Clinical and educational efficacy of a university-based .../67531/metadc... · biofeedback therapy...

CLINICAL AND EDUCATIONAL EFFICACY OF A UNIVERSITY-BASED

BIOFEEDBACK THERAPY CLINIC

Shwu-Huey Shiau, M.S., M.Ed.

Dissertation Prepared for the Degree of

DOCTOR OF PHILOSOPHY

UNIVERSUTY OF NORTH TEXAS

December 2003

APPROVED:

Cynthia K. Chandler, Major Professor Carolyn W. Kern, Committee Member Douglas Norton, Committee Member Jan Holden, Program Coordinator for Counseling Michael Altekruse, Chair of the Department of

Counseling, Development, and Higher Education

M. Jean Keller, Dean of the College of Education Sandra L. Terrell, Interim Dean of the Robert B. Toulouse School of Graduate Studies

Shiau, Shwu-Huey, Clinical and educational efficacy of a university-based

biofeedback therapy clinic. Doctor of Philosophy (Counseling), December 2003, 125

pp., 26 tables, 13 figures, references, 59 titles.

This study is a qualitative analysis and a quantitative analysis of all peripheral

biofeedback client data files of the University of North Texas Biofeedback Research and

Training Laboratory since its establishment in 1991 and through the year of 2002. The

purpose of this study is to evaluate the clinical and educational efficacy of the BRTL.

Clients’ electromyography and temperature measures, self-report of homework

relaxation exercises and progress, and the pre- and post-Stress Signal Checklist were

reviewed and analyzed.

In regard to clinical efficacy, results indicate statistically significant changes in

both temperature training and muscle tension training as a whole group. When divided

into subtypes based on the clients’ primary presenting problem, findings indicate

statistical significance in chronic pain, tension headache, and temporomandibular jaw

pain on temperature training, and show statistical significance in chronic pain, tension

headache, hypertension, migraine headache, stress, and temporomandibular jaw pain

on muscle tension training.

When analyzing the Stress Signal Checklist, only 31.5% of clients with 4 or more

treatment sessions had complete information on both pre- and post-Stress Signal

Checklist. For these 31.5%, 87.5% reported symptoms decreased. When reviewing the

clients' self-reported progress in therapist's session notes, there is no procedure for

computing a treatment success-to-failure ratio due to the inconsistency of therapists in

recording clients' statements.

This study also identifies three basic biofeedback learning curves that show how

people learn self-regulation skills in biofeedback therapy: 1) steady state and trainable

(low variability), 2) phasic state and trainable (high variability), and 3) phasic state and

low trainable (high variability).

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Copyright 2003

by

Shwu-Huey Shiau

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ACKNOWLEDGEMENTS

Profound, heartfelt thanks to Dr. Cynthia Chandler for her confidence in me, her

ongoing support, guidance, and encouragement, and her commitment to my

professional development.

I am very grateful for the support from my committee, Dr. Carolyn Kern and Dr.

Douglas Norton.

I thank Dr. Richard Herrington for his consultation on the statistical techniques

and procedures for this research.

Finally, special thanks and deep appreciation to I-Hui, whose love, friendship,

and support sustain me throughout the whole process.

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TABLE OF CONTENTS Page

ACKNOWLEDGMENTS iii

LIST OF TABLES v

LIST OF FIGURES vii

CHAPTER I

Introduction 1 Statement of Problem 3 Review of Literature 5

CHAPTER II

Purpose of Study 14 Research Questions 14 Research Assumptions 15 Methods and Procedures 15

Data Analysis 17 Limitation 19

CHAPTER III

Results and Discussion 21 Educational Efficacy of the Biofeedback Research and Training Laboratory 21 Clinical Efficacy of the Biofeedback Research and Training Laboratory 30 Discussion 73

APPENDIX A 82

APPENDIX B 87

APPENDIX C 111

REFERENCES 118

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LIST OF TABLES

Table Page

1. Sample recorded client’s statements of reported symptom decrease in other than the primary presenting problem 46 2.1 Frequency and percent of clients with 3 or less treatment session

based on primary presenting problem 52 2.2 Frequency and percent of clients with 3 or less treatment sessions

based on year 52 3.1 Frequency and percent of clients with 4 or more treatment sessions

based on year 53 3.2 Frequency and percent of clients with 4 or more treatment sessions

based on gender 53 3.3 Frequency and percent of clients with 4 or more treatment sessions

based on primary presenting problem 54 4.1 Mean, standard deviation, and standard error mean for 6 points

temperature slope 57 4.2 One-sample t-test for 6 points temperature slope as a whole group 57 4.3 Mean, standard deviation, and standard error mean for 6 points temperature slope sorted by primary presenting problem 58 4.4 One-sample t-test for 6 points temperature slope sorted by primary

presenting problem 59 4.5 Mean, standard deviation, and standard error mean for 6 points temperature slope sorted by gender 60 4.6 One-sample t-test for 6 points temperature slope sorted by gender 60 4.7 Mean, standard deviation, and standard error mean for 6 points temperature slope sorted by age 61 4.8 One-sample t-test for 6 points temperature slope sorted by age 61

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Table Page 4.9 Mean, standard deviation, and standard error mean for 6 points temperature slope sorted by number of sessions 62 4.10 One sample t-test for 6 points temperature slope sorted by number of sessions 63 5.1 Mean, standard deviation, and standard error mean for 6 points EMG slope 64 5.2 One-sample t-test for 6 points EMG slope as a whole group 64 5.3 Mean, standard deviation, and standard error mean for 6 points

EMG slope sorted by primary presenting problem 65 5.4 One-sample t-test for 6 points EMG slope sorted by primary

presenting problem 66 5.5 Mean, standard deviation, and standard error mean for 6 points EMG slope sorted by gender 67 5.6 One-sample t-test for 6 points EMG slope sorted by gender 67 5.7 Mean, standard deviation, and standard error mean for 6 points EMG slope sorted by age 68 5.8 One-sample t-test for 6 points EMG slope sorted by age 68 5.9 Mean, standard deviation, and standard error mean for 6 points EMG slope sorted by number of sessions 69 5.10 One sample t-test for 6 points EMG slope sorted by number of sessions 70

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LIST OF FIGURES

Figure Page

1. Biofeedback Research and Training Laboratory Responsibility Hierarchy 29 2.1 Number of clients treated based on year and gender 31 2.2 Number of clients treated based on ethnicity 31 2.3 Number of clients treated based on age 32 2.4 Number of clients treated based on primary presenting problem 33 2.5 Number of neurofeedback therapy clients treated based on year 34 3.1 Number of clients who reported primary presenting problem decreased 36 3.2 Number of clients who reported other types of progress 44 3.3 Number of clients who reported increased awareness 49 4.1 Number of clients with 4 or more treatment sessions based on age 55 4.2 Number of clients with 4 or more treatment sessions based on number

of sessions 55 5.1 Three basic biofeedback learning curves for training temperature increases 72 5.2 Three basic biofeedback learning curves for training muscle tension

reductions 73

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CHAPTER 1

Introduction

Biofeedback is the use of electronic equipment to teach a person physical

awareness, to increase a feeling of relaxation, to self-regulate the body’s systems, and

furthermore to reduce unwanted stress-related symptoms (Schwartz, 1995). A ten-year

review of literature suggests that biofeedback therapy is an effective treatment for a

number of psychophysiological concerns that include pediatric headache (Hermann &

Blanchard, 1997; Holden, Deichmann & Levy, 1999; Arndorfer & Allen, 2000), tension

headache (Arena, Bruno, Hannah, & Meador, 1995; Blanchard, Taylor, & Dentinger,

1992), essential hypertension (McGrady, 1994, Jurek, Higgins, & McGrady, 1992),

fecal/urinary incontinence (Tries & Brubaker, 1996; McDowell, Engberg, Sereika,

Donovan, Jubeck, Weber, & Engberg, 1999), irritable bowel syndrome (Blanchard,

Greene, Scjarff, & Schwarz-McMorris, 1993; Blanchard, Schwarz, Suls, Gerardi, Scharff,

Greene, Taylor, Berremen, & Malamood, 1992; Schwarz & Blanchard, 1991), diabetes

(McGrady, Graham, & Bailey, 1996; Sauders, Cox, Teates, & Pohl, 1994; Needham &

Eldridge, 1993), asthma (Kern-Buell, McGrady, Cornran, & Nelson, 2000; Peper &

Tibbetts, 1992), temporomandibular disorder (TMD) (Flor & Birbaumer, 1993; Mishra,

Gathel, & Gardea, 2000), phantom limb pain (Belleggia & Birbaumer, 2001), and

chronic pain (Newton-Jone, Spence, & Schotte, 1995; Flor & Birbaumer, 1993).

