Richard N. Gevirtz, PhD

Traditionally, biofeedback was considered to be a stress management technique that targeted sympathetic nervous system (SNS) overdrive with an adrenal medullary system backup. Recent advances in autonomic physiology, however, have clarified that except in extreme situations, the SNS is not the key factor in day-to-day stress. Rather, the parasympathetic branch of the autonomic nervous system appears to be a more likely candidate for mediating routine stress because, unlike the SNS, which has slow-acting neurotransmitters (ie, catecholamines), the parasympathetic nervous system has the fast-acting transmitter acetylcholine.

VAGAL WITHDRAWAL: AN ALTERNATIVE TO SYMPATHETIC ACTIVATION

Porges¹ first proposed the concept of vagal withdrawal as an indicator of stress and stress vulnerability; this contrasts with the idea that the stress response is a consequence of sympathetic activation and the hypothalamic-pituitary-adrenal axis response. In the vagal withdrawal model, the response to stress is stabilization of the sympathetic system followed by termination of parasympathetic activity, manifested as cardiac acceleration.

Respiratory sinus arrhythmia (RSA), or the variability in heart rate as it synchronizes with breathing, is considered an index of parasympathetic tone. In the laboratory, slow atropine infusion produces a transient paradoxical vagomimetic effect characterized by an initial increase in RSA, followed by a flattening and then a rise in the heart rate.² This phenomenon has been measured in people during times of routine stress, such as when worrying about being late for an appointment. In such individuals, biofeedback training can result in recovery of normal RSA shortly after an episode of anxiety.

Historically, the focus of biofeedback was to cultivate low arousal, presumably reducing SNS activity, through the use of finger temperature, skin conductance training, and profound muscle relaxation. More sophisticated ways to look at both branches of the autonomic nervous system have since emerged that allow for sampling of the beat-by-beat changes in heart rate.

HEART RATE VARIABILITY BIOFEEDBACK

The concept of modifying the respiration rate (paced breathing) originated some 2,500 years ago as a component of meditation. It is being revisited today in the form of heart rate variability (HRV) biofeedback training, which is being used as a stress-management tool and a method to correct disorders in which autonomic regulation is thought to be important. HRV biofeedback involves training to increase the amplitude of HRV rhythms and thus improve autonomic homeostasis.

Normal HRV has a pattern of overlapping oscillatory frequency components, including:

• a high-frequency rhythm, 0.15 to 0.4 Hz, which is the RSA;
• a low-frequency rhythm, 0.05 to 0.15 Hz, associated with blood pressure oscillations; and
• a very-low-frequency rhythm, 0.005 to 0.05 Hz, which may regulate vascular tone and body temperature.

The goal of HRV biofeedback is to achieve respiratory rates at which resonance occurs between cardiac rhythms associated with respiration (RSA, or high-frequency oscillations) and those caused by baroreflex activity (low-frequency oscillations).

Spectral analysis has demonstrated that nearly all of the activity with HRV biofeedback occurs at a low-frequency band. The reason is that activity in the low-frequency band is related more to baroreflex activity than to HRV compared with other ranges of frequency. Breathing rates that correspond to baroreflex effects, called resonance frequency breathing, represent resonance in the cardiovascular system. Several devices are available whose mechanisms are based on the concept of achieving resonance frequency breathing. One such device is a slow-breathing monitor (Resp-e-rate) that has been approved by the US Food and Drug Administration for the adjunctive treatment of hypertension.

Biofeedback has demonstrated success in several clinical trials targeting populations with autonomically mediated disorders. Del Pozo et al³ conducted a randomized study of HRV biofeedback in patients with coronary artery disease. Patients in the active intervention group underwent HRV biofeedback training that included breathing practice at home for 20 minutes per day. The standard deviation of normal-to-normal QRS complexes (SDNN), which is the primary measure used to quantify a change in HRV, improved from a mean of 28.0 msec to 42.0 msec after 18 weeks in the treatment group, and declined from a mean of 33.0 msec to 30.7 msec in the controls (Figure).

