Clinical Approaches

Peper, E. & Harvey, R. (2017). The fallacy of the placebo controlled clinical trials: Are positive outcomes the result indirect treatment side effects? NeuroRegulation. 4(3–4), 102–113.

This paper argues that placebo effects have a larger influence on clinical trial outcomes than purported treatment effects, raising questions about the size of effects currently attributed to clinical treatments. Placebo-controlled clinical trials usually do not include an “active” placebo and thus the clinical outcome could be due to the placebo responses to nontherapeutic side effects of the treatment.  This paper emphasizes exercising caution when interpreting results from clinical trials using pharmaceutical or surgical treatments, discusses possible mechanisms underlying the acceptance of treatment procedures which later have been shown to be ineffective or harmful, and highlights the importance of incorporating active placebo procedures to address any covert treatment side effects induced by placebo response. Finally, the authors suggest that clinical trials of bio/neurofeedback treatments carefully consider the important and consequential influences of placebos when designing studies or interpreting the results of trial outcomes.

Shaffer, F., Combatalade, D., & Peper, E. (2016). A Guide to Cleaner Skin Temperature Recordings and More Versatile Use of Your Thermistor.

Valid peripheral temperature measurements ensure the integrity of client assessment and biofeedback training. Accurate measurements require understanding of the signal and potential influences on measurement fidelity, and developing bulletproof monitoring procedures. In addition to their use in temperature biofeedback, thermistors can assist heart rate variability biofeedback practice and monitor breathing when a respirometer is not available.  In summary, skilled temperature monitoring requires familiarity with clean signals, normal values, and understanding of the factors that can affect signals. As with all biofeedback modalities, visual inspection of the raw signal is essential to ensuring measurement fidelity.  While clinicians primarily use thermistors to monitor peripheral temperature during thermal biofeedback, they can provide valuable information during HRVB practice and detect respiration when a respirometer is not available.

Peper, E., Nemoto, S., Lin, I-M., & Harvey, R. (2015). Seeing is believing: Biofeedback a tool to enhance motivation for cognitive therapy. Biofeedback, 43(4), 168-172.  DOI: 10.5298/1081-5937-43.4.03

Cognitive behavior therapy (CBT) as applied by behavioral scientists includes strategies for changing negative cognitions that contribute to depression and anxiety. Biofeedback is a useful strategy to demonstrate to clients the mind (cognitive, psychological) to body (physiological) interaction. For example, a cognitive, psychological reaction to a stimuli results in a physiological effects as illustrated by changes in skin conductance or muscle tension. A case example is used to demonstrate an anticipatory psychophysiological response resulting in covert activity of the forearm as a client simply imagines playing the piano.

Porges, S. & Peper, E. When Not Saying NO Does Not Mean Yes:
Psychophysiological Factors Involved in Date Rape

To understand how a woman who does not want to be a willing sexual partner can at times acquiesce and not fight the date rape predator, the neurobiology of our responses to threat needs to be understood. Under situations of extreme threat, instead of responding just to danger signals with only the options to fight or flee, we also retain in our nervous system a primitive immobilization response that may reflexively be expressed when our body detects life threat. The polyvagal theory proposed by Stephen Porges may explain why many rape victims do not actively resist. This discussion of the polyvagal theory supports the recently passed California law (Senate Bill 967) that requires the governing boards of California postsecondary institutions (colleges and universities) to adopt procedures and protocols requiring students to obtain ‘‘affirmative, unambiguous, and conscious decision by each participant to engage in mutually agreed-upon sexual activity.’’                                                                                             
Transforming Chained Behavior

The authors describe the format of a holistic health class provided to undergraduates at San Francisco State University in California. The class initially emphasizes self-monitoring and record keeping to enhance the students’ self-awareness of negative emotions, symptomatic behaviors, and other ‘‘chained behaviors’’ leading to various problems, such as smoking or eczema. The students cultivate a variety of positive self-care behaviors and selfregulation skills, such as mindfulness, relaxation skills, visualization techniques, and seeking social support. Finally, they learn to substitute these self-care practices for the negative emotions and behaviors, in the moments of emerging awareness, thus interrupting the ‘‘chain of behaviors’’ leading to problems. The authors provide case narratives of three students implementing this program to address personal illnesses or problems (smoking, eczema, and trichotillomania).