For treating both children and adults’ migraine headache and tension headache,

biofeedback therapy was effective in reducing headache activities (including duration,

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intensity, and frequency) and medication consumption (Blanchard, Peters, Hermann,

Turner, Bukley, Barton, & Dentinger, 1997; Grazzi & Bussone, 1993; Blanchard, Taylor,

& Dentinger, 1992). One study showed that children had greater improvement in

headache activity reductions than adults did with biofeedback therapy (Sarafino &

Goehring, 2000).

Research showed that biofeedback therapy was effective in reducing artery blood

pressure for about 5mm Hg (McGrady, 1994). Using a combination of biofeedback

relaxation and medication treatment with individuals with essential hypertension was

more effective in lowering blood pressure than using medicine alone (Jurek, Higgins, &

McGrady, 1992).

A study showed a decrease in blood glucose after thermal feedback treatment

with patients with insulin-dependent diabetes (McGrady, Graham, Bailey, 1996).

Thermal biofeedback successfully helped a diabetes patient decrease attacks of

intermittent claudication to zero (Sauders, et al., 1993). In addition, the physiological

results of thermal biofeedback promoted a sense of self-control in a patient with

diabetes and double amputation which increased his self-esteem, and furthermore,

decreased his depression symptoms (Needham & Elkdridge, 1993).

Biofeedback-assisted pelvic floor muscle training significantly decreased the

urinary accident episodes and the average number of accidents per day for older adults

(aged 60 or older) (McDowell, 1999; Burn, Pranikoff, Nochajski, Hadley, Levy, & Ory,

1993). Biofeedback training significantly improved irritable bowel syndrome (IBS)

symptoms such as abdominal pain, diarrhea, constipation, flatulence, belching, and

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nausea with a proximately 50% successful rate (Blanchard, et al., 1993; Blanchard, et

al., 1992).

Studies showed that electromyography (EMG) biofeedback was effective in

treating chronic pain and temporomandibular disorder (TMD). Patients demonstrated

significant reductions in pain frequency, duration, and intensity after biofeedback

treatment (Edwards, et al., 2000; Newton-John, Spence, & Schotte, 1995; Flor &

Birbaumer, 1993).

Statement of Problem

Since the Biofeedback Research and Training Laboratory was established in the

later part of the year 1991, the BRTL has provided educational training to hundreds of

students and delivered treatment service to numerous university students, staff and

faculty, and community citizens. On the surface, the BRTL presents as a useful, typical

service to the community. However, no objective analysis of the client services has

been performed.

Definition of Biofeedback

There are various definitions of biofeedback. For the purpose of this study,

biofeedback is defined as:

A group of therapeutic procedures that utilizes electronic or electromechanical

instruments to accurately measure, process and ‘feed back’ to persons

information with reinforcing properties about their neuro-muscular and

autonomic activity, both normal and abnormal, in the form of analogue or binary,

auditory and/or visual feedback signals. Best achieved with a competent

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biofeedback professional, the objectives are to help persons develop greater

awareness and voluntary control over their physiological process that are

otherwise outside awareness and/or under less voluntary control, by first

controlling the external signal, and then with internal psychophysiological cues

(Schwartz, 1995, p.29).

Biofeedback includes peripheral biofeedback (i.e., thermal biofeedback and

electromyography biofeedback) and central nervous system biofeedback (i.e.,

electroencephalography biofeedback). Thermal biofeedback is the use of a temperature

probe, which is made of small pieces of heat-sensitive electrical material, to measure

changing skin temperature. Electromyography is the use of an electronic instrument to

measure the electrical activities of skeletal muscles. Electroencephalography

biofeedback (neurofeedback) is the measurement of electric activity of the brain such

as frequency, amplitude, or duration of activity of delta, theta, alpha, or beta brainwave

from certain scalp or brain locations (Schwartz, 1995).

For the purpose of this study, the research would only examine the efficacy of

thermal biofeedback and electromyography biofeedback at the BRTL and excluded

electroencephalography (EEG) biofeedback because EEG has evolved into its own

independent field and has its own construct that deserves a separate and focused

investigation. However, the researcher would count the total number of EEG clients

treated in Biofeedback Research and Training Laboratory.

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Review of Literature

Migraine Headache/Vascular Headache

In Grazzi and Bussone’s (1993) study on EMG biofeedback treatment (adjunctive

with breathing exercise) on migraine, results showed significant decreases in migraine

episodes and improved in the Pain Total Index in most patients although their mean

muscle activity did not change significantly in the treatment sessions. In addition,

patients maintained their reductions of migraine episodes at the 12-month follow-up.

According to Hermann, Blanchard, and Flor (1997), home-based biofeedback

treatment significantly reduced headache activity (included frequency, duration, and

intensity) of children with migraine. Results also suggested that the child’s age,

externalizing behavior tendencies, and initial level of psychosomatic complain were

three prediction factors of treatment outcome.

After reviewing 31 studies of behavior treatments of recurrent pediatric

headache, Holden, Deichmann, and Levy (1999) concluded that thermal biofeedback

alone was probably an efficient treatment for pediatric headache.

One study compared 4 treatment conditions: thermal biofeedback (TBF) for hand

warming, thermal biofeedback for hand cooling, thermal feedback for stabilization for

hand temperature, and biofeedback to suppress alpha in the EEG, to determine if

thermal feedback for hand warming was the best biofeedback treatment for vascular

headache (Blanchard et al., 1997). Findings indicated that patients in three conditions

(TBF-warming, TBF-cooling, EEG alpha-suppress) showed significant headache activity

reductions, and reductions of medication consumption was found in both TBF-warming

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and TBF-cooling groups. However, no evidence supported the patients received TBF-

warming had greater headache reductions.

Tension Headache

Blanchard, Taylor, and Dentinger (1992) studied using a comprehensive

treatment, which included drug withdrawal, progressive muscle relaxation, and 8

sessions of thermal feedback, with patients with high-medication-consumption

headache. They found 6 of 10 subjects demonstrated clinically significant reduction of

headache activity and analgesic consumption. In the 11-month follow-up, subjects were

able to uphold these reductions as documented by their headache diary.

In a comparison study on three treatments: frontal EMG biofeedback, trapezius

EMG biofeedback and progressive muscle relaxation therapy in the treatment of tension

headache, results indicated clinically significant decreases in headache activities in all

three treatment groups. Trapezius EMG biofeedback group had the highest percentage

improvement (74%) and frontal EMG group and progressive relaxation group had

43.8% and 33.9% improvement respectively (Arena, Burno, Hannah, & Meador, 2000).

Sarafino and Goehring (2000) reviewed the archival data from 56 studies to

evaluate if there was an age difference in acquiring biofeedback control and success in

treating headache. Findings suggested both thermal biofeedback and EMG biofeedback

substantially reduced subjects’ (both children and adults) headache activities and

children demonstrated greater improvement than adults did. In thermal biofeedback,

children had 62.27% decreases in their headache activities and adults had 33.8%

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decreases. In EMG biofeedback, children and adults showed 80.78% and 47.98%

decrease in headache activities respectively.

In Arnodorfer and Allen’s (2001) study on using thermal biofeedback treatment

package with children with recurrent tension headache, they found all five children

showed a significant decrease in headache frequency, duration, and intensity. At the 6-

month follow-up, 4 of 5 children were free from headaches.

