Date: Tue, 21 Feb 1995 11:55:43 -0800 From: Deborah Stiles Subject: Biofeedback > >All of the above does not address the likelihood of general office > >populations ever conditioning themselves to use their bodies in a > >relaxed, naturally-efficient manner. I do my small bit, as do myriad Tai > >Chi Chuan, yoga, feldenkrais, and other movement teachers. This issue > >is, in my mind, the center of the hurricane for office workers. > > Biofeedback is yet another way to learn to use one's body in a relaxed > manner. It may not be exactly what you had in mind, but I would put > it in a similar category. A person can learn to release one's shoulder, > upper-back and arm muscles held in static tension. (We all know how > much more injured one becomes without the blood flow, circulation etc.) > I agree that all of the best ergonomic equipment in the world won't > get one very far unless one learns how to use their body in a relaxed > manner. > > Amara Yes, Biofeedback, particularly surface electromyography, can be a great tool to enhance your ability to use your body as efficiently as possibly. The nice thing about biofeedback is that you can actually SEE how you are doing. Often small levels of muscle tension are extremely difficult to feel. Viewing your own muscle tension levels displayed in graphs of microvolts can really make a difference. Once you see the lowest levels you can achieve, then focus on the subtle feelings that match the physiological state. This is important in order to generalize how it feels to be relaxed and efficient in your real world. Biofeedback can be used for dynamic acitivty (movement) monitoring such as keyboarding, vacuumining, or running. The latter requires portable units which often uses auditory feedback. Some of the latest technology uses wireless telemetry units so that full range of motion and activites can be analyzed. Biofeedback is not a panacea. It needs to be used with all the other techniques mentioned on this List. I think that that those of you who have used biofeedback would also benefit from other movement classes such as Feldenkrais and others. You will definitely have an advantage in understanding the true feeling of relaxed muscles and efficient postures. Likewise, I think those of you who have had other movement classes would benefit from surface EMG feedback. You could try out your learned postures and see if you can improve on them or see if you are really as relaxed and efficient as you think. This would probably only take 3 to 5, 1 hour sessions. Before you sign up for any biofeedback, check out the therapist carefully. Be specific about what you would like help with and see if they can do it. Many biofeedback therapists, if not most, do not know much about RSIs. More and more physical therapists are becoming certified in biofeedback (BCIAC) which may be the closest RSI sufferers will get to addressing your problem specifically; however, they often will not have any mind-over-body background which I feel is essential to successful control of physiology. Debbie Stiles, MN, RN, BCIAC UW Management of Stress Response Clinic dstiles@u.washington.edu =============================================================== Date: Wed, 22 Feb 1995 11:50:23 -0800 From: Glen Kohler Subject: Remarks on Training (900+ words) In a reply to one of Gary Karp's posts I mentioned the need for training in physical and mental development such as Tai Chi Chuan, Chi-kung, yoga, Feldenkrais movement, etc. For some reason, my words were quoted in posts citing bio-feedback as _the_ desireable training option. After twenty years of practicing and teaching Tai Chi Chuan and Chi- kung, I think there is a little more to say. Suffer me to say it if you have a moment to read. It was said that during bio-feedback sessions, one can "see" whether or not one is relaxed. This is a good and necessary thing; it is something that we all are capable of discerning via any number of training formats--including, but limited to, bio-feedback. All forms of complete physical training enable a person to _feel_ and modify what they are doing in this regard; be it productive or counter-productive. This functionality is not well known to the scientific community, however, so someone built a machine to perform a function that any healthy body/mind can perform by itself. That many people do not already possess this innate human skill is a tribute to the thoroughness of training to be unnatural that pervades our society. If perceiving and altering one's normally-unconscious muscular tension were the only consideration, machine-mediated self-knowledge gained in a quiet, controlled environment would be on a par with other forms of training. But there is more to this issue. The now-infamous "psycho-social factors" which play significant roles in RSI's demand real-world skills that are best transmitted by other forms of training. As useful as it is, the machine does not fulfill these needs--and the care systems that employ it rarely include exposure to other procedures to fill the gaps left by bio-feedback. We are all aware, I suppose, that un-natural use of the body is a primary ingredient of RSI's. Consider for a moment the likelihood that un-natural views of one's self, and of one's status, position, and