JANUARY 9, 2001 MEETING
TOPIC:  “MANAGING HEADACHES WITH BIOFEEDBACK THERAPY”

The East Bay Headache Support Group met on January 9, 2001 in the Aspen I/II Conference Room at John Muir Medical Center.  Seventeen people were in attendance to hear Ellen Place, RN, speak on the topic of biofeedback therapy and its usefulness to headache sufferers.  Dr. Michael Stein and Leslie Davis, co-founders, began the meeting with a history of the support group, explaining that this meeting was a celebration of the fifth anniversary for the organization; and refreshments were served.

Ms. Place has been a biofeedback therapist for more than 20 years.  She has expertise in treating various disorders using biofeedback techniques, and specializes in treating headaches at her office in San Ramon.  She began her presentation by saying that she typically meets with a new headache patient for 6 to 16 sessions.  This time frame is dependent on the length of time the patient has suffered the headaches, and if they are chronic headaches.  She said, “The goal of biofeedback therapy is to teach you something and give you skills, and then to send you on your way.”

To make her point while injecting some humor into the subject, Ms. Place showed a slide of a Peanuts cartoon, where the main character makes the statement, “My body and my brain haven’t spoken to each other in years.”  She explained that when things are not right with our bodies, “First the body whispers, then it talks, then it screams.  And ultimately the body wins.”  Biofeedback therapy teaches a person to learn how to listen to his own body, particularly when it’s at the whispering stage.  A headache is a total physiological shift that results in pain in the head.

Ms. Place stressed that it is important to listen to your body.  A slide giving the definition of biofeedback therapy was shown.  It is:  “Biofeedback is a therapeutic technique which involves the use of instrumentation to monitor and feedback to an individual psycho-physiological body processes, thereby enabling the individual to learn to observe and control these processes.”

Some tools the biofeedback therapist uses are:

·     Electromyography (EMG):  measures and feeds back muscle activity.  This machine monitors electrical activity in a muscle, and makes a noise when the muscle is tensed.  Ms. Place said that she teaches the patient how to turn off the noise by relaxing his muscle.

·     Skin temperature feedback:  measures and feeds back temperature for autonomic nervous system (ANS) control. 

·     Pulse rate.

·     Breathing.

Everything in biofeedback is about mind/body integration—creating a shift basically back to balance.  She said, “We’ll never get rid of stress, but we can get the body in balance, homeostatic.”  Following is a basic list of physical conditions that can be helped with biofeedback therapy: Headaches, Hypertension, Ulcers, Collitis, Chronic Pain, Anxiety, Reynaud's Syndrome, Reynaud’s Syndrome, Insomnia, TMY (temporomandibular joint disease)   

She showed a second cartoon, called “Fighting Invincible Tigers,” where a caveman is being stalked by a tiger.  Seeing the tiger and the danger he’s in, the caveman’s autonomic nervous system is activated.  More than 1,400 changes occur immediately when the man fears for his life.  In caveman times, he was stressed when he saw the tiger, but once he went into his cave and was out of danger he was able to relax.

Ms. Place explained the “bucket” theory:  All day every day we are putting stress chemicals into a bucket, meaning we go through this activation response many times per day, and the stress is cumulative.  She said that we’re all different, but none of us is immune to stress.  She added, “Pain is a stressor.” 

Next Ms. Place showed a slide entitled “External/Internal Stressors,” which is attached.  External stressors include:  Environmental, heredity, life changes, chemical, nutritional.  Internal stressors are:  Anger, worry, frustration, fear, fatigue, illness, injury, depression.

She said that when we activate we go through the “fight or flight” response depicted in the “Fighting Invincible Tigers” cartoon.  Ms. Place illustrated the fight or flight response with a slide showing a drawing of a human brain and a flow chart diagram listing the responses various parts of the body exhibit after perceiving a stressor.  Also attached is a slide entitled “Sympathetic Nervous System” which lists body reactions as chemicals dump into one’s system when a person experiences the fight or flight response.

These include:

·        Pupil size increases (eyes are dilated)

·        Salivation is reduced (dry mouth)

·        Hair stands up

·        Blood pressure increases

·        Heart rate increases

·        Airway size increases

·        Blood vessels constrict (get smaller)

·        Stomach secretions are reduced and the stomach halts the digestion process

·        Anal sphincter tone increases, bringing on constipation

·        Perspiration increases

Ms. Place asked the audience, “How many recognize that your hands are cold when experiencing stress?”  Most in the room raised their hands.  She said that cold hands are a potential precursor to a migraine headache.  They are a little red flag.  She explained that the body’s responses to stress are “whispers,” meaning they are normal.  But we need to learn how to bring the “whispers” back into balance.

Another slide was presented, entitled “Techniques,” which is attached.  Techniques include:

·        Autogenic relaxation

·        Assertiveness

·        Breathing

·        Imagery

·        Cognitive restructuring

·        Progressive relaxation

·        Open focus

·        Meditation

Ms. Place’s three favorite techniques for reducing stress reactions are:

·        Breathing

·        Imagery

·        Cognitive restructuring:  giving the brain more information to work with.

