Sequential comparisons of relaxation training and biofeedback in the treatment of three kinds of chronic headache or, the machines may be necessary some of the time

The Efficacy of Hypnotic and Nonhypnotic Response-Based Imagery for Self-Managing Recurrent Headache

Two experiments investigated the use of hypnotic and nonhypnotic response-based imagery training for recurrent headache. In Experiment 1, subjects with symptoms of chronic migraine headache (CMH), or chronic mixed migraine/tension headache (Mixed CMH/CTH) were assigned to a Hypnotic or Nonhypnotic Imagery group, or to a Monitoring Control group. Treatment efficacy was assessed over two-week intervals, at Baseline, Post-treatment, and three successive follow-up periods. In Experiment 2, subjects with symptoms of chronic tension headache (CTH) were assigned to four conditions (Hypnotic Imagery/Nonhypnotic Imagery/Placebo/Monitoring Control), and studied across two-week intervals at Baseline, Post-treatment, and eight-week Follow-up. Hypnotic and Nonhypnotic Imagery conditions did not differ in demonstrating efficacy in reducing headache activity in both experiments. Treatment outcome was not associated with medication consumption, or actual changes in physiologic processes (cardiovascular functioning and frontalis EMG). Headache reduction was not correlated with hypnotizability or the trait propensity to engage in vivid imagery. These results replicate and extend previous findings, and support the use of imagery strategies as a treatment component in pain management programs.

[Psychological therapy of migraine: systematic review]

This review summarizes the various forms of behavioral treatment of migraine which could demonstrate empirical efficacy. The main unimodal kinds of treatment are thermal and electromyography (EMG) biofeedback training and progressive muscle relaxation. The various relaxation techniques do not differ in their efficacy in treating migraine. On average a reduction in migraine frequency of 35-45 % is achieved. The mean effect sizes (ES) of various biofeedback techniques are between 0.4 and 0.6. Cognitive-behavioral treatment is applied as a multimodal treatment and on average achieves an improvement in migraine activity by 39 % and an ES of 0.54. All behavioral procedures can be used in combination or as an alternative to drug prophylaxis with comparable success. A combination of pharmacological and behavioral treatment can achieve additional success. There is strong evidence for the clinically significant efficacy of all forms of behavioral treatment in childhood and adolescence. There are no signs of differential indications.

Individualized Cognitive Behavioural Treatment of Chronic Pain

Cognitive behavioural treatment for chronic pain was individually tailored based on pre-treatment assessment of the subjective pain experience of each patient. Eight chronic pain patients completed the individualized treatment program which consisted of relaxation techniques, hypnotic deepening strategies, a relabeling hierarchy based upon pain descriptors, positive self-statements, didactic information, and cognitive-restructuring techniques. Patients self-monitored their pain during a two week pre-treatment baseline period, during the eight weeks of treatment and for one week post-treatment. Additional treatment outcome measures were also taken. Compared to baseline data, patients reported positive changes on many of the treatment outcome criteria, including McGill Pain Questionnaire indices, reduction in the number of hours spent in pain, and follow-up questionnaire responses. Treatment outcome measures collected at one week, six months, and 15 months post-treatment all suggested positive treatment gains. The greatest gains were reported at the six month post-treatment assessment suggesting a generalization or practice component to the therapy. Additionally, patients with constant pain were found more refractory to treatment than patients with intermittent pain.

Effects of Depression and Headache Type on Biofeedback for Muscle-contraction Headaches

The present study was designed to investigate further the possible interactive role of both depression and headache type on the outcome of a standard E.M.G. biofeedback therapy for muscle-contraction headache. Forty-eight patients applying for treatment at a headache treatment center were given forehead/posterior neck E.M.G. biofeedback therapy for 20 weeks. Twelve subjects in each of four groups had either depression with or without a history of head trauma, or were not depressed, with or without a history of head trauma. Results showed that headache activity was lowered more for non-depressed subjects and more for non-trauma subjects, although there was no interaction. However, post-hoc examination also showed that the possibility of monetary gain from legal action might have confounded the data for some of the trauma subjects. The study supports the need for separation of depressed and non-depressed patients in headache treatment and the probable need for treatment for the depression itself, aside from the headache.