Hypertension

McGrady (1994) studied patients with essential hypertension treated with group

relaxation training and thermal biofeedback. Forty-nine percent of the subjects in the

experimental group demonstrated a decrease in mean blood pressure of 5mm Hg.

Findings also indicated reductions of forehead muscle tension (from 2.9 microvolts to

1.8 microvolts), increases in finger temperature (from 87.7 °F to 90.2 °F), and

decreases in state anxiety (from scores 42.3 to 35.2) and trait anxiety (from scores 43.3

to 37.1). At the 10-month follow-up, only succeeders in the experimental group, who

continued practicing relaxation exercises at home, showed the long-term maintenance

of decreased blood pressure.

In Jurek, Higgins, and McGrady’s (1992) research on comparison of combination

of biofeedback-assisted relaxation and diuretic with diuretic alone to treat essential

hypertension, they found the combination treatment (diuretic combined with 16

sessions of biofeedback) had higher success to lower patients’ blood pressure (11 out of

20 patients) then diuretic alone (1 out of 10 patients).

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Diabetes

According to Saunders et al. (1994), thermal biofeedback (5 sessions for hand

and 16 sessions for foot) adjunctive with autogenic training homework exercises

successfully decreased attacks of intermittent claudication to zero by the 12th session

and increased walking distance to about a mile per day for a patient with non-insulin-

dependent diabetes mellitius. The patient was free of intermittent claudication and his

walking distance increased to 4.5 miles per day at the 12- and 48-month follow-up.

Needham and Eldridge (1993) studied the efficacy of using thermal biofeedback

to treat a 39-year-old man, who was diabetic, blind, and had double amputation, and to

reduce his depression and pains. The subject responded to the treatment immediately

and was able to raise his temperature up to 3.9 degrees Fahrenheit. In addition,

thermal biofeedback promoted a sense of self-control for the subject that in turn

facilitated the reductions of the subject’s depression.

Findings of a study suggested patients with insulin-dependent diabetes mellitus

reduced their average blood glucose (from 200mg/dl to 158 mg/dl) and percentage of

values above 200 mg/dl (from 43% to 22%) after 12, 30-minute weekly sessions of

biofeedback treatment (McGrady, Graham, & Bailey, 1996).

Incontinence

In McDowell’s et al. (1999) research of biofeedback-assisted pelvic floor muscle

training on 105 older adults (aged 60 years or older) with urinary incontinence, data

indicated a median 75.0% of reductions in urinary accidents in the treatment group

compared to a median 6.4% of reductions in the control group. Subjects, who

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completed treatment, decreased the average number of accidents per day from 4.0 pre-

treatment to 1.7 post-treatment.

In comparison study of effectiveness of paravaginal EMG biofeedback and pelvic

muscle exercise treatment in treating older women with urinary incontinence (UI),

results indicated that 61% reductions of UI episodes and 23% cures in the biofeedback

group and 54% reductions of UI episodes and 16% cures in the pelvic floor muscle

exercise group (Burn, Pranikoff, Nochajski, Hadley, Levy, & Ory, 1993).

Irritable Bowel Syndrome (IBS)

In one control study, eight IBS patients received 10 sessions of progressive

relaxation training with home practice. Results indicated that 50% of subjects were

significantly improved in their symptoms such as abdominal pain, diarrhea, constipation,

flatulence, belching, and nausea than subjects in the control group (Blanchard, et al.,

1993).

To examine the long-term improvement of biofeedback-assisted relaxation

treatment on IBS, Schwarz et al. (1990) conducted a 4- year follow-up study, 19 of

original 27 IBS patients participated in the follow-up. Seventeen of these 19 subjects

(89.5%) reported more than 50% improvement. Fifty percent of patients who

submitted symptom monitoring diaries showed at least a 50% reduction of IBS

symptoms such as pain, tenderness, diarrhea, nausea, and flatulence.

Blanchard, et al. (1992) conducted two studies to determine if a multicomponent

psychological treatment, which included progressive muscle relaxation, thermal

biofeedback, and cognitive therapy, was superior to other treatment. They found that a

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multicomponent psychological treatment was not superior to an attention-placebo

control (pseudo-medication and EEG alpha suppression biofeedback) and a symptom-

monitoring control when used to treat IBS. However, subjects, who were in the

multicomponent treatment group, attention-placebo group, and treatment of symptom

monitoring group, show reductions in all GI symptoms: abdominal pain, diarrhea,

constipation, belching, flatulence, nausea, and bloating. Subjects in the symptom-

monitoring group only demonstrated decreases in diarrhea and nausea.

Chronic Pain/Temporomandibular Disorder (TMD)

Mishra, Gatchel, and Gardea (2000) conducted a study to evaluate the relative

efficacy of three cognitive-behavior treatment conditions: a cognitive-behavioral skills

training (CBST) treatment group, a biofeedback treatment group, and a combination of

biofeedback and CBST treatment group, on patients with TMD. Although all three

treatment groups reported significant decreases in their Characteristic Pain Intensity

score compared to the no-treatment group, the biofeedback group showed the greatest

reductions relative to the no-treatment group.

In a case study on using electromyography feedback in the comprehensive

treatment of central pain and tremor after the subject had her initial cerebral accident 7

years ago, the 70-year-old female reported a significant decrease in duration, intensity,

and frequency of pain, a significant increase in efficacy of managing her daily pain, and

a significant increase in efficiency of sleep (Edwards, et al., 2000).

Flor and Birbaumer (1993) studied three types of treatment (cognitive-behavior

therapy, EMG biofeedback, and conservative medical treatment) for patients with

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chronic musculoskeletal pain (TMD and back pain). They found that the biofeedback

group showed the most substantial changes in Multidimensional Pain Inventory (MPI)

Pain Severity score. At the 6-month follow-up, 40% of subjects in the biofeedback

group sustained the reductions in pain severity, affective distress, catastrophizing scale,

and number of doctor visits compared with 17% in the CBT group and 8% in the

medical group. At the 24-month follow-up, the values of percentage change to 30% for

the biofeedback group, 18% for the CBT group, and 17% for the medical group.

Newton-John, Spence, and Schotte (1995) compared cognitive-behavior therapy

with EMG biofeedback in treating patients with low back pain. Findings indicated

significant improvement on the score of Pain Diary, Pain Disability Index, Pain Belief

Questionnaire, Beck Depression Inventory, and State-Trait Anxiety Inventory for

patients in both treatment groups but not in the control group. At 6-month follow-up,

patients maintained reductions of pain index, pain belief, and depression. However, no

significant differences were found between cognitive-behavior therapy and EMG

biofeedback on outcome measure.

Asthma

Kern-Buell et al. (2000) studied biofeedback-assisted relaxation for young, non-

steroid-dependent asthmatics. Findings showed 68% decreases in asthma symptoms

and 46% decreases in inhaler use in the experimental group and compared to 42%

decrease in asthma symptoms and 1.8% decrease in inhaler use in the control group.

Subjects in the experimental group demonstrated decreases in inflammation as

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demonstrated by the differences of the numbers of neutrophils and basophils in their

blood.

In a fifteen-month follow-up study by Pepper and Tibbetts (1992), results

indicated that subjects reduced their asthma symptoms, medical uses, breathless

episodes, and emergency visits after they had 16 weekly group EMG and incentive

inspirometer biofeedback sessions in combination with diaphragmatic breathing

training, guided imagery, prolonged exhalation, and desensitization strategies.

Anxiety Disorder

Watson, Tuorilla, Vickers, Gearhart, and Mendez (1997) studied 90 Vietnam War

veterans with posttraumatic stress disorder (PTSD) who were divided into three

treatment groups: relaxation instruction, relaxation instruction with deep breathing, and

relaxation instruction with deep breathing and thermal biofeedback. Although subjects’

temperature increased and EMG decreased in the 10 treatment sessions, only 4 of 21

PTSD symptoms and physiological dependent variables, which were flashbacks,

avoidance of thoughts, hyperalertness, and exaggerated startle, showed improvement.

