by Barry Keate
I frequently recommend biofeedback to people with tinnitus. I have studied the various effects of biofeedback and wrote an article on biofeedback and tinnitus.
Recently, I decided to undergo several months of biofeedback training myself. I wanted to go through the training in order to better understand it. Since I recommend it, I thought I should have a more in-depth knowledge of the process. I also was interested to see if it would help lower my hypertension and reduce my tinnitus. What I learned was surprising and quite powerful. I went far beyond my previous understanding of the therapy. This is the story of my experience.
After some investigation, I found that most practitioners are Ph.D. Clinical Psychologists. I called the University of Utah Department of Psychology and they referred me to Aharon Shulimson, Ph.D. who runs the Attention Disorders Clinic in a center not far from my home in Salt Lake City. Biofeedback and Neurofeedback are commonly used to treat Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD). Together, these are commonly referred to as AD/HD Disorder.
Dr. Shulimson is a wonderful person, warm and witty. He is extremely knowledgeable in this field and I would recommend him to anyone who is local to the area and wishes to pursue this therapy.There are biofeedback specialists in most major cities in the US.
Our first visit was spent discussing an overview of biofeedback and neurofeedback and getting to know each other. The office training is designed to teach the patient techniques to be used at home, where the majority of the therapy is practiced. It needs to be practiced on a daily basis, preferably several times a day, to become fully effective. It is necessary to become very involved in it to achieve good success. Fortunately, it is very relaxing and enjoyable to practice and results can be seen fairly quickly.
Biofeedback is used to cultivate a state of low sympathetic nervous system arousal. The sympathetic nervous system mobilizes the body’s response to stress and initiates the fight-or-flight response. By reducing the sympathetic nervous system response, the patient can achieve a deep sense of calm and relaxation. This has beneficial effects on many conditions, including tinnitus.
Neurofeedback is used to train the brain to reorient and rewire some of its basic neuronal connections and is much more involved than biofeedback. This has many applications in AD/HD disorder and is also helpful for tinnitus.
Typically, biofeedback takes about 15 visits to become adept at the basics. It can then be practiced long-term at home with only occasional visits to the practitioner. Neurofeedback takes up to 40 visits to master the basics.
Dr. Shulimson charges $120.00 per hour-long session for biofeedback training. Medicare will typically pay 80% of this. Many private insurance companies also cover biofeedback but its up to the individual to make sure their insurance will cover it. Medicare and most private insurance companies do not cover neurofeedback.
Biofeedback Modalities The first two sessions were relegated to a discussion and practice of breathing technique. This is a fundamental concept and the basis for everything that follows.
Baroreceptors are mechanical sensors located in blood vessels. They send signals to the central nervous system (CNS) to increase or decrease blood vessel resistance and cardiac output based on current blood pressure. They help regulate blood pressure in the short term.
Baroreceptors normally send signals to the CNS every 10 seconds, or 6 cycles per minute. Some people have slightly different rates but about 90% of people are attuned to this frequency.
The aim of the breathing technique is to regulate breathing to the same cycle as the baroreceptor signals. In my case, this meant I breathed in through my nose for 5 seconds then out through pursed lips for 5 seconds. The result is lowered sympathetic nervous system response (stress), reduced blood pressure and increased cardiac output.
I was instructed to practice this at home for 5 minutes, three times daily. It is very important to use a stopwatch or other timing device to keep the regularity and to keep the brain free of thoughts and concentrate on the breathing. Thoughts will pop up but I was instructed not to dwell on them or think them through but to let them go. This is very much like meditation techniques I practiced when I was younger but then I didn’t have the scientific understanding of why it was important.
Heart Rate Variability is closely tied to this breathing regimen. Our hearts do not beat at a regular rate but speed up when we inhale and slow down when we exhale. Greater variability indicates better heart health. A young athlete may have a variation of 20-30 beats per minute between fastest and slowest. As we age, the variability decreases. My beginning heart rate variability was 9 beats per minute, which was described as pretty normal for 66 years old. Practicing the breathing technique will increase heart rate variability and increase cardiac health.