Cognitive-behavioral issues in the treatment and management of chronic daily headache

Chronic daily headache is a heterogeneous group of daily or near-daily headaches that afflicts close to 5% of the general population and accounts for close to 35% to 40% of patients at headache centers. First-line drug or cognitive-behavioral therapies administered alone have minimal impact on reducing the frequency or severity of headaches. However, combined drug and cognitive-behavioral therapy shows promise in providing the most benefit for this often intractable condition. Cognitive-behavioral therapies focus on preventing mild pain from becoming disabling pain, improving headache-related disability, affective distress, and quality of life, and reducing overreliance on medication. For cognitive-behavioral therapies to be effective, it is important to address complicating factors, including medication overuse, psychiatric comorbidity, stress and poor coping, and sleep disturbance.

Age comparisons in acquiring biofeedback control and success in reducing headache pain

This article presents a review and archival analysis to assess age differences in acquiring biofeedback control and success in treating recurrent headache by using data from 56 studies with either adult (total N = 503) or child (total N = 98) subjects. All studies focused on treating headache with temperature biofeedback (TBF) or electromyographic (EMG) biofeedback. To standardize the varied measures across studies, we calculated each study's percent change scores for biofeedback performance and headache activity. All headache activity scores included assessments of pain intensity. We then calculated subject-weighted means of percent change for biofeedback performance and for headache activity by summing the products of each relevant percent change score and N and then dividing by the total number of subjects contributing to those sums. Results showed that both children and adults reported substantial improvements in headache activity with TBF and EMG biofeedback treatment (Ms ranged from 34% to 81%), but children showed significantly greater improvement than adults. No age differences were found in the acquisition of biofeedback control. Further analyses revealed two additional findings. First, biofeedback control and headache improvement were strongly correlated. Second, headache activity continued to decrease in the weeks following treatment, and this decrease was significantly greater for children than adults.

A retrospective, follow-up study of biofeedback-assisted relaxation therapy in patients with posttraumatic headache

Although biofeedback in the treatment of migraine and tension-type headache has been widely researched, there is little research examining biofeedback therapy in posttraumatic headache (PTH). In this retrospective study, 40 subjects with PTH who had received biofeedback-assisted relaxation at our headache clinic were questioned at least 3 months following the completion of therapy. Subjects were queried about improvements in headache, increases in ability to relax and cope with pain, and overall benefits, lasting effectiveness, and continued use of biofeedback in daily life. Results indicate 53% reported at least moderate improvement in headaches; 80% reported at least moderate improvement in ability to relax and cope with pain; 93% found biofeedback helpful to some degree; 85% felt headache relief achieved through biofeedback had continued at least somewhat; and 95% stated they were continuing to use biofeedback skills in daily life. A correlation analysis revealed a negative relationship between response to biofeedback and increased chronicity of the disorder. In other words, the more chronic the disorder, the poorer the response to treatment. A stepwise regression analysis found that chronicity of the disorder and number of treatment sessions significantly affected response to treatment. Data suggest that biofeedback-assisted relaxation should at least be considered when planning treatment strategies for posttraumatic headache.

Behavioral management of migraine

Behavioral treatments for migraine have received increased attention over the past 25 years. In general, research has focussed on the six following areas: 1) comparative efficacy of treatments, 2) interplay of behavioral and pharmacological approaches, 3) development of delivery models that are cost-effective, 4) identification of characteristics associated with varied levels of response to treatment, 5) maintenance of effects and factors associated with long-term outcome, and 6) mechanisms of treatment. This paper briefly and selectively reviews the available literature in an attempt to point out the status of current research.

Stress management techniques: are they all equivalent, or do they have specific effects?

This article evaluates the hypothesis that various stress management techniques have specific effects. Studies comparing various techniques are reviewed, as well as previous literature reviews evaluating the effects of individual techniques. There is evidence that cognitively oriented methods have specific cognitive effects, that specific autonomic effects result from autonomically oriented methods, and that specific muscular effects are produced by muscularly oriented methods. Muscle relaxation and/or EMG biofeedback have greater muscular effects and smaller autonomic effects than finger temperature biofeedback and/or autogenic training. EMG biofeedback produces greater effects on particular muscular groups than progressive relaxation, and thermal biofeedback has greater finger temperature effects than autogenic training. Disorders with a predominant muscular component (e.g., tension headaches) are treated more effectively by muscularly oriented methods, while disorders in which autonomic dysfunction predominates (e.g., hypertension, migraine headaches) are more effectively treated by techniques with a strong autonomic component. Anxiety and phobias tend to be most effectively treated by methods with both strong cognitive and behavioral components.