Results suggested treatments were mildly effective.

Pediatric Constipation/Encopresis

In a control group study on pediatric constipation and encopresis, children in the

experimental group, who were treated with external anal sphincter (EAS)

electromyographic biofeedback plus Standard Medical Care (SMC), showed elimination

of EAS paradoxical constriction. At the 16-month follow-up, 75% of parents, whose

children were in the experimental group, reported complete elimination of constipation

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compared to 47% parents in the control group (only SMC). Seventy-nine percent of

experimental group parents and 49% of control group parents reported complete

elimination of soiling (Cox, Sutphen, Borowitz, Dickens, & Singles, 1994).

Hand Dsytonia (Writer’s Cramp)

In Deepak and Behari’s (1999) study on using brachioradialis EMG audio

biofeedback for hand dystonia, findings indicated 9 of 10 subjects had significant

improvement in hand writing from 37% to 93% and showed significant reductions of

pain and discomfort. At the 2-month and 6-month follow-up, percentage improvement

was from 20% to 82.6% and from 23.3% to 93.3% respectively.

Phantom Limb Pain

A case study found that a treatment of combined 6 sessions of EMG and 6

sessions of thermal biofeedback successfully eliminated a 69-year-old man’s phantom

limb pain after his amputation 3 years ago (Belleggia & Birbaumer, 2001). The

participant’s skin temperature in the stump increased and EMG level decreased during

treatment sessions. At the 12-month follow-up, the participant maintained complete

elimination of phantom limb pain.

In summary, biofeedback therapy has been shown to be effective in treating

migraine headache (Grazzi & Bussone, 1993), tension headache (Sarafino & Goehring,

2000), hypertension (McGrady, 1994), diabetes (Saunders, et al., 1994), incontinence

(McDowell, 1999), irritable bowel syndrome (Blanchard, et al. 1993), chronic pain

(Mishra, Gatchel, & Gardea, 2000), asthma (Kern-Buell et al. 2000), anxiety disorder

(Watson, et al., 2000), and pediatric constipation (Cox et al., 1994).

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Chapter II

Purpose of the Study

This study performed a qualitative when appropriate a quantitative analysis of all

client data files with the exception of neurofeedback since the establishment of the

Biofeedback Research and Training Laboratory in 1991 through the year 2002 for the

purpose of determining the clinical and educational efficacy of this service. The

researcher:

1. determined the variety of presenting concerns treated;

2. compared concerns treated with what the literature suggest biofeedback is

effective in treating;

3. determined the efficacy of such treatment at the Biofeedback Research and

Training Laboratory of a variety of disorders; and

4. determined if the Biofeedback Research and Training Laboratory provides a

useful service to the community.

Research Questions

This study was designed to answer the following questions:

1. Does the Biofeedback Research and Training Laboratory treat a variety of

concerns and disorders?

2. Does the Biofeedback Research and Training Laboratory treat concerns related to

what the literature suggests biofeedback is effective in treating?

3. Is the treatment for a variety of disorders provided at the Biofeedback Research

and Training Laboratory clinically effective?

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4. Does the Biofeedback Research and Training Laboratory provide useful services

to the community of clients and students?

Research Assumptions

The research assumptions were:

1. The Biofeedback Research and Training Laboratory treats most concerns

suggested for treatment by the literature.

2. The Biofeedback Research and Training Laboratory provides useful services to

the community of clients.

a. The Biofeedback Research and Training Laboratory treats a variety of

concerns and disorders.

b. The treatment provided at the Biofeedback Research and Training Laboratory

is effective in reducing or eliminating symptoms.

c. The Biofeedback Research and Training Laboratory provides treatment at low

cost.

3. The Biofeedback Research and Training Laboratory provides useful services to

the community of students (i.e., therapists in training).

Methods and Procedures

Data collection methods included in-depth interviews with the Director of BRTL

and an unobtrusive method of reviewing archival data client files. Client data files

included therapist’s session notes, client’s physiological measures, and the Stress Signal

Checklist. The Stress Signal Checklist is a list of 50 items commonly associated with

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stress with a 0-5 Likert response format. No research validity or reliability data is

available on the Stress Signal Checklist.

The researcher performed a qualitative analysis and a quantitative analysis of the

archival data of all clients’ files from 1992 to 2002. The client’s data files were divided

into two categories: clients who completed three or less treatment sessions (N = 88)

and clients who completed four or more treatment sessions (N = 321). For the clients

who completed four or more treatment sessions, the researcher examined and analyzed

each element of the data files that included:

1. number of clients treated with thermal biofeedback and/or electromyography

biofeedback by year, by gender, and by primary presenting problem,

2. the pre- and post- Stress Signal Checklist,

3. pre-, middle-, and post- electromyography and temperature measures, and

4. client’s self-report of homework relaxation exercises and progress (i.e.,

therapist’s session notes).

For pre-, middle-, and post- electromyography and temperature measures, the

researcher collected every client’s beginning and ending temperature and/or

electromyography in the first, middle, and last training session. This resulted in six

temperature measures and/or six electromyography measures for each client. These six

physiological measures (either temperature or electromyography measures) were used

to generate a slope for each client. Then the slope of each client’s growth trajectory

was used as the dependent variable to perform a one-sample t-test (Kraemer &

Thiemann, 1989; Maxwell, 1998; & Willett, 1994, Willett, 1989). The use of each

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individual’s slope as the dependent measure (i.e., intense design) can increase

statistical power (Maxwell, 1998).

For the clients who completed three or less treatment sessions, the researcher

only examined the number of clients treated with thermal biofeedback and/or

electromyography biofeedback by year, by gender, and by primary presenting problem.

The researcher counted the total number of EEG neurofeedback clients by year

although the measure of efficacy of EEG neurofeedback was not included in this study.

The unique complexities of EEG deserve an independent inquiry.

Role of the Researcher

In this study, the researcher functioned as an outside consultant and an inside

advocate. As an outside consultant, the researcher’s main goal was to evaluate the

efficacy and effectiveness of the treatment program in the BRTL. The evaluator wanted

to understand if the program has been effective, to what degree, and under what

conditions. As an inside advocate, the researcher promoted that the BRTL has provided

a quality program that has benefited university students, staff and faculty, and

community citizens.

Data Analysis

The procedure of data analysis included organizing the data, generating

categories, themes, and patterns, coding the data, testing emergent understandings,

searching for alternative explanation, and writing the report (Marshall & Rossman,

1999).

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In quantitative analysis, the data were organized and categorized by year, by

gender, by age, by ethnicity, and by primary presenting problem for all clients. The

researcher calculated the total number and percentage of clients based on year,

gender, age, and primary presenting problem. The researcher examined the data of the

pre- and post- Stress Signal Checklist and calculated the percentage of clients whose

symptoms decreased. One-sample t-test and factor analysis were used for statistical

analysis on physiological measures (both temperature and electromyography

measures). Effect sizes were computed by using Pearson’s r to determine the clinical

significance (Rosenthal, 1991). S-techniques were used to perform factor analysis. S-

technique factors individuals across occasions (Minke, 1997). In this study, occasions

refer to the six time points (beginning and ending measures of the first, middle, and

last session) where temperature and muscle tension measures were collected.

According to Budzynski (1989), the criteria for EMG training is to decrease frontal

EMG level to less than 2.5 microvolts in the cases of tension headache or 4.0 microvolts

in cases of migraine. Stoyva (1989) stated that the criterion on the autogenic training

and biofeedback combined was for clients to learn to keep EMG level at 3.5 microvolts

or less. For temperature training, the goal was that clients learned to produce hand

temperature greater than 90 degrees Fahrenheit (Budzynski, 1989) or greater than 89

degrees Fahrenheit for the nonfeedback average (Stoyva, 1989). Therefore, to avoid

the ceiling effect and floor effect on the physiological measures, the researcher

excluded clients whose beginning temperatures were over 90 degrees Fahrenheit

and/or whose beginning electromyography reading was below or equal 2.5 microvolts

19

on both one-sample t-test and factor analysis (see Appendix A-collection of fitted

individual growth trajectories)

In the qualitative analysis, the research examined and analyzed therapist’s

session notes that were based on clients’ self-report of symptom reductions and

homework relaxation exercises, and therapists’ observations of client’s progress to find

and generate the themes and patterns of treatment progress. Therapist’s session notes

were categorized into four areas: 1) decreased primary presenting problem, 2) report of

other types of progress other than primary presenting problem, 3) increased

awareness, and 4) negative experiences reported by clients.