Clinical Tip: Relax and Relax More

Sit comfortably. Raise your shoulders, hold, relax . . . relax more. What did you experience? If you are like most people, you noted that the second instruction to relax more, you may have felt your shoulders dropping even more and relaxed even deeper. Thus, we recommend that practitioners teaching relaxation instruct their clients after tightening a muscle, such as lifting the shoulder, to repeat the relaxation instruction at least twice so that the muscle can totally relax before it is reactivated.

Support Healthy Brain Development: Implications for Attention Deficit/ Hyperactivity Disorder

Neglecting and disregarding our evolutionary background during infant, toddler and childhood stages of development may contribute to the increase in diagnosis and treatment of attention deficit/hyperactivity disorder (ADD/ADHD). To optimize healthy brain development, the following factors need to be supported:1) Breast feed children at least for one year and concurrently introduce new foods slowly after 6 or 8 months to reduce the risk of developing food allergies; 2) Respect the importance of face-to-face contact to provide safety, develop empathy and nurture social connection; 3) Provide routine and ongoing parental attention and support circadian rhythms; 4) Integrate vision with touch and movement by encouraging motor development such as crawling, playing in nature, and physical movement that occurs while playing games instead sitting and being entertained by smartphones, computers, tablets or TV screens; and 5) Provide face-to-face reassurance when overwhelmed with rapidly changing visual and auditory stimuli. Health implications of new digital devices are discussed.

Pain as a contextual experience in Townsend Letter-The Examiner of Alternative medicine

Pain is not simply a neurological or biological experience, it occurs in context. Major lessons include the need for clients to feel totally safe and accepted, with components of the experience including trust, hope, and faith.

Single-Session Treatment of Hip Pain: Factors Underlying the Healing Process

“After experiencing your guided exercises on the gym floor, I slept comfortably and without any pain for the first time in four years. This morning when I went grocery shopping, I could walk straight with a normal stride and again without pain. I feel great.”  -Paul Maassen

The rapid successful resolution of pain described above occurred as the result of a spontaneous teaching moment with a person in the gym. This success is not just a case of magical/spontaneous healing but of the integration of multiple factors that promote healing and underlie somatic awareness practices and successful biofeedback training. In this clinical note, we describe 1) how the educational treatment began, 2) the educational/clinical coaching sequence, and 3) factors that therapists may want to consider in their treatment.

Falls and hip fractures are not inevitable: A return to nature

Falls and hip fractures may not be inevitable, however, at prevent time they account for a significant portion of morbidity and contribute significantly to mortality in the elderly. This paper offers an evolutionary perspective with the concept of learned disuse as one of the major factors contributing to falls and hip fractures. The concepts are illustrated through experiential exercises. These exercises can be used both diagnostically and as preventive/educational approaches. Pragmatic recommendations are provided to reduce the risk of falls and improve strength and balance.

Exercise or Play? Medicine of Fun

Patients often equate biofeedback training homework to mandatory activities, which are often viewed as one more thing to do. Changing the perception from that of work to fun can encourage laughter and joy and help overcome a chronic pain pattern all necessary for healing. This paper encourages therapists to explore utilizing childhood activities and paradoxical movement to help patients release tension patterns and improve range of motion. A strong emphasis is placed on linking diaphragmatic breathing to movement.

Healing a Shoulder Injury

This case report describes an indirect approach incorporating diaphragmatic breathing, imagery, role rehearsal and surface electromyographic (SEMG) feedback to successfully reduce pain and increase left shoulder mobility in a 23 year old woman with a left pectoralis muscle injury from a skiing accident. It demonstrates how direct biofeedback or therapeutic interventions may be counterproductive and indirect approaches guided by SEMG activity may facilitate clinical success. Discussed are specific concepts, rationales and strategies employed that guided the successful therapeutic intervention. This article offers a case description with process and outcome comments from the client’s and therapist’s perspectives. It is offered as a model to increase therapeutic efficacy when an initial biofeedback intervention appears not to work.

Healing of Vulvodynia from the Client perspective 2015-06-15

This article discusses one individuals healing of Vulvodynia from the client perspective. The participant’s interpretation of what she experienced and her perception for reasons for success, including triggers for illness and triggers for healing are discussed.

