Respiratory Biofeedback RFB.micro
1. In German - speaking medicine autogenous training (AT) is, at present, the best understood and most widely used method of psychotherapy. The scientific researcher J. H. SCHULZ, who developed this ingenious system of con centrative self-relaxation, devoted decades of work to the testing of its broad spectrum of indications as relaxation therapy. It comprises all "nervous" or neuro-vegetative, therefore functional or conversion neurotic clinical pictures, psychosomatic diseases such as Asthma bronchiale, Colitis ulcerosa, essential hypertonia, etc. But, after thorough practice in this pragmatic method, the patient can also learn to control, more or less himself, psychoneurotic symptoms, such as states of anxiety, slight depressive neuroses and character maladjustments. Principally, therefore, those 30-40% of all patients who suffer from diseases with psychological or partially psychological causes can be treated by AT. But, as is well-known, this method can also help healthy people, by means of the "prophylactic pause", to reduce and prevent stress to which ever-increasing numbers of the population are exposed nowadays.
1.1 The AT therapy requires that the doctor himself masters the method and personally instructs his patient in it. The patient must meet certain requirements of intelligence, emphaty and strength of character with regard to the regular exercise he has to perform himself.
1.2 The effect of AT depends, to a certain extent, on the feedback to the cerebral cortex of the state of muscular tension (sense of heaviness), of the vascular circulation (experience of warmth), of the respiratory process (respiratory control), and the blood circulation in the epigastrium ("solar plexus"); this is achieved by a gradually increasing awareness of the above-named vegetative body functions. It is only after months of continuous practice that the patient achieves the decisive control of these functions ("Practising method").
2. During the last decade there has been a tendency in scientific research in the USA to use electronic instruments for such "Bio-Feedback" processes. The aim of these experiments, as far as they are concerned with therapeutic application in human beings, has been to create a state of modified consciousness and of relaxation, similar to that achieved by AT. Out of the various possibilities, however, only two bio-feedback systems have emerged which, on the strength of broad basic research, may claim to be of clinical interest. These are the feedback of muscular actions by means of the Electromyelograph (EMG-feedback) for the treatment of migraine and tension headache, and the control of the heart action in cases of cardiac disorders. The latter procedure is still on trial.
3. In Germany a group of researchers worked along different lines. They examined the feedback of the respiratory movement, referred to as "Respiration Feedback" (Rfb) under its scientific designation, or as "Breathing Feedback" in its practice-related name. Professor Hanscarl Leuner, neurologist and psychotherapist, Head of the Department of Psychotherapy and Psychosomatics of the teaching hospital of Göttingen University, who is well-known for his many years of research in the field of modified states of consciousness, observed that physical-psychological relaxation (Hypnoid) and respiratory type correlate in a certain way (e.g. in AT, sleep, coma, during Yoga and meditation exercises). Since 1970 he and his study group have been developing and testing an electronic apparatus which scans the respiratory movement by means of a sensor on the patient and converts it without delay by amplification into an optical and/or acoustic signal, that is, translates it into a light of increasing and decreasing intensity and/or a tone (headphone) of changing pitch. The patient is thus distinctly aware of his breathing rhythm and his respiratory rate, without requiring any prior training. Prof. Leuner's expectations were not only confirmed, but in part even exceeded during the physiological and clinical trials. The EEG distinctly shows a considerable reduction in cerebral activity and thus the state of wake-fulness. It exceeds the EEG-changes during hypnosis, AT (and Alpha-Feedback) in the sense of a marked reduction of violance. At the same time the muscular tone (sense of heaviness in AT and in EMG-feedback) is distinctly reduced. There is a strong subjective awareness of the psychological influence of the procedure, which runs parallel to this physical "conversion" ("Umschaltung", J. H. SCHULZ ). It was possible to establish this statistically with significant frequency by means of the semantic differential ("Polaritätenprofil", HOFSTÄTTER ) in the following adjectives of subjective experience: "relaxed, at ease, indifferent, composed, comfortable, sure, safe, free, light, serene".
3.1 The clinical trial of Rfb was carried out on a random group of 200 outpatients. They came from a medical and a psychiatric policlinic of a teaching hospital as well as from a neurological practice (ages 18-50 years, average age 33 1/2 years, average duration of symptoms 4 years). Patients with psychoses and internal diseases were excluded. The complete course of treatment consisted of 15 half-hour sessions and was to be supported by a further 8 sessions. After about 5 sessions at the latest the above-mentioned state of deep relaxation was achieved. Just under 90% of the patients felt that the treatment was agreeable, about 50% were willing to continue with it, in over 70% an objectively adequate to very good improvement of their symptoms could be observed. A comprehensive paper is available on request.
3.2. What are the Advantages of Respiratory Feedback?
a) The time required for the instruction in relaxation is cut down considerably; the tangible therapeutic effect manifests itself within 3-4 weeks.
b) The training aim is achieved with a high degree of certainty.
c) The state of relaxation is intensive, and thus especially efficacious.
d) Rfb makes no demands on empathy, intelligence or will-power on the part of the patient, except for the ability to yield to the state of relaxation.
e) The method is therefore suitable for patients of all social groups.
f) The doctor need not himself have learned the procedure. The training of the patient can largely be left to trained auxiliary personnel (training courses on request).
3.3. Practical Suggestions
3.3.1 Indications: Generally speaking: almost all conditions for which neuro-vegetative or the well-known minor tranquillizers are prescribed, or where AT is indicated; vegetative-functional disorders of all kinds (after an organic background has been eliminated), so-called conversion neuroses or psychosomatic states, but also psycho-neurotic symptoms, such as states of anxiety, phobias, slight depressive neuroses, as well as the group of acute or chronic stress-related reactions. Stress prophylaxis in stress susceptible asthenic persons or persons exposed to great stress.
A statistical survey of the groups of diseases, the change of the test profiles and some individual reports by patients are available. Only about 5% of an unselected group of patients proved totally unsuitable for the treatment.
3.3.2 Contra Indications: Severe psychiatric symptoms, such as psychoses or suspected psychoses, or borderline cases, an abnormally restricted level of intelligence, imaginary of the patient with regard to the method or its rejections for any other reasons (clarifying discussion before commencing treatment).
3.3.3 External Conditions: A quiet, darkened exercise room, positioning of the apparatus, comfortable couch (with BIOSWING-System are the best), auxiliary personnel trained in the procedure (with first-hand experience, i.e. introduction by means of a course organized by MFB.
3.3.4 Time Schedule: One exercise takes 30-40 minutes. Double sessions are also possible. Including contact conversation, fitting of the sensor and brief concluding discussion, 50 minutes have to be allowed per session. A course of treatment consists of 15 sessions. 3-4 sessions per week should be carried out, depending on the severity of the symptoms. If the patient refuses to continue with the treatment after 5 sessions (as is extremely rarely the case), or if he believes that he does not benefit from the treatment, Rfb is not indicated.
3.3.5 After-treatment: 8 sessions, once weekly, are recommended in order to maintain the effect. Occasionally patients avoid the after-treatment if they are feeling well. In the concluding discussion an offer of after-treatment should be made which the patient may take up if he should experience renewed difficulties at a later date. After the course of treatment is completed the doctor should conduct a brief concluding orientation discussion, in order to form an impression of the effect of Rfb and to determine further therapy accordingly.
3.3.6 Medication: During the treatment with Rfb an attempt should be made to discontinue any neuro-vegetative and/or sedative medication. In cases where medication is indispensable, the dosage should be reduced to a minimum and then kept at a constant level (Instruction of the patient).
3.3.7 Interference Factors: In the treatment with Rfb these may arise from circumstances connected with the patient's own psyche, such as imaginary fears.
1 Leuner, H.: Das Respiratorische Feedback (Rfb), intensive Entspannungstherapie und ihre klinischen Ergebnisse bei Neurosen und psychovegetativen Störungen.
The results of a survey of 20 practicing doctors - mostly general practitioners, but also some neurologists - who have been treating patients with Respiration Feedback (Rfb) for years is a clinical illustration of the Rfb's importance in basic medical treatment. The essence has been collected in 6 categories.
Reports of practicing Physicians
- In their practices Rfb is an "indispensable therapy technique."
- Compared to continuous prescription of psychopharmalogical drugs (tranquillizers, sedatives and sleeping pills) Rfb saves money. The desired - but unnecessary - special examinations, as CT, etc., which are liked with insufficient treatment also cease. Through Rfb-relaxation patients often become convinced of the functional character of their complaints.
- The technique demonstrates a counteractive effect against dependence on alcohol and medication; due to the rapid symptomatic improvement, prescription of medication is unnecessary and / or addicted patients can "better withstand withdrawal."
- The relationships to autogenous training are characterized as follows: "better and more rapidly effective than AT"; not dependent on the mental level of the patient; a great help in the practice of AT.
- Rfb is an aid in the psychotherapy of patients, who are not motivated and open for it. For patients, who do not have the prerequisites for psychotherapy, Rfb can be substituted for it.
- Most reports express a lack of understanding over the fact that Rfb was excluded from payments of German health insurance by a decision of the State Board of Health in April 1986 and are pleading or have filed a petition for the inclusion of Rfb in the current revision of the Health Insurance Assessment Regulations.
Source: MFB 7/1990
Doctors Statements Dr. B. from Oberndorf
"Since I work in a rural area, my clientele consists primarily of workers, part-time farmers, about 10% foreign workers and their dependents. Many patients are prejudiced against medication. When they come to my office with medical complaints, many of them do not have the prerequisites for autogenous training, but Rfb is suitable for them. . - The patients response/resonance to the Rfb treatment greatly exceeds my original expectations. -Indeed, the fact that over 80% of the patients, who have gained just a little experience with Rfb, often arrive punctually after travelling many miles for their relaxation session speaks for itself..." - "At last after the tenth session, after which another consultation takes place, I observe an increasing self-confidence, tranquillity and a more realistic attitude by the majority of my patients. Even skeptics repeatedly express this opinion: "As simple as the method is, it helps me."
My colleague further described a case of crisis intervention with Rfb: "A highly agitated middle-aged man came into my practice while I was making house calls. He panicked because no one could give him the necessary sedative injection. In this situation it was possible for my technician to talk him into undergoing Rfb. As I arrived about 35 minutes later, he said, "I'm O.K. now, I don't need an injection any more."
Dr. W. from Wuppertal (general practitioner)
I have been working with this method for more than two years and I cannot imagine working without this psychiatric therapy spectrum. Insomnia, agitated depression and neuroses, psychiatric complaints arising during withdrawal from, e.g., alcohol and nicotine, nervous behavioral disturbances and any other disorders are readily and lastingly susceptible to Rfb. Our own statistics show that much more than 90% of our patients have (first) remained for the total therapy period of 20 sessions ... and (second) that after completing the therapy the patients spontaneously expressed their enthusiasm about its success. All of my patients who have been treated with Rfb either no longer need medication, such as tranquillizers, or that they are motivated to stop using them. So-called "quitters" are extremely seldom. In spite of the great amount of time required for this therapy (one hour 2-3 times per week), none of the patients have ever complained... Both in terms of the method and the effect, Rfb is located between autogenous training and hypnosis. This has been particularly confirmed by the patients who had previously attended autogenous training courses. The dropout rate of AT courses is known to be much higher. These patients consider Rfb to be distinctly more effective. Rfb is also very useful as an adjuvant in psychotherapy.
This method does not directly require an intensive investment of the doctor's time, but it does mean a not inconsiderable burden for the operation of practice: a room which is nearly soundproof and a comfortable variable-position couch must be made available... The physician must keep track of the success of each completed session, so that he may correctively intervene if necessary. In difficult cases the physician must also ... suggestively influence the program."
William Shearouse RRT, Respiratory Associates Inc. West Palm Beach, Florida
Introduction: I sought to determine whether patients suffering from COPD would benefit from respiratory biofeedback (RFB). RFB is accomplished by using an amplifier that feeds the respiratory rhythm to the reticular formation found in the brain. The biofeedback loop starts at the sensor that scans the patient's breathing rhythm. The sensor is connected to an amplifier that converts the electrical impulses into acoustical and visual outputs. These outputs are transferred to the patient by a headpiece, which is made up of an eyeshield with lights and stereo earphones. Outputs increase and decrease in volume and intensity as the patient inhales and exhales.
Methods: 10 patients were treated using the RFb 5000 (RFB Technologies, Boca Raton FL). I measured O2 saturation (SpO2) via a Nellcor N-200 before, during, and after treatment. Patients' dyspnea scores (ATS Grade) were evaluated before and after therapy. The patients were given 12 treatments, each lasting 30 min.
Results: All patients had improvements in both their O2 saturations and their ATS dyspnea scores. Mean (SD) SP O2 was 90 (2) %, increasing to 95 (2) % post-therapy. The average dyspnea score of 4.5 decreased to 2.5. One patient who had been confined to bed for 3 mo with an O2 saturation of 88% (on 4 l/ min nasal cannula) increased her O2 saturation to 96% on 2 l/ min nasal cannula. Since her therapy, she has been ambulatory with portable O2. Conclusion: The intensity of dyspnea is clearly related to conscious perception of the effort involved in breathing. Dyspnea may arise from the inappropriate relationship between the force of contraction of respiratory muscles and the volume of air exchange. It is my belief that this modality realigns this relationship and decreases the work of breathing. Further studies are warranted.
Brief Case Reports on the Therapeutic Influence of Respiration Feedback (RFB) According to LEUNER
The 4-year clinical trial of the RFB extended to a random sample of 200 patients suffering from psycho-neurotic, conversion-neurotic and psychosomatic illnesses, of neuro-vegetative and functional syndromes. The patients came from the poly-clinics of a medical and a psychiatric teaching hospital, and thus constituted selected problem cases. A further group came from a psychiatric practice. The treatment was conducted by Prof. Leuner's study group at the Psychiatric Clinic of Göttingen University.
The following text is an account of the statements made by a selection of successfully treated patients. The treatment consisted of 12 sessions of 30 minutes each, 3 to 4 sessions per week. (Permanent effects are considerably improved after 15 sessions, plus an additional 8 sessions once weekly as a "maintenance dosage"!)
- 28-year-old housewife who had suffered from depressive ill-humor and phobias, declared after the 12th session, "Since I have been undergoing treatment here I don't cry any more. The stomach pains occur less frequently, and my sleep is improved. But the most amazing thing is that I feel more confident. After the 8th session I went shopping again in a supermarket, without my husband. This was the first time in 1 1/2 years. Before then I had always been afraid of the crowds."
- 44-year-old cleaner: she complained of palpitations, states of
anxiety, nausea and general nervousness. The patient had been depressive for one year, since the sudden accidental death of her 20-year-old son, and was brooding over the "shotgun" wedding of her 19-year-old son. The patient grew much calmer in the course of the treatment and said at the end, "I feel like a new woman." She stated that her symptoms had disappeared "completely", and that she could view her son's death with greater detachment now.
- 23-year-old theology student, who had suffered from an essential tremor of both hands for 10 years, summarized the concluding discussions in 3 points: "1) General decrease of nervousness; 2) the impression to be more at one; 3) since I started the relaxation therapy my tremor has diminished considerably."
- 20-year-old assembly-line worker: she was so nervous that, when treatment first began, she was hardly capable of spending the whole time lying down on the couch. She had been suffering from severe back-ache and insomnia for 10 years. On completion of the therapy she stated, "Today I would have been able to lie still for much longer; at the beginning I used to be glad when I could get up after half an hour. My insomnia has disappeared, and I can go to sleep easily now. The back-ache occurs less frequently, and no longer every day; the pain used to last for days, now it is of short duration and no longer so severe. I have consulted many doctors, and now something like this has helped me. I can hardly believe it, but it is true."