Specific effects and biofeedback versus biofeedback-assisted self-regulation training

In any field, clear and logical conceptualizations are the basis of accurate models → correct research design → correct results → correct conclusions → advancement in the field. Faulty conceptualizations → faulty models → faulty research design → faulty results → faulty conclusions → confusion. In analyzing the conceptualizations of “biofeedback” as expressed by John Furedy (1987) in, “Specific versus Placebo Effects in Biofeedback Training: A Critical Lay Perspective,” we focus on two issues: Does biofeedback have a treatment effect? Is biofeedback necessary for the training effect? In discussing issue (1) we describe the multiple meanings of “biofeedback” and raise the fundamental question: Is biofeedback a treatment? We argue that faulty conceptualizations of clinical biofeedback (1) assume that the treatment in clinical biofeedback is “biofeedback” with specific effects, (2) assume that the scientific basis of biofeedback is dependent upon demonstrations of these specific effects through double-blind designs that distinguish “specific” from “placebo effects,” and (3) trivialize clinical research by attempting to determine the usefulness of biofeedback information — usefulness that is already understood logically by professionals and consumers and demonstrated by clinical studies in the laboratory and in the clinic. We further argue that accurate conceptualizations of clinical biofeedback (1) identify self-regulation skills as the treatment with specific effects of physiological change and symptom reduction, and (2) describe the use of information from biofeedback instruments as scientific verification of self-regulation skills. Finally, the scientific basis of clinical biofeedback is based on (1) evidence from experimental and clinical control studies that have demonstrated the effectiveness of self-regulation skills for symptom alleviation, and (2) the use of biofeedback instruments to verify the acquisition of self-regulatory skills, thus fulfilling the scientific dictum of verifiability.     

Specific versus placebo effects in biofeedback training: A critical lay perspective

Recent interchanges on the question of how to evaluate biofeedback have been cast in terms of a researcher versus clinician dichotomy. This tends to make the arguments ad hominem and focuses attention on minutiae that are of limited general interest. Accordingly, one purpose of the present paper is to state the specific-effects approach to biofeedback evaluation from a critical lay, rather than a research, perspective. The logic of the specific-effects approach to treatment evaluation is first illustrated by a hypothetical example (the Minefield Parable), and it is then suggested that the approach is appropriate for the evaluation of any treatment, be it physical, psychological, or some complex combination. The other purpose of the paper is to further clarify the specific-effects position by responding to some difficulties that have been raised by critics of the position. Some of these difficulties are based on misrepresentations of the position, while others are genuine. However, even for the genuine difficulties, practical solutions are available. The paper concludes that the question of whether a particular class of treatments works is one that is properly raised by the intelligent consumer, and that, for the answer to that question, only the facts, based on adequately controlled clinical studies, will do.The preparation of this paper was supported by a grant from the National Science and Engineering Research Council of Canada. I am indebted to Hal Scher and Donna Shulhan for comments on an earlier draft.     

Specific versus placebo effects in biofeedback training: a critical lay perspective

Recent interchanges on the question of how to evaluate biofeedback have been cast in terms of a researcher versus clinician dichotomy. This tends to make the arguments ad hominem and focuses attention on minutiae that are of limited general interest. Accordingly, one purpose of the present paper is to state the specific-effects approach to biofeedback evaluation from a critical lay, rather than a research, perspective. The logic of the specific-effects approach to treatment evaluation is first illustrated by a hypothetical example (the Minefield Parable), and it is then suggested that the approach is appropriate for the evaluation of any treatment, be it physical, psychological, or some complex combination. The other purpose of the paper is to further clarify the specific-effects position by responding to some difficulties that have been raised by critics of the position. Some of these difficulties are based on misrepresentations of the position, while others are genuine. However, even for the genuine difficulties, practical solutions are available. The paper concludes that the question of whether a particular class of treatments works is one that is properly raised by the intelligent consumer, and that, for the answer to that question, only the facts, based on adequately controlled clinical studies, will do.     

Specific versus placebo effects in biofeedback: some brief back-to-basics considerations

Following the semantic complexities raised in earlier papers, this paper seeks to return to some of the more basic considerations arising from the preceding discussion. A critical part of the context of that discussion is the increasingly important issue of accountability. In this context, the citing of supportive studies is not enough; one must also be able to justify the logical relevance of those studies. The discussion therefore turns on the logic of treatment evaluation, which must be treated as objectively as possible. Also critical is the distinction between the question of whether an effect is present and the question of what the source of that question might be. In the quest for treatment evaluation, only the former question is important. However, this quest is one that is in the interest of researchers, clinicians, and consumers, for all of whom only the facts will do.     