Presentation of humor and facilitation of a relaxation response among internal and external scorers on Rotter's scale

40 men and 40 women categorized on the dimension of locus of control were measured for relaxation following exposure to humorous or nonhumorous stimuli. Internal scorers showed enhanced relaxation during subsequent measurement of biofeedback.

Depression and the chronic pain experience

The present study examined the relationship between depression and a constellation of pain-related variables that describe the experience of chronic pain patients. Thirty-seven depressed and 32 non-depressed heterogeneous chronic pain patients were identified through structured interviews, use of standardized criteria and scores on the Beck Depression Inventory (BDI). The 2 groups were compared on demographic variables and scores on the Marlowe-Crowne Social Desirability scale (MC), as well as measures of disability and medication use, pain severity, interference due to pain and reported pain behaviors. The depressed group was found to be younger and to score lower on the MC than the non-depressed group. Multivariate analyses of covariance (MANCOVA), using age and MC as covariates, revealed that depressed chronic pain patients, relative to their non-depressed counterparts, reported greater pain intensity, greater interference due to pain and more pain behaviors. There were no group differences on the measures of disability and use of medications. The results provide further support for the importance of incorporating depression into clinical and theoretical formulations of chronic pain. Future use of structured interviews and standardized criteria for diagnosing depression may clarify some of the inconsistencies found in the literature.

Meta-analysis of non-medical treatments for chronic pain

A meta-analysis was conducted on 109 published studies which assessed the outcome of various non-medical treatments for chronic pain. Of these studies, 48 provided sufficient information to calculate effect sizes. The remainder were examined according to proportion of patients rated as improved. Studies were compared as a function of type of treatment, type of pain, and type of outcome variable. In general, effect sizes were positive and of modest magnitude indicating the short-term efficacy of most treatments for most types of pain. This finding suggests that the effectiveness of treatments may be attributable not to the differences between treatments, but to the features they have in common. Mood and number of subjective symptoms consistently showed greater responses to treatment than did pain intensity, pain duration, or frequency of pain, indicating the importance of using a multidimensional framework for pain assessment. This finding also suggests that the benefit of psychological approaches to pain management may lie in reducing the fear and depression associated with pain, rather than relieving the pain itself. The present study also highlights the advantages of meta-analytic reviews.

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 design 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.

Psychological factors affecting outcome of treatment after transcutaneous electrotherapy for persistent tinnitus

We used transcutaneous electrotherapy to treat 27 patients with persistent tinnitus. Each patient was tested with the short form of the Minnesota Multiphasic Personality Index test (MMPI) prior to the commencement of treatment. The "unimproved" group of patients (n = 15) showed higher pretreatment scores for depression (P less than 0.05), psychasthenia (P less than 0.05) and schizophrenia (P less than 0.02). Our findings indicate that patients having significantly pathological scores on at least one of these three scales will fail to benefit from treatment. These findings also show that there appear to be psychological prognostic factors that can be used to evaluate patients receiving transcutaneous electrotherapy for persistent tinnitus.

Client variables and the behavioral treatment of recurrent tension headache: a meta-analytic review

Meta-analysis revealed that in studies evaluating behavioral treatments for tension headaches, the treatment outcome has varied with the client samples (e.g., age, gender, referral source) that have been used but not with the treatment procedures (e.g., type of behavioral intervention, length of treatment, whether or not efforts were made to facilitate transfer of training) or the research designs (e.g., internal validity, explicitness of diagnostic criteria) that have been used. Mean client age proved the best predictor of treatment outcome, accounting for 30% of the outcome variance following behavior therapy. Significantly poorer outcomes have also been reported in recent studies than were reported in early studies. These findings suggest that outcomes obtained with behavioral interventions have been less dependent upon the treatment variables that have been the primary focus of research attention than upon characteristics of client samples and behavioral interventions may be less effective in reducing headache activity than has previously been assumed.

A review and clinical perspective on the use of EMG and thermal biofeedback for chronic headaches

A comprehensive survey of EMG and thermal biofeedback for chronic muscle contraction and migraine headaches is presented. The studies done to date suggest a high degree of short-term efficacy of biofeedback, which has been maintained on long-term follow-ups. While comparisons of biofeedback with relaxation generally have shown approximately equivalent effectiveness, the two forms of therapy may be differentially effective with different subjects. Attempts to correlate EMG and/or thermal parameters with headache parameters generally have failed to produce significant results, particularly in more recent and better-controlled studies; however, numerous technical and procedural difficulties have obscured meaningful interpretation of physiological data. Results with pseudofeedback do suggest a likely specific contribution of frontalis EMG to muscle contraction headaches, at least for some subjects. Comparable evidence for a specific contribution of thermal parameters to migraines is almost totally lacking. Clinical outcome research suggests that biofeedback in general may be more effective in younger anxious subjects who show no chronic habituation to drugs, and that there is little apparent benefit from repeating biofeedback for more than about 12 sessions maximum. Three broad areas for subsequent research are suggested: longitudinal study of EMG and thermal parameters in a naturalistic setting, specification of processes critically involved in biofeedback, and clinically relevant comparative outcome research with biofeedback and alternative therapies.