She polled the audience as to how many suffered from migraines, and almost all responded affirmatively.  A slightly smaller group said they have muscle tension headaches, and some said they have a combination of muscle tension and migraine headaches.  She then asked how many notice muscle tension in their necks and shoulders, and almost all responded that they did.

Ideally, the message the brain passes on to the body leads to muscle contraction, which is a healthy thing, Ms. Place explained.  To illustrate, she showed a slide of a gymnast holding a pose and the words:  Message from brain -- Muscle contraction -- Movement and balance.  But when the autonomic nervous system (ANS) is activated, the stress message causes bracing; for example, when a cat sees a dog.

EMG (electromyography) is a tool that biofeedback therapists use to measure and feed back muscle activity.  Ms. Place pointed out highlights of an article written by David R. Hubbard, MD, entitled “Myofascial Trigger Points Show Spontaneous Needle EMG Activity,” from the Department of Neurosciences, University of California, San Diego; and the Pain Research Institute, Rehabilitation Center, Sharp Memorial Hospital, San Diego, dated September 1, 1992.

Ms. Place asked, “What is the trigger point in muscles?”  Then she told the audience to think about receiving a massage, right on the “owie” spot deep within a muscle where we feel pain when pressure is applied.  The trigger point in a muscle is the palpable firmness you can feel when the muscle is tensed.  We can get referred pain when the trigger point is put under pressure.  Ms. Place drew a picture of a muscle bundle, attached, and talked about extrafusal fibers and intrafusal fibers.  She drew an arrow to the trigger point.  The EMG article made the statement, “The traditional teaching that there is no sympathetic innervation of muscle is no longer correct.  The sympathetic nervous system innervates not extrafusal fibers, but intrafusal fibers.”

When we stress a person, chemicals go into the trigger point and cause it to tighten.  The tense feeling from muscles is really being driven by stimuli from the autonomic nervous system (ANS).

How does this tie into biofeedback?  Ms. Place said it was discovered that dramatic results were not achieved from muscle relaxing only, but only when we effected a temperature change (warming), and breathing change.  The goal of skin temperature feedback is to get the hands to a temperature of 92 to 95 degrees Fahrenheit.  In the past, when a patient was diagnosed with muscle pain, insurance companies instructed biofeedback therapists to only use electromyography (EMG).

Ms. Place made the statement, “If we teach you how to relax on the inside, then you’ll relax on the outside.  If you only do outside work, it doesn’t really work.”

Some techniques are massage, movement, ice, heat.  She said if we consistently rub out trigger points, then intrafusal fibers will relax.

Diaphragmatic breathing is another technique used by biofeedback therapists.  It leads to decreased autonomic nervous system activation, increased balance, warming, decreased muscle bracing, decreased SCL/SCR, decreased headaches, and decreased muscle pain.

Ms. Place ended her presentation with the attached slide about rules to follow:  “Rule No. 1 is, don’t sweat the small stuff.  Rule No. 2 is, it’s all small stuff.”  And, “If you can’t fight and you can’t flee, flow.”

Questions and Answers

Q.  A massage therapist in the audience asked Ms. Place if she recommends deep tissue massage.

A.  Yes, if the therapist gently goes deep.  A comment was made about Swedish, or “just feel good” massage.  These are used in Reflexology or Shiatsu.  There are many trigger points in the upper back and neck.

Q.  Dr. Stein, co-founder of the East Bay Headache Support Group and medical advisor, asked Ms. Place if she has tried using biofeedback therapy devices on a patient who has tried the new Botox injections currently being touted as a treatment for headaches.

A.  She replied that she’s found a generalized decrease, but for one patient the Botox injection didn’t make a huge difference.  One patient felt he was helped by the Botox injection and another of her patients was not helped.  A member of the audience said that she tried the Botox injections, but it didn’t make any difference in her headaches.  She added that it was “an expensive little experiment.”

Ms. Placed commented that most motivated biofeedback therapy patients get best results because they practice the techniques they learn.  “It doesn’t work if the patient comes in determined to take 8 Vicodin per day.”

Q.  Is biofeedback therapy covered by most insurance companies?

A.  Ms. Place said she can’t see a patient without a referral from a doctor (MD, PhD, or DDS).  She added that every insurance company is different and individual policies are different also.  Check with your health insurance provider to see if there are any particular criteria that must be met.  For instance, if you have Blue Cross, biofeedback therapy is only covered if it is performed by an MD or a PhD.  Ms. Place stressed that it’s important to make certain you work with a person who is certified to do biofeedback therapy.  She said that legally anyone can hang up a shingle as a biofeedback therapist.

Ms. Place said that the Kaiser Permanente HMO covers up to 10 visits with her, but an audience member added that this is only if your headaches have been diagnosed as migraines, not if they are tension headaches.  Ms. Place responded that it depends on your doctor now—they are relaxing their rules.  She said the insurance thing is complex.

As a final comment, Dr. Stein said, “At least with biofeedback therapy you won’t have an allergic reaction, and there are no side effects.  You won’t gain weight, or lose your hair,” referring to some of the side effects that one can experience when taking medications to control headaches.

The intention of the East Bay Headache Support Group is to provide information and resources.  It does not provide medical advice, which should be obtained directly from a physician.