Specific versus placebo effects in biofeedback: Some brief back-to-basics considerations

Following the semantic complexities raised in earlier papers, this paper seeks to return to some of the more basic considerations arising from the preceding discussion. A critical part of the context of that discussion is the increasingly important issue of accountability. In this context, the citing of supportive studies is not enough, one must also be able to justify the logical relevance of those studies. The discussion therefore turns of the logic of treatment evaluation, which must be treated as objectively as possible. Also critical is the distinction between the question of whether an effect is present and the question of what the source of that question might be. In the quest for treatment evaluation, only the former question is important. However, this quest is one that is in the interest of researchers, clinicians, and consumers, for all of whom only the facts will do.The preparation of this paper was supported by grants from the National Science and Engineering Research Council of Canada to both authors. We are indebted to Hal Scher for comments on an earlier draft.     

Specific and nonspecific effects of EMG biofeedback

This study investigated the effects of performance feedback and EMG biofeedback on perceptions of the self (i.e., self-esteem, self-control, self-efficacy, and locus of control) as well as on a self-control behavior (study skills) the subjects performed outside the laboratory. Forty-seven college students were randomly assigned to one of four groups in a 2(high and low success feedback) × 2(true and false EMG biofeedback) factorial experiment with repeated measures. All of the participants received four sessions of EMG biofeedback, and later they were asked to self-monitor their study habits for 2 weeks. Results showed that the self-esteem measure and perceptions of study skills improvement were differentially affected by success feedback but unrelated to the true or false EMG manipulation. Shifts toward an internal locus of control and perceptions of improved self-control were also noted, but they were independent of the subjects' group membership. Implication of the results are briefly discussed.     

Specific and nonspecific effects of EMG biofeedback

This study investigated the effects of performance feedback and EMG biofeedback on perceptions of the "self" (i.e., self-esteem, self-control, self-efficacy, and locus of control) as well as on a self-control behavior (study skills) the subjects performed outside the laboratory. Forty-seven college students were randomly assigned to one of four groups in a 2(high and low success feedback) x 2(true and false EMG biofeedback) factorial experiment with repeated measures. All of the participants received four sessions of EMG biofeedback, and later they were asked to self-monitor their study habits for 2 weeks. Results showed that the self-esteem measure and perceptions of study skills improvement were differentially affected by success feedback but unrelated to the true or false EMG manipulation. Shifts toward an internal locus of control and perceptions of improved self-control were also noted, but they were independent of the subjects' group membership. Implication of the results are briefly discussed.     

Independent biofeedback self-regulation of EEG alpha and skin resistance

Skin resistance and EEG alpha were recorded concurrently during alpha biofeedback, in which the participant attempted to control alpha, and during skin resistance biofeedback, in which the participant attempted to control skin resistance. Alpha production changed significantly (p<0.001) during alpha biofeedback, indicating successful self-regulation of alpha, but did not change significantly during skin resistance biofeedback. Similarly, skin resistance changed significantly (p<.001) during skin resistance biofeedback but did not change significantly during alpha biofeedback. The results show independent control of alpha and skin resistance, and may reflect independent self-regulation of cognitive and somatic tension-relaxation systems.A longer version of this paper was presented at the meeting of the Biofeedback Society of America, Orlando, Florida, March 1977. Laurie Franconi, Tammy Johnson, and Dan Smith were invaluable during data collection. This research was supported in part by Grant #SMI76-04946 from the National Science Foundation to the author.     

Clinical and electromyographic effects of biofeedback training in mandibular dysfunction

Twenty patients with mandibular dysfunction, 10 acute and 10 chronic, were trained with electromyographic biofeedback from either m. masseter or m. frontalis area. The electromyographic activity in both muscle areas were recorded during six training sessions. The mean electromyographic activity decreased significantly within the sessions for both muscle areas, progressively more often for the m. masseter area. The activity did not decrease significantly between sessions for any muscle area. The clinical and subjective symptoms of mandibular dysfunction improved significantly after the training. No differences, electromyographically or clinically, among acute, chronic, m. masseter area, or m. frontalis area feedback patients could be observed. No correlation between decrease in electromyographic activity and symptoms could be established. Since a simplistic neuromuscular learning model for biofeedback training gains little support from these results, alternative views are discussed.This research was supported by grants to Sven G. Carlsson and Elliot N. Gale from the Swedish Council for Research in the Humanities and Social Sciences.     