After examining each element of client data files (both quantitative and

qualitative data), the researcher formulated hypothesis and tested emergent

understanding and searched for alternative explanations to answer some questions that

have not been answered. For example, why clients terminated treatment prematurely

(i.e., having three or less sessions), what factors contributed to symptom reliefs, and

how clients learned to increase temperature and/or decrease muscle tension in

treatment sessions.

Limitation

Qualitative research is inherent with researcher’s bias (Mashall & Rossman,

1999). In addition, the researcher works as a teaching assistant in the BRTL and the

Director of BRTL is also the major professor of the researcher. Under these conditions,

bias is likely to happen. However, the researcher strived to maintain objectivity and had

been encouraged to remain in a neutral position by the major professor.

20

This study examined archival data so no names from the data files were revealed

in order to protect clients’ privacy. The Stress Signal Checklist, which has not yet been

published, was used with permission of Dr. Barbara Peavey, practitioner of Grapevine,

Texas. No reliability and validity research has been performed with this instrument.

21

CHAPTER III

Results and Discussion

Educational Efficacy of the Biofeedback Research and Training Laboratory

The Biofeedback Research and Training Laboratory (BRTL) was established the

latter part of the year 1991 at the University of North Texas (UNT) by the Director, Dr.

Cynthia K. Chandler. Dr. Chandler is a full-time professor in the Counseling Program of

the College of Education, a national certified biofeedback therapist (BCIA-C), a national

certified neurofeedback provider (BCIA-EEG), a licensed professional counselor (LPC)

and a licensed marriage and family therapist (LMFT) in the state of Texas.

The mission of the Biofeedback Research and Training Laboratory is “to provide

a teaching, learning, and research environment for training, provision of services and

advancement of knowledge in the area of biofeedback” (Chandler, 1999, p.1). Since

1992, the BRTL has provided quality, but affordable, biofeedback therapy for an

abundance of clients. The clientele include university students, faculty and staff, and

community citizens from a large metropolitan area.

Goals of the Biofeedback Research and Training Laboratory

There are three main goals for the BRTL: 1) to provide training in the field of

biofeedback, 2) to conduct faculty-directed research, and 3) to offer quality, but

affordable, biofeedback therapy and other services to the University and DFW

metroplex community.

The BRTL is utilized to provide training in the field of biofeedback therapy on a

full-time basis by the following graduate classes: Introduction of Biofeedback,

22

Biofeedback Practicum, Advanced Practicum in Biofeedback, and Advanced Clinical

Training in Biofeedback and Neurofeedback. Introduction of Biofeedback is offered in

the Summer I semester. In this class, graduate students (masters and doctoral

students) learn the knowledge and techniques for performing biofeedback and

neurofeedback therapy. Biofeedback Practicum is offered in the Summer II semester.

Students use the laboratory equipment to provide biofeedback therapy for clients with

different conditions. Advanced Practicum in Biofeedback is offered in the Fall semester.

Students use biofeedback and neurofeedback therapeutic techniques with clients. In

addition, students can enroll in Advanced Clinical Training in Biofeedback and

Neurofeedback, to gain more clinical experience during any semester.

From 1992 to 2002, there have been 183 graduate students who have enrolled

in Introduction of Biofeedback and 118 students who have enrolled in Biofeedback

Practicum. Eighty students have enrolled in Advanced Practicum in Biofeedback from

1995 to 2002. Fifty-six students have enrolled in Advanced Clinical Training in

Biofeedback and Neurofeedback from 1993 to 2002 (UNT Student Information

Management System, 2002). The average per semester enrollment is approximately 17

graduate students enrolled in the introductory course, 11 students enrolled in the

practicum course, 8 students enrolled in the advanced practicum courses, and 11

students enrolled in the clinical course. In addition, 3 to 5 masters’ and post-masters’

students work in the BRTL as interns to gain experience and hours for their license as

professional counselors every semester (C. K. Chandler, personal communication, April,

2002).

23

To offer quality, but affordable, biofeedback therapy, the BRTL charges the small

fee of $25.00 per session for community clients, $10.00 per session for staff and faculty

members of the University of North Texas, and $5.00 per session for UNT students. All

treatment services are provided by graduate students and interns under faculty

supervision.

In 1999, the BRTL created a website, www.coe.unt.edu/edhe/Biofeedback1.htm,

to serve as an educational resource. Community citizens can use this website to find

biofeedback-related information and resources such as resources for referral and

information on biofeedback therapy and certification.

Facility

The BRTL is part of the University of North Texas’s Counseling and Human

Development Center (CHDC). The CHDC consists of a secretary’s office, a waiting room,

a staffing room, a control room, a conference room, a library, a biofeedback office, two

restrooms, 3 group counseling rooms, 3 play therapy rooms, 4 biofeedback therapy

rooms that can double as individual counseling rooms when needed, and 5 individual

counseling rooms (Holden & Kern, 1996). Prior to the year of 2002 there were 15 TV-

VCR stations in the control room, from which professors and/or supervisors can view,

videotape, or both for ongoing sessions. In 2002, the CHDC purchased new electronic

equipment that included 10 DVD video recorders, 2 CD writers, and 17 computers.

Currently, there are 10 DVD-TV-VCR stations (7 stations are in the intern room and 3

stations are in the control room) and 17 computers, which are in the control room and

hook up to each counseling room to record counseling sessions automatically (L. Steen,

24

Personal Communication, May, 2003). Each biofeedback room contains swivel chairs, a

reclining chair, a computer, a wooden computer cabinet, a printer, a cassette-CD

player, and biofeedback equipment.

The BRTL shares the facility such as the video control room, receptionists,

waiting room, and library with the CHDC. However, the BRTL functions independently in

terms of having its own budget account, client waiting list, telephone line and answer

machine, filing system, recruitment of clients, and scheduling of clients.

Types of Biofeedback Treatment

The Biofeedback Research and Training Laboratory provides six types of

biofeedback treatments:

1. Thermal biofeedback: this modality is used to train persons to increase their

finger or toe temperature,

2. Electromyography (EMG) feedback: this modality is used to help persons to

reduce their muscle tension or to gain motor control,

3. Electroencephalography (EEG) feedback: this modality is used to train to

either increase or decrease a person’s brainwave rhythms,

4. Electrodermal response (EDR): this modality is used to train to reduce sweat-

gland activity,

5. Pulse: this modality is used to train regular heartbeat, and

6. Breathing rate: this modality is used to train diaphragmatic breathing.

25

In addition to the above modalities, treatment protocols include autogenic

relaxation training, progressive muscle relaxation techniques, diaphragmatic breathing,

guided imagery, systematic desensitization, and cognitive restructuring.

Typical Treatment Procedure

First session.

At the first visit, a client fills out paperwork with the therapist that includes the

biofeedback intake form, the Stress Signal Checklist, a body map for discomforts, and

an informed consent. The biofeedback therapist also gives an oral description of what

fight-or-flight response is, how people react to stressful situations, and what and how

biofeedback therapy can help deal with stress. The attempt of this introduction is to

educate clients and to inform them of what they can expect in the treatment sessions.

Next, the therapist briefly explains the biofeedback equipment to the client while

attaching sensors to him or her and then conducts a standard psychophysiological

assessment (PPA) to gain baseline information in order to formulate a treatment plan.

Treatment sessions.