The instrumentation used interested me very much. A typical biofeedback device uses a laptop with biofeedback software installed. There is a transducer box that accepts inputs from different types of electrical contacts that measure heart rate, muscle tension, skin temperature, conductivity and so on. The transducer feeds into the computer. For measuring heart rate, electrical sensors were taped to my wrists.
Biofeedback instrumentation is quite expensive and there is a lot of knowledge required to operate one of these so it’s not typically something a person would be able to do at home.
The program for breathing and heart rate variability showed several functions at once. Moving across the screen was a waveform with a cycle of 6 times per minute. This allowed me to calibrate my breathing with the baroreceptors. Superimposed on this was heart rate, which showed it speeding up when inhaling and slowing when exhaling. This showed the variability between high and low heart rate.
Also on the screen was a graph of three heart rhythms in different colors. The high frequency rhythm is associated with normal breathing, which is shallow and fast, and was in red. The low frequency is associated with the slow breathing I was practicing and was in green. A third, very low frequency, is associated with sympathetic nerve increase, or stress, and was in blue.
Before the breathing, the red (shallow and fast) graph was the highest. As my breathing slowed and deepened, the red diminished and the green (slow breathing) began to predominate. At one point Dr. Shulimson asked me to count backward from 1,000 in 7’s. I tensed somewhat as this daunting thought troubled me. At that moment, the blue (stressful) graph shot up. It was explained that as I practiced breathing and freed my mind, the blue graph would show the effects of lowered stress.
So the information on this one screen showed my breathing pattern, my heart rate variability and my stress level. I would learn to consciously reduce my stress level by breathing and keeping my mind clear and the results were instantly observable.
Progressive Muscle Relaxation teaches us to deeply relax the muscles of the body. Dr. Shulimson gave me a CD of an audio relaxation program he had recorded several years earlier. It was designed to lead me through a series of muscle relaxation exercises. He began by telling me to tense my right hand as hard as possible without pain and hold it for a few seconds. After relaxing it, I would tense it 50% as hard, then 25%, and finally tense it just enough to notice.
I then did the same exercise with my right arm, followed by left hand and left arm. Then raised shoulder muscles followed by forehead, feet and legs.
This exercise has to be gone through in a thorough and patient way. It doesn’t pay to rush it and the program takes 15 minutes to finish.
I was asked to practice breathing exercises for 5 minutes, three times daily and muscle relaxation for 15 minutes, once daily. This amounted to about a half hour of time devoted to these exercises daily.
Electromyography (EMG) feedback measures electrical output of the muscles in microvolts. Voltages range from 20 to 50 microvolts. The lower the voltage, the more relaxed the muscle. Electrodes are placed on muscles that may be causing problems. By watching the feedback rise and fall, and simultaneously practicing breathing exercises, I was able to lower the output and reduce tension in the muscles being monitored.
Attached to the masseter muscle, which is responsible for chewing, EMG feedback can be helpful in treating bruxism and TMJ. Any muscle that causes problems can be treated with EMG. It is helpful for lower back pain and other muscles. It is also helpful with tension headache, hypertension and tinnitus.
Peripheral Skin Temperature biofeedback is one of the most versatile modalities and the easiest to perform at home without expensive equipment. As a person breathes according to the baroreceptor cycle and keeps a quiet mind, concentrating on the breathing, cardiac output increases and skin temperature also increases. The optimal skin temperature is 95 degrees F. When this is reached, cardiac output is at its optimal. Skin temperature is normally monitored on the inside of the finger pads.
Dr. Shulimson told the story of some researchers who took biofeedback equipment to Tibet in the 1960’s to work with Tibetan Buddhist monks. When the monks were meditating, they were breathing 3-4 breaths per minute and were radiating tremendous amounts of heat from their hands. Buddhist monks were forerunners of modern biofeedback.
I purchased an inexpensive stress thermometer from Amazon.com. I also bought paper tape from a pharmacy. Paper tape is necessary because plastic tape will hold heat in and give a higher reading. My breathing exercises are always accompanied with the skin temperature reading. It is gratifying to see that I can raise my skin temperature by 2-4 degrees depending on my mood and degree of stress or calm.