Physiological changes after biofeedback and relaxation training for multiple-pain tension-headache patients

This paper is concerned with the psychophysiology of "muscle-contraction" headaches in a group of Compensation patients suffering from multiple pain problems in addition to headaches. A total of 55 of these patients were divided into 4 groups which received frontalis EMG biofeedback, relaxation training, combined biofeedback-relaxation training, or no treatment. Differences were observed among the 3 experimental treatments and the control group with respect to headache changes, but there were no differences among groups with respect to the changes observed in four underlying physiological responses as a function of time or practice. While the subjects who showed the largest changes in headache characteristics were those who exhibited the largest decreases in frontalis EMG, these were also the subjects whose initial frontalis EMG levels were the highest. It is concluded that, in keeping with a growing literature, the link between frontalis EMG and "muscle-contraction" headaches is a tenuous one and that the changes brought about in headache symptomatology through biofeedback or relaxation training are most likely attributable to a generalization of feelings of mastery over the environment or of self-efficacy brought about in the subjects through apparent success at the task.

GSR feedback and Schultz relaxation in tension headaches: a comparative study

A comparative study of the use of GSR feedback (n = 16) and Schultz relaxation (n = 15) with patients presenting tension headaches showed that there was no significant improvement in the group treated by relaxation at the end of the treatment whereas the group treated by GSR feedback showed significant improvements with respect to frequency and intensity of headaches and to anxiety as measured by subjects' self-evaluation (P less than 0.05). Intergroup comparison demonstrated a greater improvement in headache intensity for the GSR feedback group than for the relaxation group (P less than 0.05) at the post-treatment stage. Likewise, the percentage of patients showing at least 50% improvement as to headache frequency was significantly higher (P less than 0.05) in the GSR feedback than in the relaxation group. High pre-treatment EMG and high pre-treatment weekly pain level indicate a good prognosis of improvement with respect to post-treatment headache frequency and intensity respectively in the case of the GSR feedback group. We found no prognostic factor for post-treatment clinical improvement in the relaxation group.

Mediating factors in non-medical treatment for migraine headache: toward an interactional model

The inadequacy of traditional (i.e. pharmacological) treatment for migraine headache has led to the development of numerous non-medical interventions (e.g. biofeedback, relaxation, cognitive-behavioral programs). All of these non-medical interventions have produced at least some success in reducing migraine headache parameters. However the mechanism of treatment efficacy is unclear, with a number of not mutually exclusive relationships proposed. Purported mediators of successful outcome in these treatments include specific control of vascular activity, general reduction of autonomic arousal, biochemical changes, cognitive, affective, and behavioral change, therapist contact and support, and credibility and placebo expectancy. The present paper attempts to discuss and evaluate the mechanisms of change that have been proposed as mediators of successful treatment of migraine headache. An interactional model of adaptive change as a function of treatment is presented. The implications of the model for assessment and treatment are discussed. It is suggested that the interactional model may be applicable to the treatment of a range of chronic pain problems.

Depression in chronic pain patients: relation to pain, activity, and sex differences

Depression is commonly reported among chronic pain patients and receiving increased attention from clinicians and researchers. There is, however, little empirical evidence concerning variables that differentiate depressed from non-depressed chronic pain patients, and whether depression is related to factors such as gender, pain report, and activity. As part of a study to address these questions, 63 chronic pain patients completed daily diaries of activity, pain levels, and medication intake, and completed questionnaires and interviews assessing depression, medical history, and demographic variables. Male and female depressed and non-depressed chronic pain patients did not differ on demographic and medical history data, but sex differences were found in patterns of the relationships of depression, activity, and pain. For women, depression was closely related to pain report, whereas for men depression was more strongly related to impairment of activity. Pain report was related only minimally to activity for male and female patients. Implications of the results of behavioral research on depression in chronic pain patients are discussed. Researchers are urged to carefully consider sex differences in future research with chronic pain patients.