In the second session, the therapist presents a treatment plan to a client to sign

and also explains type of treatment (for example, thermal biofeedback, or EMG

biofeedback), goals of treatment, and an estimated target date for completion of

treatment, and the rationale for treatment that a client is receiving. A therapist also

explains to the client how the audio feedback is used on the biofeedback equipment to

train him or her to increase skin temperature or decrease muscle tension for treatment

of a particular condition.

26

All treatment sessions have some similarities in format: a 5 minutes baseline

phase, a 15-20 minutes training phase (i.e., a therapist reads a training script and

coaches a client), and another 5 minutes baseline phase. Clients receive audio feedback

throughout the whole process. In thermal biofeedback sessions, the therapist typically

uses an autogenic script (Schultz, 1969) to facilitate feelings of relaxation, heaviness,

and warmth. A client is instructed to raise the external skin temperature as measured

on a finger thermister. In EMG training, a progressive muscle relaxation script (Wolpe,

1973) is used to assist in relaxing different muscle groups. A client is instructed to relax

a muscle group as it is measured by an EMG sensor on the surface of the skin that near

the muscle group.

In the beginning of every session, a therapist asks about progress of homework

relaxation exercises and answers any questions or concerns a client might have. At the

end of each session, the therapist discusses the session with the client and elicits

feedback about his or her experience in the session. Then a new homework exercise is

assigned and the client is encouraged to practice at home. Typical homework includes

instructions for listening to a 15 minute relaxation tape (provided by the therapist)

daily, or at least 3-5 times per week, and record practice sessions on a homework log.

Termination session.

At the end of the final treatment session, the client completes another Stress

Signal Checklist and a counselor evaluation form. Furthermore, therapist and client

review experiences and progress that the client has made and reiterates how to

generalize self-regulation skills to daily living.

27

Treatment goals

1. To increase finger temperature.

2. To decrease muscle tension.

3. To reduce or eliminate symptoms.

Equipment in the Training Setting

The BRTL has a variety of equipment that includes 2 sets of portable battery

operated equipment not integrated with a computer: two Autogenics AT-42s for skin

temperature training and two AT-33s Autogenic for muscle tension training; and 4 sets

of computerized equipments: two Pro-Comp with Biograph software from Thought

Technology, and two Focused Technology F-1000s.

1. AT-42 Autogenic Single Channel Temperature Trainer is a portable, single-

channel temperature training instrument with rechargeable batteries. It has a

built-in microprocessor to collect and analyze session data and present

temperature information.

2. AT-33 Autogenic EMG is a portable, single channel EMG training instrument and

has rechargeable batteries, a LED digital meter, and a LED light bar displays that

are activated by pressing a panel button. The AT-33 also has a 3 variations of

audio feedback played through the internal speaker or optional earphones.

3. Focused Technology F-1000 computerized system has two channels for

temperature training, two channels for EMG and EEG training, one channel for

skin conductance training, two channels for respiration training, and one channel

28

for heart rate. It has a built-in sound synthesizer, analog, digital and FFT filter,

and versatile data logging and presentation (www.focused-technology.com).

4. Pro-Comp from Thought Technology with Biograph software computerized

system has 8 channels of any combination of modalities, including EEG, skin

conductance, heart rate, blood volume pulse, temperature, and respiration

(www.bio-medical.com).

Of the three primary goals of the BRTL mentioned earlier the two goals that

receive the greatest attention are 1) to provide and support training and education in

biofeedback therapy to students, and 2) to service the community by providing

biofeedback therapy. The third primary goal of the BRTL, to provide faculty-directed

research in biofeedback, is the least attended to area of the BRTL. Since the inception

of the BRTL and through the year 2002, four articles have been published as a result of

the BRTL research, two national and two state (Chandler, Bodenhamer-Davis, Holden,

Evenson, & Bratton, 2001; Bodenhamer-Davis & Chandler, 1998; Chandler, 1996;

Chandler & Sanders, 1994). In addition, the BRTL research has resulted in two

international and three national professional presentations as well as six state

presentations (Chandler & Brew, 2001; Chandler, Lawson, Molenaar, DeSalme, Pinzon,

Pope-Cody, Linebarger, & Lang, 1999; Lawson, Chandler, Molenaar, Pinzon, Pope-Cody,

Linebarger, & Lang, 1998; Chandler & Mosse, 1996; Chandler & Sanders, 1993;

Chandler & Brew, 1999; Chandler, Lawson, Molenaar, DeSalme, Pinzon, Pope-Cody,

Linebarger, & Lang, 1998; Chandler, 1998; Chandler, Holden, Bodenhamer-Davis, &

Evenson, 1997; Chandler & Mosse. 1996; Chandler, 1992).

29

Biofeedback students are active in ongoing biofeedback research and

presentations and over the years have received 9 state research scholarship awards (7

from the Biofeedback Society of Texas and 2 from the Texas Association for Counselor

Education and Supervision) and 2 national research/scholarship award from the

Association for Applied Psychophysiology and Biofeedback.

Client fees received for biofeedback services are utilized to support the

maintenance of the BRTL, provide for research support, and award an annual $1000

student scholarship in biofeedback study.

Biofeedback Research and Training Laboratory Responsibility Hierarchy (see Figure 1)

Figure 1. Biofeedback Research and Training Laboratory Responsibility Hierarchy

The BRTL teaching fellow and students enrolled in the biofeedback courses

↓ reports to

Director of the Biofeedback Research and Training Laboratory

↓ reports to

Chair of the Department of Counseling, Development, and Higher Education

↓ reports to

Dean of the College of Education

↓ reports to

President of the University of North Texas

Job Descriptions.

The Director of the BRTL is a full-time graduate faculty Professor in a counseling

program and is nationally certified in biofeedback and neurofeedback through the

30

national organization the Biofeedback Certification Institute of America

(hppt://www.bcia.org). She is also a licensed professional counselor and a licensed

marriage and family therapist. As part of her faculty duties, the Director of the BRTL

supervises all students and interns performing biofeedback therapy, teaches all of the

biofeedback related courses and oversees the administration of the biofeedback

laboratory including the supervision of the teaching fellow of the BRTL.

The BRTL teaching fellow is a doctoral student in a counseling program who

specializes in biofeedback therapy and/or research. The teaching fellow performs the

daily administrative tasks required to run the BRTL. These include: returning phone

calls, maintaining the biofeedback equipment and supplies, maintaining the client

waiting list, maintaining administrative files, supervising the organization and

completion of client files, assisting in the instruction of biofeedback in the didactic

biofeedback course, assisting in the supervision of students during biofeedback clinical

courses.

Clinical Efficacy of the Biofeedback Research and Training Laboratory

From 1992 to 2002, the Biofeedback Research and Training Laboratory provided

peripheral biofeedback therapy for 409 clients. Figure 2.1 shows the number of male

and female clients treated in the BRTL each year. Three hundred and twelve clients

were female and 97 clients were male. Among these 409 clients, 270 clients had

information regarding their ethnicity. For these 270 clients, 90% were Caucasian, 4.1%

were Hispanic, 3% were Africa American, 2.2% were Asian, 0.7% were others (see

31

Figure 2.2). Clients’ ages ranged from 15 to 76 years old. Seventy-eight percent were

between 25 to 55 years old (see Figure 2.3).

Figure 2.1. Number of clients treated based on year and gender.

1

9

22

61

53

3036

4235

16

71

7 7

17 16

812 13 10

2 4

0

10

20

30

40

50

60

70

1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Num

ber o

f Clie

nts

FemaleMale

Figure 2.2. Number of clients treated based on ethnicity.

8 6

243

11 20

50

100

150

200

250

300

AfriicaAmerican

Asian Caucasian Hispanic Others

Ethnicity

Num

ber o

f Clie

nts

32

Figure 2.3. Number of clients treated based on age.

4

57

131

104

84

29

0

20

40

60

80

100

120

140

15-17 18-24 25-35 36-45 46-55 56-76

Age

Num

ber

of C

lient

s

This data does not include an estimated 1,000 client contact hours or over 100

clients in which students provided biofeedback therapy for fellow students to meet the

certification requirement that all biofeedback therapists must have 10 hours as a client

as part of their biofeedback training. Most of these trainees did not have a significant

presenting concern. The data also does not include 2 client contact hours every doctoral

student in the counseling program is required to do for the observation/participation

requirement for the doctoral program. The Director of the BRTL was on research

sabbatical in 2002 and thus client activity of the BRTL was minimal. Activity picked back

up to normal in 2003.