Improved HRV may suggest an improved risk status: Kleiger et al⁴ found that the relative risk of mortality was 5.3 times greater for people with SDNN of less than 50 msec compared with those whose SDNN was greater than 100 msec. In Del Pozo’s study, eight of 30 patients in the intervention group achieved an SDNN of greater than 50 msec (vs 0 at pretreatment) compared with three of 31 controls (vs two at pretreatment).³ As an additional benefit of HRV biofeedback, patients in the intervention group who entered the study with hypertension all became normotensive.

In a meta-analysis, van Dixhoorn and White⁵ found fewer cardiac events, fewer episodes of angina, and less occurrence of arrhythmia and exercise-induced ischemia from intensive supervised relaxation therapy in patients with ischemic heart disease. Improvements in scales of depression and anxiety were also observed with relaxation therapy.

Other studies have shown biofeedback to have beneficial effects based on the Posttraumatic Stress Disorder Checklist, the Hamilton Depression Rating Scale, and, in patients with mild to moderate heartfailure, the 6-minute walk test.^6–8

The proposed mechanism for the beneficial effects of biofeedback found in clinical trials is improvement in baroreflex function, producing greater reflex efficiency and improved modulation of autonomic activity.

CONCLUSION

A shift in emphasis to vagal withdrawal has led to new forms of biofeedback that probably potentiate many of the same mechanisms thought to be present in Eastern practices such as yoga and tai chi. Results from small-scale trials have been promising for HRV biofeedback as a means of modifying responses to stress and promoting homeostatic processes that reduce the intensity of symptoms and improve surrogate markers associated with a number of disorders.

Traditionally, biofeedback was considered to be a stress management technique that targeted sympathetic nervous system (SNS) overdrive with an adrenal medullary system backup. Recent advances in autonomic physiology, however, have clarified that except in extreme situations, the SNS is not the key factor in day-to-day stress. Rather, the parasympathetic branch of the autonomic nervous system appears to be a more likely candidate for mediating routine stress because, unlike the SNS, which has slow-acting neurotransmitters (ie, catecholamines), the parasympathetic nervous system has the fast-acting transmitter acetylcholine.

VAGAL WITHDRAWAL: AN ALTERNATIVE TO SYMPATHETIC ACTIVATION

Porges¹ first proposed the concept of vagal withdrawal as an indicator of stress and stress vulnerability; this contrasts with the idea that the stress response is a consequence of sympathetic activation and the hypothalamic-pituitary-adrenal axis response. In the vagal withdrawal model, the response to stress is stabilization of the sympathetic system followed by termination of parasympathetic activity, manifested as cardiac acceleration.

Respiratory sinus arrhythmia (RSA), or the variability in heart rate as it synchronizes with breathing, is considered an index of parasympathetic tone. In the laboratory, slow atropine infusion produces a transient paradoxical vagomimetic effect characterized by an initial increase in RSA, followed by a flattening and then a rise in the heart rate.² This phenomenon has been measured in people during times of routine stress, such as when worrying about being late for an appointment. In such individuals, biofeedback training can result in recovery of normal RSA shortly after an episode of anxiety.

Historically, the focus of biofeedback was to cultivate low arousal, presumably reducing SNS activity, through the use of finger temperature, skin conductance training, and profound muscle relaxation. More sophisticated ways to look at both branches of the autonomic nervous system have since emerged that allow for sampling of the beat-by-beat changes in heart rate.

HEART RATE VARIABILITY BIOFEEDBACK

The concept of modifying the respiration rate (paced breathing) originated some 2,500 years ago as a component of meditation. It is being revisited today in the form of heart rate variability (HRV) biofeedback training, which is being used as a stress-management tool and a method to correct disorders in which autonomic regulation is thought to be important. HRV biofeedback involves training to increase the amplitude of HRV rhythms and thus improve autonomic homeostasis.

Normal HRV has a pattern of overlapping oscillatory frequency components, including:

• a high-frequency rhythm, 0.15 to 0.4 Hz, which is the RSA;
• a low-frequency rhythm, 0.05 to 0.15 Hz, associated with blood pressure oscillations; and
• a very-low-frequency rhythm, 0.005 to 0.05 Hz, which may regulate vascular tone and body temperature.

The goal of HRV biofeedback is to achieve respiratory rates at which resonance occurs between cardiac rhythms associated with respiration (RSA, or high-frequency oscillations) and those caused by baroreflex activity (low-frequency oscillations).

