
rates biofeedback for foot ulcers at level 2 efficacy, possibly efficacious (p. 22).

involves excessive sweating. While it is normal to perspire when excited or following physical exertion, these individuals constantly perspire, often without obvious triggers, from their palms and soles, and less frequently from their armpits, chest, and back.

Generalized hyperhidrosis
may be caused by autonomic dysregulation or it may be due to a metabolic disease, fever-inducing illness, or cancer. Localized hyperhidrosis may be due to abnormal regrowth of damaged sympathetic axons, an abnormal number or arrangement of eccrine sweat glands, or other vascular abnormalities. Where generalized hyperhidrosis often starts in adulthood, localized hyperhidrosis is often first seen in childhood or adolescence. Both forms of hyperhidrosis can severely embarrass these individuals and produce occupational disability (Altman, 2004).

Conventional therapies for this disorder include antiperspirants, Botox injections, lotions, oral medications, and in extreme cases, endoscopic transthoracic sympathectomy (ETS).

Hyperhidrosis affects more than 200,000 Americans. Internationally, palmoplantar hyperhidrosis (excessive sweating from the hands and feet) affects the Japanese 20 times more often than other ethnic groups (Altman, 2004). The incidence of hyperhidrosis in adolescents and young adults in the United States is estimated at 0.6-1.0%. This condition affects both men and women, and all age groups (Schwartz & Altman, 2005).

The rationale for using electrodermal biofeedback to treat hyperhidrosis is that sympathetic activation can increase sweating, which raises skin conductivity, and that decreasing skin conductivity can both reduce sympathetic arousal and resultant perspiration. Also, in cases where hyperhidrosis is triggered or exacerbated by stressors, a biofeedback-assisted intervention could improve patient symptoms through better stress management. The evidence of biofeedback efficacy in hyperhidrosis is weak, based on small pretest-posttest studies without control groups.

Gentry (1980) reported successful visual water vapor biofeedback treatment of 11 of 14 adults who reduced their excessive sweating 6 weeks following the end of treatment. The author hypothesized that the relaxation component of treatment may have been responsible for their improvement.

Singh and Singh (1993) reported that a program of electrodermal biofeedback-assisted relaxation helped 6 of 10 male patients significantly reduce their sweating. The authors found that clinical improvement was strongly correlated with reductions in skin conductivity.

Now that you have completed this module, compare the evidence supporting the diverse autonomic applications. For which disorders is the evidence of efficacy strongest and weakest?

Altman, R. (2004). Hyperhidrosis. eMedicine.

Blanchard, E. B., Schwartz, S. P., Suls, J. M., Gerardi, M. A., Scharff, L., Greene, B., et al. (1992). Two controlled evaluations of multicomponent psychological treatment of irritable bowel syndrome. Behavioral Research and Therapy, 30(2), 175-189.

Brooks, M. B. (2005). Pregnancy, preeclampsia. eMedicine.

Duller, P. G. (1980). Use of biofeedback in treating chronic hyperhidrosis: A preliminary report. Br J Dermatol, 103(2), 143-146.

Fiero, P. L., Galper, D. I., Cox, D. J., Phillips, L. H., & Fryburg, D. A. (2003). Thermal biofeedback and lower extremity blood flow in adults with diabetes: Is neuropathy a limiting factor? Applied Psychophysiology and Biofeedback, 28(3), 193-203.

Fishman, T. D. (2004). Wound care information network.

Flor, H, Haag, G, Turk, D. C., & Koehler, H. (1983). Efficacy of EMG biofeedback, pseudotherapy, and conventional medical treatment for chronic rheumatic back pain. Pain, 1(17), 21-31.

Guyton, A. C., & Hall, J. E. (1997). Human physiology and mechanisms of disease. Philadelphia: W. B. Saunders Company.

King, R. W., & Worthington, R. (2005). Arthritis, rheumatoid. eMedicine.

Lavigne, J. V., Ross, C. K., Berry, S. L., Hayford, J. R., & Pachman, L. M. (1992). Evaluation of a psychological treatment package for treating pain in juvenile rheumatoid arthritis. Arthritis Care and Research, 5(2), 101-110.

Leahy, A., Clayman, C., Mason, I., Lloyd, G., & Epstein, O. (1998). Computerised biofeedback games; A new method for teaching stress management and its use in irritable bowel syndrome. Journal of the Royal College of Physicians of London, 32(6), 552-556.

Lehrer, J. K., & Lichtenstein, G. R. (2005). Irritable bowel syndrome. eMedicine.

McGrady, A., Kern-Buell, C., Bush, E., Devonshire, R., Claggett, A. L., & Grubb, B. P.(2003). Biofeedback-assisted relaxation therapy in neurocardiogenic syncope: A pilot study. Applied Psychophysiology and Biofeedback, 28(3), 183-192.

Palumbo, P. J., & Melton, L. J. (1985). Diabetes in America: Diabetes data compiled in 1984. (NIH publication No, 851468). Washington, DC: U.S. Government Printing Office.

Pinzur, M. S. (2004). Diabetic foot. eMedicine.

Rice, B., Kalker, A. J., Schindler, J. V., & Dixon, R. M. (2001). Effect of biofeedback-assisted relaxation training on foot ulcer healing. Journal of the American Podiatric Medical Association, 91(3) 132-141.

M. S. Schwartz, & F. Andrasik (Eds.). (2003). Biofeedback: A practitioner's guide (3rd ed.). New York: The Guilford Press.

Schwartz, R. A., & Altman, R. (2005). Hyperhidrosis. eMedicine.

Schwartz, S. P., Taylor, A. C., Scharff, L., & Blanchard, E. B. (1990). Behaviorally treated irritable bowel syndrome patients: A four-year follow-up. Behavioral Research and Therapy, 28(4), 331-335.

Singh, G., & Singh, G. (1993). Biofeedback assisted relaxation (BAR) in management of hyperhidrosis: A preliminary study. Indian Journal of Dermatology, Venereology, and Leprology, 59(4), 187-189.

Soliman, E., & Gellido, C. (2005). Diabetic neuropathy. eMedicine.

Stacy, G., & Basu, A. P. (2005). Osteoarthritis, primary. eMedicine.

Tortora, G. J., & Derrickson, B. H. (2006). Principles of anatomy and physiology (11th ed.). New York: John Wiley & Sons, Inc.

Yucha, C. B., & Gilbert, C. D. (2004). Evidence-based practice in biofeedback and neurofeedback. Wheat Ridge: AAPB.