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  Metabolism  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 & TTHA AD/HDA Urinary IncontinenceA Anxiety D/OB FS/MPSB Heart Dz/HTNB 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  associated with Anxiety Depression Heart disease  associated with relaxation response and cognitive focus Elicited by mind-body approaches & exercise

Physiologic process—HR  with inspiration &  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  Negative emotion Low arousal  High arousal

High Arousal CreativityAnger JoyAgitated Depression Focus + Emotions - Emotions ContentmentDepression CreativityPassivity 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): March. Childe, D. & Martin, H. : The HeartMath Solution, Harper, San Francisco, 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.