Spectral analysis has demonstrated that nearly all of the activity with HRV biofeedback occurs at a low-frequency band. The reason is that activity in the low-frequency band is related more to baroreflex activity than to HRV compared with other ranges of frequency. Breathing rates that correspond to baroreflex effects, called resonance frequency breathing, represent resonance in the cardiovascular system. Several devices are available whose mechanisms are based on the concept of achieving resonance frequency breathing. One such device is a slow-breathing monitor (Resp-e-rate) that has been approved by the US Food and Drug Administration for the adjunctive treatment of hypertension.

Biofeedback has demonstrated success in several clinical trials targeting populations with autonomically mediated disorders. Del Pozo et al³ conducted a randomized study of HRV biofeedback in patients with coronary artery disease. Patients in the active intervention group underwent HRV biofeedback training that included breathing practice at home for 20 minutes per day. The standard deviation of normal-to-normal QRS complexes (SDNN), which is the primary measure used to quantify a change in HRV, improved from a mean of 28.0 msec to 42.0 msec after 18 weeks in the treatment group, and declined from a mean of 33.0 msec to 30.7 msec in the controls (Figure).

Improved HRV may suggest an improved risk status: Kleiger et al⁴ found that the relative risk of mortality was 5.3 times greater for people with SDNN of less than 50 msec compared with those whose SDNN was greater than 100 msec. In Del Pozo’s study, eight of 30 patients in the intervention group achieved an SDNN of greater than 50 msec (vs 0 at pretreatment) compared with three of 31 controls (vs two at pretreatment).³ As an additional benefit of HRV biofeedback, patients in the intervention group who entered the study with hypertension all became normotensive.

In a meta-analysis, van Dixhoorn and White⁵ found fewer cardiac events, fewer episodes of angina, and less occurrence of arrhythmia and exercise-induced ischemia from intensive supervised relaxation therapy in patients with ischemic heart disease. Improvements in scales of depression and anxiety were also observed with relaxation therapy.

Other studies have shown biofeedback to have beneficial effects based on the Posttraumatic Stress Disorder Checklist, the Hamilton Depression Rating Scale, and, in patients with mild to moderate heartfailure, the 6-minute walk test.^6–8

The proposed mechanism for the beneficial effects of biofeedback found in clinical trials is improvement in baroreflex function, producing greater reflex efficiency and improved modulation of autonomic activity.

CONCLUSION

A shift in emphasis to vagal withdrawal has led to new forms of biofeedback that probably potentiate many of the same mechanisms thought to be present in Eastern practices such as yoga and tai chi. Results from small-scale trials have been promising for HRV biofeedback as a means of modifying responses to stress and promoting homeostatic processes that reduce the intensity of symptoms and improve surrogate markers associated with a number of disorders.

Traditionally, biofeedback was considered to be a stress management technique that targeted sympathetic nervous system (SNS) overdrive with an adrenal medullary system backup. Recent advances in autonomic physiology, however, have clarified that except in extreme situations, the SNS is not the key factor in day-to-day stress. Rather, the parasympathetic branch of the autonomic nervous system appears to be a more likely candidate for mediating routine stress because, unlike the SNS, which has slow-acting neurotransmitters (ie, catecholamines), the parasympathetic nervous system has the fast-acting transmitter acetylcholine.

VAGAL WITHDRAWAL: AN ALTERNATIVE TO SYMPATHETIC ACTIVATION

Porges¹ first proposed the concept of vagal withdrawal as an indicator of stress and stress vulnerability; this contrasts with the idea that the stress response is a consequence of sympathetic activation and the hypothalamic-pituitary-adrenal axis response. In the vagal withdrawal model, the response to stress is stabilization of the sympathetic system followed by termination of parasympathetic activity, manifested as cardiac acceleration.

Respiratory sinus arrhythmia (RSA), or the variability in heart rate as it synchronizes with breathing, is considered an index of parasympathetic tone. In the laboratory, slow atropine infusion produces a transient paradoxical vagomimetic effect characterized by an initial increase in RSA, followed by a flattening and then a rise in the heart rate.² This phenomenon has been measured in people during times of routine stress, such as when worrying about being late for an appointment. In such individuals, biofeedback training can result in recovery of normal RSA shortly after an episode of anxiety.