Figure 2.4 demonstrates the number of clients and the number of variety of

concerns and symptoms treated in the BRTL that included anxiety, chronic pain,

fibromyalgia, gastrointestinal problems, migraine headache, hypertension, performance

33

anxiety, Raynaud’s, sleep problem, stress, tension headache, test anxiety,

temporomandibular joint pain, and others. Symptoms that were included as

gastrointestinal problems were irritable bowel syndrome, gastritis, stomach cramp/pain,

ulcer, colitis, and spastic colon. Symptoms that are under the others category are nail

biting, mood swing, smoking cessation, caffeine addiction, blepharospasm, Bell’s palsy,

concentration problem, asthma, vocal cords problem, blushing, and eating disorder.

Chronic pain, stress, anxiety, and tension headache, which composed 62.3% of

all 409 clients, were the top four primary presenting problems that the BRTL treated.

Figure 2.4. Number of clients treated based on primary presenting problem.

49

87

919

44

22 2012

713

75

17 17 18

0102030405060708090

100

Anx

iety

Chr

onic

Pai

n

Fibr

omya

lgia

Gas

troin

test

inal

Pro

blem

Tens

ion

Hea

dach

e

Hyp

erte

nsio

n

Mig

rain

eHea

dach

ePer

form

ance

Anx

iety

Ray

naud

's

Sle

ep P

robl

em

Stre

ss

Test

Anx

iety

TMJ

Oth

ers

Primary Presenting Problem

Num

ber o

f Clie

nts

The BRTL also provided neurofeedback therapy for clients with Attention Deficit

Disorder/Attention Deficit Hyperactivity Disorder. From 1994 to 2002, 98 clients that

were not part of 409 peripheral biofeedback clients received neurofeedback therapy in

the BRTL. Figure 2.5 represents the number of neurofeedback clients treated based on

34

year. Number of neurofeedback clients treated depends on the availability of the

student therapists with that particular interest area.

Figure 2.5. Number of neurofeedback therapy clients treated based on year.

13

33

26

10

6 5

13

10

5

10

15

20

25

30

35

1994 1995 1996 1997 1998 1999 2000 2001 2002

Year

Num

ber

of C

lient

s

Results of Clients’ Self-Reported Progress

Clients’ self-reported progress included the pre- and post- Stress Signal Checklist

and therapist’s session notes which included: 1) clients’ report of practice of homework

exercises, and 2) clients’ self-reported progress and therapists’ observations. Clients’

self-reported progresses were only examined for the 321 clients who completed 4 or

more treatment sessions.

Stress Signal Checklist

For the 321 clients, only 101 clients (31.5%) had completed information on both

pre- and post- Stress Signal Checklist. Of these 101 clients, 88 clients (87.1%) reported

symptom decrease, 4 clients (4%) reported remaining the same, and 9 clients (8.9%)

reported symptom increase.

35

Therapist’s Session Notes: Clients’ report of practice of homework exercises

Eighty percent of the 321 clients with 4 or more treatment sessions reported

doing their relaxation homework exercise. However, there was no specific information

regarding number of homework exercises that clients practiced per week.

Therapist’s session notes: Clients’ self-reported progress and therapist’s observations

Therapists’ session notes that included clients’ self-reported progress and

therapist’s observations were categorized into four areas: 1) decreased primary

presenting problem, 2) report of other types of progress other than primary presenting

problem, 3) increased awareness of primary presenting problem and/or other areas,

and 4) negative experience.

There is no procedure for computing a treatment success to failure ratio using

therapist’s session notes due to the inconsistency of therapists in recording clients’

statements. For 321 the clients who had 4 or more treatment sessions, only 218 clients

(68%) had self-reported progress recorded in files by their therapists.

Decrease in primary presenting problem.

Decrease in primary presenting problem was defined as decrease in severity and

frequency of symptoms. The following findings are based on clients with 4 or more

treatment sessions who had self-reported progress recorded in their files by therapists

(i.e. 218 client files). For those 218 clients, 101 clients (46.3%) reported primary

presenting symptoms decreased. Figure 3.1 summarizes the number of clients who

reported primary presenting problem decreased. The following paragraphs are detailed

36

qualitative results from therapist’s session notes classified by each primary presenting

problem.

Figure 3.1. Number of clients reported primary presenting problem decreased.

24

45

511

2418

15

4 2 4

34

8 10 913 15

25

148 9

2 14

15

3 4 6

05

101520253035404550

Anxi

ety

Chr

onic

Pai

n

Fibr

omya

lgia

Gas

troin

test

inal

Pro

blem

Tens

ion

Hea

dach

e

Hyp

erte

nsio

nM

igra

ine

Hea

dach

ePe

rform

ance

Anx

iety

Ray

anud

's

Slee

p P

robl

em

Stre

ss

Test

Anx

iety

TMJ

Oth

ers


Num

ber o

f Clie

nts

Clients had self-reportedinformationClients reported primarypresenting problem decreased

Anxiety.

There were 36 clients with 4 or more treatment sessions who had anxiety as

their primary presenting problem. Only 24 of the 36 clients with anxiety as primary

presenting problem had self-reported information recorded by their therapists and 13 of

these 24 clients (54.2%) reported that anxiety level and symptoms decreased and they

felt calmer and more relaxed in general. One client with a panic attack stated that she

was able to relax in stressful situations and use deep breathing to help gain emotional

stability. Another client reported not having panic attacks for 2 weeks. She stated she

was able to talk herself out of a panic attack. One client stated she noticed

37

improvement in her overall feelings of well-being and felt more confident and less

anxious. One client who had a phobia of flying reported her symptoms decreased

significantly when flying.

Chronic pain.

There were 67 clients with 4 or more treatment sessions who had chronic pain

as their primary presenting problem. Only 45 of the 67 clients with chronic pain as

primary presenting problem had self-reported information recorded by their therapists

and 15 of these 45 clients (33.3%) reported severity and frequency of pain decreased

or eliminated. Clients reported being able to recognize tension location and able to

reduce and alleviate muscle tension and pain. One client with shoulder pain stated his

shoulders were not as tense as before and felt like a weight was lifted. In addition, he

stated he was able to mentally pull himself out of high stress situations. Another client

reported being able to achieve relaxation even in midst of pain and distress. He stated

pain had become more a disconcerting certainty rather than a dreadful consuming

suffering.

Fibromyalgia.

There were 6 clients with 4 or more treatment sessions who had fibromyalgia as

their primary presenting problem. Five of the 6 clients with fibromyalgia as primary


these 5 clients (40%) reported symptoms decreased. One client reported having no

shoulder and back pain for over a week and feeling much better overall. Another client

stated she realized there was no need for her to hold tension in her body and she was

38

able to let go more. In addition, the intensity of her headache and muscle tension

decreased.

Gastrointestinal problem.

There were 17 clients with 4 or more treatment sessions who expressed

gastrointestinal problem as their primary presenting problem. Only 11 of the 17 clients

with gastrointestinal problem as primary presenting problem had self-reported

information recorded by their therapists and 5 of these 11 clients (45.5%) reported

gastrointestinal symptoms decreased. One client with spastic colon stated she had less

stress attacks of colon. One client with irritable bowel syndrome stated she was able to

use relaxation techniques in situations that had previously been very stressful. In

addition, she began to go out to public to eat which she had previously avoided.

Hypertension.

There were 21 clients with 4 or more treatment sessions who had hypertension

as their primary presenting problem. Eighteen of the 21 clients with hypertension as


and 8 of these 18 clients (44.4%) reported blood pressure decreased. Five clients had

blood pressure measured before and after each treatment session. One client

decreased his systolic blood pressure an average of 7 mmHg and diastolic blood

pressure an average of 5 mmHg. Another client reduced blood pressure an average of

11 mmHg for her systolic blood pressure and 2.5 mmHg for her diastolic blood pressure

after the biofeedback session. One client reduced an average of 5.8 mmHg and 0.4

mmHg respectively for systolic and diastolic blood pressure. The last one reduced an

39

average of 6 mmHg for systolic blood pressure and 2 mmHg for diastolic blood

pressure. One client’s physician cut down his hypertension medication to half and his

kidney function was returning to normal at the end of his treatment. One client

reported her blood pressure decreased significantly.

Migraine headache.

There were 18 clients with 4 or more treatment sessions who expressed migraine

headache as their primary presenting problem. Fifteen of the 18 clients with migraine

headache as primary presenting problem had self-reported information recorded by

their therapists and 9 of these 15 clients (60%) reported decreases in frequency and

severity of migraine and being able to use relaxation skills to better deal with migraine.

One client reported being able to work through her migraine a little better and feeling

more relaxed. Another client stated she felt like her everyday life had been affected

positively and her migraine had alleviated. One client stated she was able to use

breathing to fight off what felt like an on coming migraine and she was much more

attentive to her physical self.

Performance anxiety.

There were 9 clients with 4 or more treatment sessions who had performance

anxiety as their primary presenting problem. Only 4 of the 9 clients with performance

anxiety as primary presenting problem had self-reported information recorded by their

therapists and 2 of these 4 clients (50%) reported decreases in frequency of anxiety.

One client stated her two speaking engagement went better. Another client reported

40

using breathing to calm herself when she was anxious and she was happier and more

confident.

Raynaud’s disease.

There were 6 clients with 4 or more treatment sessions who had Raynaud’s

disease as their primary presenting problem. Only 2 of the 6 clients with Raynaud’s

disease as primary presenting problem had self-reported information recorded by their

therapists and 1 of these 2 clients (50%) reported her symptoms decreased. She stated

she was able to warm her hands and used relaxation skills to reduce tension. Her

energy level increased that enabled her to spend time with her friends after work which

she was not able to do before. She was more alert and focused. In addition, she was

able to let go more and not worried too much.

Sleep problem.

There were 7 clients with 4 or more treatment sessions who had sleep problem

as their primary presenting problem. Only 4 of the 7 clients with sleep problem as


and all of these 4 clients (100%) reported quality of sleep improved that included easier

to fall asleep, sleep longer, no frequent awakenings during the night, no too-early

awakenings in the morning, and/or reduced use of sleep aides.

Stress.

There were 60 clients with 4 or more treatment sessions who had stress as their

primary presenting problem. Only 34 of the 60 clients with anxiety as primary


41

these 34 clients (44.1%) reported reducing general stress level and feeling better

overall. One client reported having quicker recovery from stress. Another client stated

she was able to recognize stressors and developed coping strategies for coping with

work and family stress. Six clients reported being able to identify stressful situations

and using relaxation techniques such as deep breathing to stay calm and control stress.

One pregnant woman reported she had less headache and nausea after biofeedback

training.

Tension headache.

There were 35 clients with 4 or more treatment sessions who had tension

headache as their primary presenting problem. Only 24 of the 35 clients with tension

headache as primary presenting problem had self-reported information recorded by

their therapists and 14 of these 24 clients (58.3%) reported decreasing in frequency

and severity of headache and having learned how to deal with or prevent headaches.

One client reported being able to stop her headaches by using the autogenic relaxation

tape. In addition, she had changed her attitude about relaxation. Another client stated

life overall was still stressful but she learned how to better handle it. One client stated

she went on an entire day with no discomfort or pain from tension; furthermore, she

was much more positive and calm and felt physically less stressed.

Test anxiety.

There were 11 clients with 4 or more treatment sessions who had test anxiety as

their primary presenting problem. Eight of the 11 clients with test anxiety as primary


42

these 8 clients (37.5%) reported their test anxiety level reduced. One client stated she

was able to sleep better, retained more of what she studied, and remembered and

recalled more. Another client with test anxiety stated he felt less restless in the situation

where he had to sit for prolonged period of time and more relaxed during tests.

Temporomandibular joint pain.

There were 14 clients with 4 or more treatment sessions who had TMJ as their

primary presenting problem. Only 10 of the 14 clients with TMJ as primary presenting

problem had self-reported information recorded by their therapists and 4 of these 10

clients (40%) reported symptoms decreased and experiencing no or less pain. One

client stated she was able to alleviate her jaw pains by being aware how and where she

held the tension and leaving some space between her teeth. Another one reported no

headaches and jaw pains for 2 weeks. In addition, she said, “I wish more people would

learn what I did instead of turning to drugs or alcohol.”

Others.

There were 14 clients with 4 or more treatment sessions whose primary

presenting problem was under the others category. Only 9 of the 14 clients whose

primary presenting problem was under others category had self-reported information

recorded by their therapists and 6 of these 9 clients (66.7%) reported symptoms

decreased. One client with nail biting problem reported having less nail biting behavior

because she was more aware when she engaged in nail biting and then she was able to

stop it. One client with vocal cords problem stated having some improvement in his

voice quality. One woman with eating disorder reported she ate healthier and was not

43

thinking about a laxative. She used relaxation for stress reduction, not a laxative and

she was happier. One client with blepharospasm stated her twitches did not occur and

she felt she was able to control it. In addition, relaxation exercises helped her fall

asleep.

One client who had a blushing problem stated that he was less tense and had

less blushing. His increased ability to relax and let go helped him feel more comfortable

when he was lecturing in class. One client with chronic fatigue syndrome reported

feeling more present and relaxed despite the pain. She was aware of her tiredness and

learned how to respect her body’s needs. Another client with concentration problems

reported being able to concentrate better and using deep breathing when she was

stressed.

Report of other types of progress other than primary presenting problem.

For 218 clients (64.7%) who had self-reported statements recorded by their

therapists, 141 clients (64.7) reported having positive gains or progress in one or more

areas not directly related to their primary presenting symptom. Figure 3.2 shows the

number of clients reported other types of progress other than their primary presenting

problem based on primary presenting problem.

44

Figure 3.2. Number of clients who reported other types of progress other than primary

presenting problem based on primary presenting problem.

24

45

511

2418 15

4 2 4

34

8 10 9

1825

4 7

1814 12

1 1 2

22

6 7 4

05

101520253035404550

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Clients had self-reportedinformation

Clients reported other typesof progress

Seventy-five percent of clients with anxiety as primary presenting problem

reported other types of progress. Four out of five clients (80%) with fibromyalgia as

primary presenting problem reported other types of benefits form the biofeedback

training. Eighty percent of clients with TMJ as their primary presenting problem

reported other types of benefits and gain from the biofeedback training sessions. Six

out of 8 clients (75%) with test anxiety as their primary presenting problem and 18 out

of 24 clients (75%) with tension headache as their primary presenting problem reported

having other types of progress. Eighty percent of clients with migraine headache as

primary presenting problem reported other benefits from the biofeedback training.

45

Following is a list of examples of client’s statements recorded by therapists that

reported positive progress that clients made in the sessions that was not directly related

to their primary presenting problem.

1. Decreases in the other related symptoms for clients who had multiple

symptomatology (see Table 1);

2. Having a more positive attitude and positive feelings such as feeling happier,

calmer, rested, energetic, secured, more alive, more relaxed, and more

confident;

3. Having less negative feelings such as feeling less irritable, rushed, anxious,

restless, guarded, and nervous;

4. Improving quality of sleep such as easier to fall asleep and/or being able to sleep

through the night;

5. Incorporating deep breathing into daily life to deal with difficult times at work or

at home;

6. Being able to use deep breathing and/or relaxation techniques to calm

themselves in a stressful situation;

7. Having a quick recovery from stress;

8. Being able to use relaxation techniques to prevent symptoms occurring such as

headache, jaw pain;

9. Increases in self-care behaviors such as decreasing caffeine and/or nicotine

intake, exercising more, and taking time for pleasurable activity;

46

10. