Biofeedback ClinicBiofeedback Clinicfor Functional Abdominal Painfor Functional Abdominal Pain

ProposalProposal

Division of PediatricDivision of Pediatric

Gastroenterology and Nutrition Gastroenterology and Nutrition Children’s Specialists of San Children’s Specialists of San DiegoDiegoUniversity of California San DiegoUniversity of California San Diego

Recurrent Abdominal Pain Recurrent Abdominal Pain (RAP)(RAP)

Most common childhood G.I. Most common childhood G.I. DisorderDisorder

Affects up to 34% of world’s Affects up to 34% of world’s childrenchildren

Three bouts of pain severe enough Three bouts of pain severe enough to disrupt activities in a three to disrupt activities in a three month periodmonth period

No organic causeNo organic cause

Recurrent Abdominal Pain (RAP)

• Leading cause of childhood school Leading cause of childhood school absencesabsences

• Increased medical utilizationIncreased medical utilization

• Family disruptionFamily disruption

• In nearly 50%, the complaints persist over many years of their life-span to adolescence or adulthood.

Why Biofeedback Why Biofeedback treatment?treatment?

Painless/Non-invasive techniquesPainless/Non-invasive techniques

Research shows biofeedback is a Research shows biofeedback is a successful treatment for successful treatment for functional abdominal conditionsfunctional abdominal conditions

Engaging and fun treatment Engaging and fun treatment modality for childrenmodality for children

What is Biofeedback?What is Biofeedback?

Electronic biofeedback instruments Electronic biofeedback instruments connected to sensors on the bodyconnected to sensors on the body

Real-time physiological information Real-time physiological information (feedback) is displayed to patient on (feedback) is displayed to patient on computer monitorcomputer monitor

A certified biofeedback professional A certified biofeedback professional provides instruction and interpretation provides instruction and interpretation

How does biofeedback How does biofeedback treat Functional treat Functional Abdominal Pain?Abdominal Pain? Autonomic nervous system (ANS) Autonomic nervous system (ANS)

imbalance exacerbates abdominal imbalance exacerbates abdominal dysfunction. dysfunction.

ANS feedback (i.e. heart rate, ANS feedback (i.e. heart rate, respiration, skin conductance) educates respiration, skin conductance) educates patients about effects of stress on their patients about effects of stress on their symptoms.symptoms.

The therapist guides the patient through The therapist guides the patient through techniques to balance ANS. techniques to balance ANS.

Home practice assignments reinforce Home practice assignments reinforce techniques for better resultstechniques for better results

Pre/Post Assessment:Pre/Post Assessment:VivoMetrics, Inc. LifeShirt,tmVivoMetrics, Inc. LifeShirt,tm

• 12 hour continuous12 hour continuous Ambulatory Monitoring (Heart Ambulatory Monitoring (Heart rate/Respiration/Personal Diary Entries of rate/Respiration/Personal Diary Entries of Pain/Psychosocial Stress)Pain/Psychosocial Stress)

J&J Engineering, Inc. Biofeedback Equipment

I-330-C2 Plus Clinical System $3,170.00

Example of CurrentlyExample of Currently Running Biofeedback Program #1 Running Biofeedback Program #1

Department of Preventive Medicine Department of Preventive Medicine Biofeedback ProgramBiofeedback Program

In continuous service past 7 years.In continuous service past 7 years.

Little to no advertisingLittle to no advertising

Patients self-referred and/or referred Patients self-referred and/or referred by Kaiser physicians. by Kaiser physicians.

Example of Currently Running Example of Currently Running Biofeedback Program #1:Biofeedback Program #1:

Cost ConsiderationsCost Considerations

Billing= $75 dollars in advance for 50 Billing= $75 dollars in advance for 50 minute session.minute session.

Average number of sessions per patient= 3Average number of sessions per patient= 3

Approximate number of sessions in 2004 = Approximate number of sessions in 2004 = 300300

300 sessions X $75 = $22,500/annually300 sessions X $75 = $22,500/annually

This is with 1 to 2 part time employees.This is with 1 to 2 part time employees.

Example of Currently Example of Currently Running Biofeedback Running Biofeedback

Program #2 Program #2

Kaiser Permanente Kaiser Permanente Pediatric Gastroenterology Biofeedback Pediatric Gastroenterology Biofeedback

ProgramProgram

Program has been in continuous Program has been in continuous service for past 4 yearsservice for past 4 years

Biofeedback sessions held in GI Biofeedback sessions held in GI clinicclinic

Example of Currently Running Example of Currently Running Biofeedback Program #2:Biofeedback Program #2:

Cost ConsiderationsCost Considerations

Billing through Kaiser Permanente InsuranceBilling through Kaiser Permanente Insurance

Average number of sessions per patient= 6Average number of sessions per patient= 6

Program Director: Warren L. Shapiro, M.D.Program Director: Warren L. Shapiro, M.D.

Staff: AIU/CSPP doctoral psychology interns Staff: AIU/CSPP doctoral psychology interns

AIU/CSPP supervisor: Richard Gevirtz, Ph.D.AIU/CSPP supervisor: Richard Gevirtz, Ph.D.

Case Study (Sowder et al., 2004)Case Study (Sowder et al., 2004)From biofeedback program at Kaiser From biofeedback program at Kaiser PermanentePermanente

36 kids with RAP/IBS

Significantly lowered ratings of pain Significantly lowered ratings of pain intensity and frequency post-treatmentintensity and frequency post-treatment

56% pain-free at follow up (3mo, to 2yrs)

AIU Case Study ConclusionsAIU Case Study Conclusions

Effective, non-invasive, and timelyEffective, non-invasive, and timely treatment optiontreatment option

Potential to reduce costs/ further Potential to reduce costs/ further distress (avoiding unnecessary & distress (avoiding unnecessary & uncomfortable GI testing)uncomfortable GI testing)

Findings support autonomic dysfunction Findings support autonomic dysfunction as a precipitating factor in RAP as a precipitating factor in RAP

AIU Case Study (Sowder et al., 2004)AIU Case Study (Sowder et al., 2004)Recently presented in Princeton, NJ at theRecently presented in Princeton, NJ at the

2004 International Society for the 2004 International Society for the Advancement of Respiratory and Psychophysiology Advancement of Respiratory and Psychophysiology

(ISARP) Conference(ISARP) Conference

All DXAll DX ABD ABD PAIN PAIN DX1DX1

ABD ABD PAIN PAIN DX2DX2

ABD ABD PAIN PAIN DX3DX3

PATIENTSPATIENTS 1,8131,813 392392 5959 1818

%% 23%23% 3%3% 1%1%

Children’s Hospital Physician Management Group, Inc.

Gastroenterology New Patients (Outpatient only) in one year: 8-1-03 through 8-31-04

Proposal Proposal Biofeedback Treatment Biofeedback Treatment Center CSSD and UCSDCenter CSSD and UCSD

GI physicians from Children’s and GI physicians from Children’s and community will refer patients community will refer patients

Patients will meet with Patients will meet with Biofeedback therapist in medical Biofeedback therapist in medical setting at Children’s Hospitalsetting at Children’s Hospital

Patients will be seen for all 6-8 Patients will be seen for all 6-8 sessions. sessions.

Proposed CSSD/UCSD Proposed CSSD/UCSD Biofeedback Center Biofeedback Center

ProtocolProtocolPrior to 1Prior to 1stst session session

– Provide instructional DVD with Provide instructional DVD with demo of what to expect in demo of what to expect in biofeedback sessionsbiofeedback sessions

– Collect payment Collect payment ($100/session for all 8 sessions)($100/session for all 8 sessions)

– Complete paperwork (intake, Complete paperwork (intake, demographics, consent)demographics, consent)

Proposed CSSD/UCSD Proposed CSSD/UCSD Biofeedback Center Biofeedback Center Protocol Protocol ContinuedContinued

11stst Session: Session: – Collect paperwork / Answer questionsCollect paperwork / Answer questions– Connect VivoMetrics LifeShirt (wear at Connect VivoMetrics LifeShirt (wear at

least 8 hours)least 8 hours) 22ndnd - 7th Sessions: - 7th Sessions:

– Biofeedback TrainingBiofeedback Training– Cognitive TherapyCognitive Therapy– Home practice assignmentsHome practice assignments

88thth Session: Session: – Connect VivoMetrics LifeShirt (8 hours)Connect VivoMetrics LifeShirt (8 hours)

Typical Home Biofeedback Typical Home Biofeedback Practice RegimenPractice Regimen

Daily Homework Assignments Daily Homework Assignments (Reviewed in weekly sessions)(Reviewed in weekly sessions)– Takes 20 minutes/dayTakes 20 minutes/day– Daily pain/stress diaryDaily pain/stress diary– Psychophysiological self-monitoring Psychophysiological self-monitoring

practice tools:practice tools: Hand temperature biofeedback device Hand temperature biofeedback device

($20) ($20) Paced breathing compact disc ($15)Paced breathing compact disc ($15) Freeze-framer heart rate/breathing Freeze-framer heart rate/breathing

training device (optional)training device (optional)

www.bio-medical.comwww.bio-medical.com & & www.beingart.comwww.beingart.com

Proposed CSSD/UCSD Proposed CSSD/UCSD Biofeedback Center Biofeedback Center Protocol Protocol ContinuedContinued

Staff:Staff:Certified Biofeedback Certified Biofeedback TechnicianTechnician

Clinical Psychologist SupervisorClinical Psychologist Supervisor -(1 day per week)-(1 day per week)

Doctoral Interns Doctoral Interns – Alliant International University (AIU) Alliant International University (AIU)

California School of Professional California School of Professional Psychology (CSPP)Psychology (CSPP)

Biofeedback CenterBiofeedback Center

Other:Other:Use pre-existing secretarial Use pre-existing secretarial staff for receptionstaff for reception

Biofeedback officeBiofeedback officeUse of underutilized, pre-Use of underutilized, pre-existing MOB space under G.I. existing MOB space under G.I. Dept.Dept.

Potential Financial Potential Financial ConsiderationsConsiderations

One time costsOne time costs::

2 Biofeedback clinical systems2 Biofeedback clinical systems $6,000 $6,000

VivoMetrics LifeShirt equipment VivoMetrics LifeShirt equipment $25,000$25,000

$$31,00031,000

Potential Financial Potential Financial ConsiderationsConsiderations

ProfitsProfits– 10% goes to billing dept.10% goes to billing dept.– 10% goes to taxes10% goes to taxes– 50% overhead, equipment, office50% overhead, equipment, office– 30% goes to staff30% goes to staff

Psychologist SupervisorPsychologist Supervisor Certified Biofeedback TechnicianCertified Biofeedback Technician Intern (Stipend)Intern (Stipend)

Future DirectionsFuture Directions

Expand Biofeedback Clinic to Expand Biofeedback Clinic to other locations within San Diego other locations within San Diego County.County.

Open clinics that treat other Open clinics that treat other diagnoses such as migraines, diagnoses such as migraines, chronic pain, fibromyalgia, and chronic pain, fibromyalgia, and other stress related disordersother stress related disorders