Historically, the focus of biofeedback was to cultivate low arousal, presumably reducing SNS activity, through the use of finger temperature, skin conductance training, and profound muscle relaxation. More sophisticated ways to look at both branches of the autonomic nervous system have since emerged that allow for sampling of the beat-by-beat changes in heart rate.

HEART RATE VARIABILITY BIOFEEDBACK

The concept of modifying the respiration rate (paced breathing) originated some 2,500 years ago as a component of meditation. It is being revisited today in the form of heart rate variability (HRV) biofeedback training, which is being used as a stress-management tool and a method to correct disorders in which autonomic regulation is thought to be important. HRV biofeedback involves training to increase the amplitude of HRV rhythms and thus improve autonomic homeostasis.

Normal HRV has a pattern of overlapping oscillatory frequency components, including:

• a high-frequency rhythm, 0.15 to 0.4 Hz, which is the RSA;
• a low-frequency rhythm, 0.05 to 0.15 Hz, associated with blood pressure oscillations; and
• a very-low-frequency rhythm, 0.005 to 0.05 Hz, which may regulate vascular tone and body temperature.

The goal of HRV biofeedback is to achieve respiratory rates at which resonance occurs between cardiac rhythms associated with respiration (RSA, or high-frequency oscillations) and those caused by baroreflex activity (low-frequency oscillations).

Spectral analysis has demonstrated that nearly all of the activity with HRV biofeedback occurs at a low-frequency band. The reason is that activity in the low-frequency band is related more to baroreflex activity than to HRV compared with other ranges of frequency. Breathing rates that correspond to baroreflex effects, called resonance frequency breathing, represent resonance in the cardiovascular system. Several devices are available whose mechanisms are based on the concept of achieving resonance frequency breathing. One such device is a slow-breathing monitor (Resp-e-rate) that has been approved by the US Food and Drug Administration for the adjunctive treatment of hypertension.

Biofeedback has demonstrated success in several clinical trials targeting populations with autonomically mediated disorders. Del Pozo et al³ conducted a randomized study of HRV biofeedback in patients with coronary artery disease. Patients in the active intervention group underwent HRV biofeedback training that included breathing practice at home for 20 minutes per day. The standard deviation of normal-to-normal QRS complexes (SDNN), which is the primary measure used to quantify a change in HRV, improved from a mean of 28.0 msec to 42.0 msec after 18 weeks in the treatment group, and declined from a mean of 33.0 msec to 30.7 msec in the controls (Figure).

Improved HRV may suggest an improved risk status: Kleiger et al⁴ found that the relative risk of mortality was 5.3 times greater for people with SDNN of less than 50 msec compared with those whose SDNN was greater than 100 msec. In Del Pozo’s study, eight of 30 patients in the intervention group achieved an SDNN of greater than 50 msec (vs 0 at pretreatment) compared with three of 31 controls (vs two at pretreatment).³ As an additional benefit of HRV biofeedback, patients in the intervention group who entered the study with hypertension all became normotensive.

In a meta-analysis, van Dixhoorn and White⁵ found fewer cardiac events, fewer episodes of angina, and less occurrence of arrhythmia and exercise-induced ischemia from intensive supervised relaxation therapy in patients with ischemic heart disease. Improvements in scales of depression and anxiety were also observed with relaxation therapy.

Other studies have shown biofeedback to have beneficial effects based on the Posttraumatic Stress Disorder Checklist, the Hamilton Depression Rating Scale, and, in patients with mild to moderate heartfailure, the 6-minute walk test.^6–8

The proposed mechanism for the beneficial effects of biofeedback found in clinical trials is improvement in baroreflex function, producing greater reflex efficiency and improved modulation of autonomic activity.

CONCLUSION

A shift in emphasis to vagal withdrawal has led to new forms of biofeedback that probably potentiate many of the same mechanisms thought to be present in Eastern practices such as yoga and tai chi. Results from small-scale trials have been promising for HRV biofeedback as a means of modifying responses to stress and promoting homeostatic processes that reduce the intensity of symptoms and improve surrogate markers associated with a number of disorders.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.