Making the Unaware Aware-Surface Electromyography to Unmask Tension and Teach Awareness

Poor awareness of covert low-level muscle tension and poor ergonomics can result in chronic muscle bracing and the development of clinical symptoms. This article introduces a simple exercise to teach awareness and control of residual muscle contraction, presents evidence of its effectiveness, and concludes with a case study in which it contributed to the treatment of severe pelvic girdle pain.

The Power of Words, Biofeedback, and Somatic Feedback to Impact Illness Beliefs

The article explores the use of words, biofeedback and somatic feedback as tools to change illness beliefs. These tools can make patients aware of the mind-body connection, illustrating how thoughts and emotions can affect their body.

Treating Prostate Cancer with Immune Therapy Using the GorterModel

Clinical research on prostate cancer treatment has shown that watchful waiting and healthier lifestyle frequently leads to an improved clinical outcome. Encouraging outcomes with newer treatments suggest that supporting and enhancing the body’s own immune capabilities offer significant promise in the fight against prostate cancer. This article outlines a protocol of immune therapies developed by Robert Gorter, MD, PhD, founder and director of the Medical Center Cologne, in Cologne, Germany, which provides integrative cancer treatment.

Experience the Mind-Body Connection: A Metaphor for Immune Competence

Feeling overwhelmed, hopeless, and powerless are common feelings especially when sick. We often forget that evoking or ruminating on negative thoughts decreases our energy level and strength. This change in strength can be used as a metaphor for immune competence. In many cases caretakers of a family member with Alzheimer disease or a disabled child have reduced immune competence. For many of these care takers, life feels like being on a treadmill with no end in sight. Just recalling or ruminating on a hopeless, helpless, powerless memory causes our energy to drop. Experience the change in energy and physical strength when you shift your thoughts in the following exercise taken from our book, Fighting Cancer-A Nontoxic Approach to Treatment (Gorter and Peper, 2011).

Current Applications of Biofeedback to Physical Medicine and Rehabilitation

Clinical biofeedback has a 35 year history of developing applications to disorders in physical medicine and rehabilitation. The authors summarize the paradigm of biofeedback, discuss its mechanisms, and review current protocols for the treatment of asthma, epilepsy, fibromyalgia, headache, myofascial pain disorders, repetitive strain disorders, and urinary incontinence. Biofeedback interventions are compatible with and often augment the therapeutic effects of conventional medical, pharmacologic and manual interventions. Biofeedback offers evidence-based alternative therapies for a variety of common disorders in rehabilitation.

Place Yourself in Your Client’s Shoes with Biofeedback to Promote Healing

Applied psychophysiology appears useful to uncover whether the external persona represents the internal physical and emotional experience.  Observing the ongoing physiological changes within an individual can be helpful to guide the clinical interventions and can be used by the therapist to uncover ongoing psychological and emotional processes, describe and help label the subjective experience, offer a physiological rationale for the illness process, and offer interventions to promote healing.  Speaking for the client, utilizing a YES set and reframing may increase rapport and allow the client to feel understood—a process, which may induce symptom relief and relaxation.

How to do Clinical Biofeedback in Psychosomatic Medicine

Biofeedback interventions, based on the psychophysiological principle that thoughts, emotions, and body interact, affecting each other, have been shown to be powerful clinical tools for use in psychosomatic medicine settings and primary care settings where 75% of patients may present with symptoms of unknown causes. This paper describes both overt and covert factors supporting successful biofeedback training. This case illustrates that clinical biofeedback is more than just attaching sensors or having the person mechanically practice some prescribed behavior.

Biofeedback: An Evidence Based Approach in Clinical Practice

Clinical biofeedback procedures are highly effective ameliorating a variety of symptoms that range from urinary incontinence to hypertension as well as assess a person’s somatic awareness by making the invisible visible. The paper reviews the biofeedback process and some psychosomatic applications. This process is illustrated through the description of a single session with a patient who experienced severe gastrointestinal distress and insomnia.

Thermal biofeedback training in children with headache 

Two young girls with a history of headaches were trained with autogenic training phrases and with thermal biofeedback training. Both girls rapidly learned to control their peripheral temperature in two training sessions while practicing for 3 weeks at home and school; both have been symptom free (without medication) for the last 6 months. This learning process may foster a shift in health attitudes from helplessness to self-responsibility.

An holistic merger of biofeedback and family therapy 

This article is a positive consideration of the integration of self-regulation skills (biofeedback and autogenic training), and family therapy in order to create a holistic approach which includes the individual, the family, the social network and the belief system within which one lives.