Peripheral skin temperature can be helpful for all conditions that are treated by biofeedback. However, it is also very effective for migraine headache. The thinking is that by diverting blood away from the head and into the hands before a migraine gets going will help reduce the intensity or even stop it.
Galvanic Skin Response measures changes in skin conductivity caused by sweating. If a person is anxious or afraid, he will sweat more and skin conductivity increases.
Although this isn’t used much anymore, it can be helpful for treating asthma, stuttering and desensitization of phobias.
Quantitative Electroencephalography (QEEG) is a method of recording brain waves and determining how an individual brain functions. It is commonly referred to as brain mapping and is used in many medical professions including Neurofeedback. It shows a color portrait of electrical activity in the brain that can be used for diagnosing conditions such as AD/HD disorder. It can also be used to localize any hyperactivity, such as that found with tinnitus.
The procedure can take up to an hour. A skull-cap with 19 to 100 electrodes is placed over the head. The electrodes are connected to a wire harness that connects with a computer. Preparation is close to 30 minutes, making sure every electrode has good electrical contact with the skin. A goopy, electrically conductive gel is inserted into the cap and over the electrodes to achieve contact.
I was then asked to focus on a point on the far wall and erase thoughts from my brain. We did this for several sessions of a few minutes each then repeated everything with my eyes closed. Dr, Shulimson said we only needed a few seconds of clear data to get the information but stress, anxious thoughts, almost anything could scramble the electrical signals.
When I returned the following week for the follow-up I was in for a big surprise. I was told that my brain is significantly out of whack compared to other people. The concern was with the beta waves, which are the waves generated by alert, actively engaged thinking. The problem was that my beta waves would not slow down, even with my eyes closed. A normal person has slowed beta waves when they close their eyes.
Dr. Shulimson said this is referred to as a busy brain. It just doesn’t want to turn off and can create a host of problems. Potential problems include:
1 – Sleep disturbance, 2 – Anxiety/Worry, 3 – Irritability, 4 – Abuse of central nervous system relaxants such as alcohol and marijuana.
He said this leads to a dramatic increase in stress levels. As we know, stress is a major aggravator of tinnitus. To illustrate, he held out his hand, palm down, at about waist level. He said this is the normal person’s resting stress level. He then held his hand at forehead level and said this is where most people flip out due to too much stress. Lastly, he held his hand at chest level and said this is where my resting stress level is. So I have much less room to maneuver than a normal person when stress levels increase. He said a person with my condition should not even be on speaking terms with caffeine. He also said if he had seen this chart for someone he didn’t know, he would prescribe anti-seizure medications, such as Neurontin.
I asked him if this is why I have such a hard time emptying my mind while meditating and doing the breathing exercises. He said it definitely is. Everyone has a hard time keeping all thoughts at bay but mine just keep tumbling in and are very difficult to control.
This was quite a shock to me and altered the way I see myself. I recognized that I have always seemed to be a stressful person and become overwrought easily if stress becomes too high. This has been a lifelong situation for which I have finally discovered the answer.
I certainly have no intention of taking prescription medications for this. But I do know that GABA is the neurotransmitter that slows electrical activity in the brain and L-Theanine is a precursor to GABA. So, I began taking 200 mg of L-Theanine three times daily.
Today I am totally caffeine free. I had a few days of low-level headache while withdrawing but it wasn’t too bad. I take L-Theanine several times a day. I do breathing exercises at least twice daily and do the progressive muscle relaxation exercise when I can.
Has this helped with my hypertension and tinnitus? I would say definitely yes. My tinnitus has not been very loud for many years and I cannot say the objective loudness has decreased significantly. However, the aggravation factor has declined significantly.
This has been a great experience for me and has changed my life in many important ways. I now know the cause of my high stress level and am able to deal with it in an efficient manner. I am a much calmer person than I have ever been. This has beneficial effects for all aspects of my life, including my relationships with family and other people.