Clinical and electromyographic effects of biofeedback training in mandibular dysfunction

Twenty patients with mandibular dysfunction, 10 acute and 10 chronic, were trained with electromyographic biofeedback from either m. masseter or m. frontalis area. The electromyographic activity in both muscle areas were recorded during six training sessions. The mean electromyographic activity decreased significantly within the sessions for both muscle areas, progressively more often for the m. masseter area. The activity did not decrease significantly between sessions for any muscle area. The clinical and subjective symptoms of mandibular dysfunction improved significantly after the training. No differences, electromyographically or clinically, among acute, chronic, m. masseter area, or m. frontalis area feedback patients could be observed. No correlation between decrease in electromyographic activity and symptoms could be established. Since a simplistic neuromuscular learning model for biofeedback training gains little support from these results, alternative views are discussed.     

Effects of biofeedback-assisted attention training in a college population

A program of stress management employing open-focus attention-training workshops was developed at Baruch College to bring the benefits of stress reduction to students. The purpose of the research reported here was to evaluate the results of the open-focus attention-training technique. Open-focus technique without biofeedback training was used for two semesters. Biofeedback training was incorporated in the third semester. In the first study, changes in grade point average (GPA), stress-related symptoms, and physiological measures were examined. The experimental subjects' stress data for this study was reported previously (Valdés, 1985). In the second study, changes in the same variables for experimental and control subjects were evaluated. Students in the control group showed decreased GPA, while those who participated in open-focus training showed a trend toward improved GPA. Stress-related symptoms associated with anxiety and management of emotional problems showed significant posttraining improvement, as did physiological measures in all of the biofeedback modalities in which the experimental subjects were specifically trained. The results support the hypothesis that the workshops were successful in reducing stress levels, and suggest that further controlled research be conducted to verify these findings, and to identify the most effective components of the training procedure.Portions of this report were presented at the Fifteenth Annual Meeting of the Biofeedback Society of America, Alburquerque, March 1984. Special thanks and acknowledgement are due to Dr. Manus Rabinowitz, professor of statistics and computer information systems; Ms. Angela Anselmo, M. S. Ed., of the Department of Compensatory Programs, and Mr. Eric Laner, a graduate assistant. Professor Rabinowitz was responsible for the study, development, and evaluation of statistical data, tests, and computer programs. Ms. Anselmo assisted in conducting the workshops.     

Cognitive skills training versus EMG biofeedback in the treatment of tension headaches

In an effort to study the role of cognitive skills training in the treatment of psychosomatic disorders, two single-case design experiments were conducted to assess the relative effectiveness of biofeedback procedures and cognitive coping techniques in the alleviation of tension headaches. For both subjects, biofeedback training influenced mean frontalis EMG levels, although such changes were not associated with concomitant reductions in headache activity. It was the presence or absence of cognitive skills training, however, that determined whether each subject reported changes in headache levels. These results suggest that a more efficient treatment approach for tension headaches would involve an increased emphasis on the modification of maladaptive cognitive activity. The present findings support the general view that a comprehensive approach in the treatment of stress-related disorders requires a concomitant focus on the cognitive, behavioral, and affective dimensions of the symptom. It was also suggested that biofeedback technology may be a useful tool for studying the physiological consequences of particular cognitive processes and in identifying particular cognitions with anxiety-provoking properties.     

Effects of biofeedback-assisted attention training in a college population

A program of stress management employing open-focus attention-training workshops was developed at Baruch College to bring the benefits of stress reduction to students. The purpose of the research reported here was to evaluate the results of the open-focus attention-training technique. Open-focus technique without biofeedback training was used for two semesters. Biofeedback training was incorporated in the third semester. In the first study, changes in grade point average (GPA), stress-related symptoms, and physiological measures were examined. The experimental subjects' stress data for this study was reported previously (Valdés, 1985). In the second study, changes in the same variables for experimental and control subjects were evaluated. Students in the control group showed decreased GPA, while those who participated in open-focus training showed a trend toward improved GPA. Stress-related symptoms associated with anxiety and management of emotional problems showed significant posttraining improvement, as did physiological measures in all of the biofeedback modalities in which the experimental subjects were specifically trained. The results support the hypothesis that the workshops were successful in reducing stress levels, and suggest that further controlled research be conducted to verify these findings, and to identify the most effective components of the training procedure.     

Finger pulse amplitude and frontalis EMG biofeedback effects of single- and two-system training

The relationship between finger pulse amplitude (PA) and frontalis EMG was studied first by looking at general physiological changes accompanying successful bidirectional PA control. Seven successful subjects were then asked to produce two patterns of PA and EMG (PAincEMGdec and PAdecEMGdec) while receiving both PA and frontalis EMG biofeedback. Results indicate subjects can easily produce the differentiation pattern of PAdecEMGdec but cannot produce the integration pattern of PAincEMGdec. These rather paradoxical results may indicate subjects were using an attentional rather than arousal strategy for controlling PA and have implications for the use of peripheral vasomotor training as a general relaxation technique.     

Generalization of EMG biofeedback training

Five young adults received audio biofeedback training to reduce trapezius EMG levels while they engaged in reading in an office, seated at a table. A multiple-baseline-across subjects design was employed in two separate studies. After training, all subjects demonstrated reduced EMG levels while reading in a home or library setting. The first study suggested that subjects reduced EMG levels by minimizing movements and altering their postures; the second study systematically demonstrated changes in such behavior, which was correlated with EMG levels. The data provide evidence that EMG biofeedback resulted in response generalization across several motoric classes, and in stimulus generalization from the training setting to the natural environment. The importance of assessing generalization is discussed.     

Generalization of EMG biofeedback training

Five young adults received audio biofeedback training to reduce trapezius EMG levels while they engaged in reading in an office, seated at a table. A multiple-baseline-across subjects design was employed in two separate studies. After training, all subjects demonstrated reduced EMG levels while reading in a home or library setting. The first study suggested that subjects reduced EMG levels by minimizing movements and altering their postures; the second study systematically demonstrated changes in such behavior, which was correlated with EMG levels. The data provide evidence that EMG biofeedback resulted in response generalization across several motoric classes, and in stimulus generalization from the training setting to the natural environment. The importance of assessing generalization is discussed.     

Finger pulse amplitude and frontalis EMG biofeedback effects of single- and two-system training.

The relationship between finger pulse amplitude (PA) and frontalis EMG was studied first by looking at general physiological changes accompanying successful bidirectional PA control. Seven successful subjects were then asked to produce two patterns of PA and EMG (PAincEMGdec and PAdecEMGdec) while receiving both PA and frontalis EMG biofeedback. Results indicate subjects can easily produce the differentiation pattern of PAdecEMGdec but cannot produce the integration pattern of PAincEMGdec. These rather paradoxical results may indicate subjects were using an "attentional" rather than "arousal" strategy for controlling PA and have implications for the use of peripheral vasomotor training as a general relaxation technique.     

Methodological issues in alpha biofeedback training

Current controversies concerning outcomes of EEG alpha feedback training are at least in part due to methodological differences among different studies. The aim of this paper is to provide future and present researchers in this field with an analysis of methods used in most of the studies published from 1968 to 1976, and to comment on those methodological issues we think most important. These include alpha assessment, training schedules, and uni- versus bidirectional training. This analysis is accomplished in part by a series of tables listing 45 studies and the detailed methodologies used. It is believed that the probabilities of successful feedback enhancement of alpha can be substantially improved by incorporating the following suggestions: (a) employing at least four training sessions, (b) the use of continuous rather than dichotomous feedback, supplemented by periodic quantitative scores of progress, and (c) using training trials of at least 10 minutes' duration.     

Sustained effects of biofeedback-assisted relaxation therapy in essential hypertension.

The usefulness of biofeedback-assisted relaxation as an adjunct or substitute for pharmacotherapy in essential hypertension can be enhanced if the effects are shown to persist after formal treatment has ended. Patients with essential hypertension successfully treated with biofeedback-assisted relaxation were recalled for follow-up yearly after the termination of treatment. Twenty-six of 40 patients met the BP criterion for success. At one-, two-, and three-year follow-up, 31%, 38%, and 27% of the successful completers continued to meet the criterion for success. The pretreatment-posttreatment decreases in BP were accompanied by decreases in forehead muscle tension and urinary cortisol. Forehead muscle tension, urinary cortisol, and anxiety levels were significantly lower than pretreatment one year after the end of treatment. Self-report data were used to assess continued relaxation practice. No relationship was found between practice and any other dependent measure. It appears that some patients trained in biofeedback-assisted relaxation can maintain lowered blood pressure, muscle tension, anxiety, and cortisol levels over the long term; however, the role of relaxation practice in maintaining these lowered levels remains unclear.