role within a social matrix, pose equally potent threats to physical health. Complete systems of physical training bring a person to more comfortable, functional terms with our physical nature--including mental and emotional responses within our physiology to social stimuli which create potentially damaging levels of muscular tension. The bottom line is that RSI's are a sub-set of human experience that reflects the state of our total health; physical, mental, and emotional. Solutions which are capable of facilitating full participation in the larger scheme of things are necessary, whether they are used at first need, or at the last resort. RSI's and the challenges they present during diagnosis, treatment, and in formulating adaptive strategies, also devolve around the issue of self-reliance, versus unwitting ceding of one's power to authority. How many sad RSI stories began with the assumption by am injured worker that s/he would be adequately monitored, understood, and competently served by doctors, insurers, or the employer--only to find the converse to be true? Not all, mind you--but sufficient numbers to merit this paragraph, I think. For that matter, don't most computer-use-related RSI cases begin with the unconscious assumption that if a job "requires" un-ending keyboard or mouse commands, the worker's comfort and health is of little or no object in the day-to-day operational picture? The way home begins with tackling such challenges as an equal player in the game. For this effort, capacities developed by complete physical and mental training far outweigh the convenience of temporary machine-mediated calmness in an environment designed and administrated to preserve the prestige of its practitioners above all else. (If this point be disputed, ask ten medical patients whether they feel sufficiently empowered in this environment to question their care providers and participate in the decision-making process.) In any case, the even, instantly- adjustable muscular tonicity--and continuous, free breathing(!!!)-- developed in yoga and Tai Chi, is built during conditions of actual use of the body. These benefits are then readily available to meet the challenges of daily life. The Tai Chi system, in particular, provides a series of graded exposures to increasing physical and mental demands--thus producing a very high degree of mental and muscular relaxation throughout a wide range of stresses. Other training methods do not provide this functionality. There is a price, of course. It is paid in time, energy, and commitment, as for everything else worthwhile. In my reply to Gary's post I included a comment to the effect that the general population of office workers shows few signs of achieving acceptably high levels of personal wellness. But we all owe it to ourselves, our families, and, if you believe in this sort of thing, to the community at large, to take steps on our own initiative to be as healthy and functional as we can be. . If there were infinite time to experiment--and money to finance the experiments--I would not advance this thesis at such length. But just ask your workers comp insurer or vocational rehab counselor how extensive the resources at your command are! Time and money, and mental focus and vital energy, must be budgeted wisely, as we all somehow cope with life. Please forgive me for posting at such length; I believe the subject merits it. Best Regards, Glen Glen Kohler, CMT gkohler@crl.com : Box 9719, Berkeley, CA 94709 Health Arts Wellness Services : 510/845-8485 =============================================================== Date: Wed, 22 Feb 1995 18:14:21 -0500 From: Cleo Parker Subject: Re: Yoga & Biofeedback Glen Kohler wrote, It was said that during bio-feedback sessions, one can "see" whether or not one is relaxed. This is a good and necessary thing; it is something that we all are capable of discerning via any number of training formats--including, but limited to, bio-feedback. All forms of complete physical training enable a person to _feel_ and modify what they are doing in this regard; be it productive or counter-productive. I have to agree with Glen - I have been taking yoga for about 10 years and happened to join a treatment study for Reynaud's Phenomenon ("White Finger") this past year. I was randomized into the biofeedback group and the therapist considered me quite the star pupil because I had learned to relax specific muscle groups through yoga. I'm just at an "awakening" stage about my CPT at this stage, but I'm making an effort to encorporate the relaxed and natural postures I practice in yoga into my keyboard work. Cleo Parker cparker@DETROIT.bozell.com =============================================================== Date: Mon, 27 Feb 1995 18:10:48 -0800 From: Deborah Stiles Subject: Biofeedback-lengthy post On Wed, 22 Feb 1995, Glen Kohler wrote: > In a reply to one of Gary Karp's posts I mentioned the need for > training in physical and mental development such as Tai Chi Chuan, > Chi-kung, yoga, Feldenkrais movement, etc. For some reason, my > words were quoted in posts citing bio-feedback as _the_ desireable > training option. >... > It was said that during bio-feedback sessions, one can "see" whether > or not one is relaxed. This is a good and necessary thing; it is > something that we all are capable of discerning via any number of > training formats--including, but limited to, bio-feedback. All > forms of complete physical training enable a person to _feel_ and > modify what they are doing in this regard; be it productive or > counter-productive. > > This functionality is not well known to the scientific community, > however, so someone built a machine to perform a function that any > healthy body/mind can perform by itself. That many people do not > already possess this innate human skill is a tribute to the > thoroughness of training to be unnatural that pervades our society. I have to speak a few words about biofeedback, because I use biofeedback with some of my clients. True, biofeedback, simply used by itself, is just that, a machine that is monitoring your physiology. A good example is taking your blood pressure. Blood pressure monitoring can be thought of as a form of biofeedback. The actual blood pressure readings are useless UNLESS you have other counseling as to what you are supposed to do with your life to get your pressure under control. Most people can not tell when there pressure is high, so having a measurement device or tool is helpful. Other biofeedback monitoring methods are no more unnatural than having your blood pressure or temperature taken. They are measuring your natural physiology. Building machines to measure subtle physiological indices has been a very welcome and needed way for Western medicine to research vague health-related issues particularly that may be related to psychosocial factors. It has been helping to wipe the mystery out of the reasons why forms of Eastern methodologies work, as well as promoting a number of alternative therapies in gaining recognition, especially with insurance companies. > If perceiving and altering one's normally-unconscious muscular > tension were the only consideration, machine-mediated self-knowledge > gained in a quiet, controlled environment would be on a par with > other forms of training. But there is more to this issue. The > now-infamous "psycho-social factors" which play significant roles in > RSI's demand real-world skills that are best transmitted by other > forms of training. As useful as it is, the machine does not fulfill > these needs--and the care systems that employ it rarely include > exposure to other procedures to fill the gaps left by bio-feedback. > This really depends on the practitioner's background. Again, biofeedback is just a tool, a tool used to help establish baselines, to assess potential problems, and monitor progress or lack of progress. The progress is dependent on what the practitioner is trying to do. For example, a physical therapist who uses surface electromyography is not simply and only hooking someone up to machines. They use it as only one method of treatment. Biofeedback has made great advances in neuromuscular rehabilitation for people suffering from automobile injuries, paralytic injuries, post-op orthopedic or neurologic surgeries, spasticity, stroke patients, etc. Most every chronic Pain Clinic in the country has some form of biofeedback services. That does not mean that biofeedback is used by itself. These problems are complex and require comprehensive programs. In my case, my background is in mental health and psychophysiology. I use biofeedback as a tool to allow people to SEE how stress affects their physiology--how it affects every system of their bodies. Some common forms of biofeedback used for stress-related disorders include skin temperature, heart rate, blood pressure, surface electromyography, skin conductance (sweat activity), pneumographs (breathing), and some of the newer work being done with EEG training (brain wave activity). Obviously, as a stress-management specialist, I can not simply hook people up to a machine and then expect them to be relaxed or cured. Although every client is different, I may emphaisze a number of other skills, such as cognitive/behavioral skills, communication skills, systematic desensitization, anger management skills, problem-solving skills, etc. My clients have daily cognitive homework and relaxation exercises to perform on their own without machines. A gradual weaning process begins with clients as soon as they enter our program. Biofeedback is used temporarily. The client is continually taught how to generalize these skills to the real world. All of our clients are also part of a long term study at the UW. The biofeedback provides us with concrete pre- and post-test physiological data. Some clients are followed for a year after treatment with another "test". We also administer a number of psychometric questionnaires at several intervals before, during, and after treatment. If I see a client with an RSI, they often are coming to me as a last resort before surgery. This makes my job difficult, as I prefer prevention. I may help them with worksite changes (mostly on the work stress situations), visit their worksite, talk with managers, and negotiate accomodations. I may help them make the final decision for or against surgery. I also teach basic relaxation techniques and mind/body connections. The biofeedback is mostly used to teach more efficient postures and movements but also to assess potential neuromuscular imbalances. For example, I recently had a CTS client who was a reporter/writer who had a severe muscle assymmetry that I picked up using surface electromyography. His left side of his cervical and upper trapezius muscles were about 150% more tensed than his right side. The client was completely unaware of this. He had no pain or feelings of tenseness in this area. After biofeedback he was able to balance his muscles within acceptable ranges while typing and doing other activities, and thus learn how to _feel_ the subtle tension. Follow up appointments showed improvements both in his symptoms and in his biofeedback data. Biofeedback helped determine the specificity of the problem. I might also add that biofeedback, because of its "high-tech" flare, brings in a number of people with chronic injuries/illnesses to mental health services who otherwise would not come. Biofeedback is a safer concept than going to see a "shrink", and often has better insurance coverage than if just seeing a mental health provider. It also is safer to have biofeedback in your health records than mental health issues in terms of confidentiality. All of this of course is assuming your biofeedback therapist has a psychology background. I currently am using biofeedback as a tool for prevention in the workplace. Very few people are doing this except some ergonomists who use surface EMG for research and analysis. Again, biofeedback machines by themselves in the workplace would be useless. I encourage a multifacted approach with biofeedback as only one of many methods to use. Could I do what I do without the machines? Yes and there are times when I do not use biofeedback; however, the biofeedback gives abstract concepts like "stress" meaning to otherwise skeptical clients, insurance companies, employers and employees. It gives people some hope that they can control or at least reduce some of their symptoms. It shows them improvement which gives them immediate rewards for continuing the techniques. It can often justify proper ergonomic setups. It gives concrete meaning to issues like workload, control, co-worker conflicts, boss conflicts, the need for proper training, time urgency, etc. Research in the future will continue to show that psychosocial issues in the workplace are critical to wellness. The new field of psychoneuroimmunology is an example of a new discipline that is trying to prove connections between the mind and body. This field uses a number of biofeedback monitoring devices as well as immune system monitoring methods. Biofeedback really SUPPORTS other Eastern techniques and really should be embraced as helping Tai Chi and others, not looked at as a competitive technique. Tai Chi, yoga and others are great forms of relaxation and can be used to continue the benefits of the temporary use of the machines, and to promote the other relaxation techniques learned. Depending on what your biofeedback therapist has a background in, you will also learn different techniques to use. For example, I teach several handy cognitive/behavioral techniques for stress management purposes that are unlikely to be found in other treatments. Physical and occupational therapists, in addition to the biofeedback, would also teach the safest strenghtening exercises and may use other forms of treatment such as TENS. These are additional concepts employed WITH biofeedback and that are generally specialized and different from other services. I think its great when a client learns our relaxation techniques quicker because they have had prior relaxation training! It makes my job easier. If everything looks normal with a client's initial biofeedback assessment and they are already able to effectively relax and apply relaxation to stressors, then they don't need stress management or the biofeedback tools I use. If this person still has some health problem, I would refer them elsewhere (PT, OT, physician specialist, etc). >... > The way home begins with tackling such challenges as an equal > player in the game. For this effort, capacities developed by > complete physical and mental training far outweigh the convenience > of temporary machine-mediated calmness in an environment designed > and administrated to preserve the prestige of its practitioners > above all else. (If this point be disputed, ask ten medical > patients whether they feel sufficiently empowered in this > environment to question their care providers and participate in the > decision-making process.) In any case, the even, instantly- > adjustable muscular tonicity--and continuous, free breathing(!!!)-- > developed in yoga and Tai Chi, is built during conditions of actual > use of the body. These benefits are then readily available to meet > the challenges of daily life. > Again, I often recommend classes in yoga and Tai Chi and other movenment classes for my clients. This helps to continue the learned relaxation techniques they have acquired through our wholistic program. Just like Tai Chi or any other program, one must continue to practice. If someone just uses biofeedback then goes home and never practices the techniques, they will not benefit to the degree they need. I can not force someone into being motivated. Often I see people who are coming to be cured and who have little motivation to do much themselves. Forget it, if people are not willing to work at getting well, our program will not work. As far as client empowerment, the client is the one who is controlling their physiology. On the contrary, every client I have seen leaves the program feeling very empowered to self-manage their symptoms far better than when they entered. Our research shows this. Because we emphasize self-management, the clients are the only ones who can make decisions. I am just the coach or educator. I strive to make clients understand and feel comfortable with all procedures. Granted, some people might be turned off by physiological monitoring or worried about the gadgetry. That's OK. They should check out other treatments or just see me for "talk" therapy. I see older folks a bit intimitdated with the computer equipment, but most people seem to enjoy it and are intrigued with the technology and with learning more about themselves and their stress responses. Most of the people who have not been pleased with biofeedback are people who did not either finish a complete program, entered a poorly managed program, were not ready to change something about themselves, did not like or get along with their therapist, or were not motivated to continue and practice the learned skills during and after treatment. The latter reason is the one I see the most of--just like anything it takes practice. They want quick fixes which don't exist for many chronic problems. It needs to become a way of life. > The Tai Chi system, in particular, provides a series of graded > exposures to increasing physical and mental demands--thus producing > a very high degree of mental and muscular relaxation throughout a > wide range of stresses. Other training methods do not provide this > functionality. This is called systematic desensitization in mental health terms. We use it to one degree or another depending on the problem. I have clients first imagine that they are in progressively stressful situations while monitoring for arousal. Before moving on to the next level they must reduce stress levels. Then, we work on real life stressors, that is, actually being confronted with the stressor. Often this is without machines or we use portable units, or simply have the person take a mental scan of their own body, or take heart rate, or check breathing style and rate, etc. It is a learning process and takes practice. Sys. Desent. is used a great deal with phobias. I tend to see a number of clients with fears of public speaking or of driving. Our pre and post test using the biofeedback always involves stressors induced in the lab. > ... > If there were infinite time to experiment--and money to finance the > experiments--I would not advance this thesis at such length. But > just ask your workers comp insurer or vocational rehab counselor how > extensive the resources at your command are! Time and money, and > mental focus and vital energy, must be budgeted wisely, as we all > somehow cope with life. It is difficult to study which relaxation techniques are better than another. Most of it comes down to client motivation and committment to a program of health or getting well. Unfortunately, RSIs are multifaceted and deserve comprehensive strategies. As I stated before, if you are considering biofeedback, check out the entire program and background of the therapist. Ask specifically what you will be doing. The programs really vary. I know therapists who train Olympic athletes with biofeedback to enhance speed or performance. Combined with biofeedback they work on relaxation and mental imagery of the event they are about to perform. There are endless applications and clinics and programs that use biofeedback as only one tool in the whole program. Biofeedback is not, by itself, effective unless the health care provider is combining it with a comprehensive program. To say that biofeedback is used to "preserve the prestige of its practitioners above all else" is unfounded and unwise. In fact, Tai Chi and other forms of Eastern techniques have gained popularity in this culture in large part because of advances in research that use forms of biofeedback monitoring devices to "prove" their efficacy. As sad as that may be, our culture likes to prove things work. In my work, I am constantly using biofeedback in a research setting. I have nothing to hide except to open my work up for critiquing and constant improvement. This is not to say that there are some biofeedback therapists out there who are soley using machine-mediated treatment and who do not do anything else. California has their fair share of these. Just like any discipline, there are good teachers and not so good teachers. Do your own research before joining any program or treatment procedure. Sorry for length of this, but really wanted to clarify some of these biofeedback comments. I am not trying to make everyone go out and try it, I am just trying to educate you about biofeedback. It is complicated and not easily understood. There are many misconceptions out there. Debbie Stiles, MN, RN, BCIAC Management of Stress Response Clinic University of Washington School of Psychosocial Nursing dstiles@u.washington.edu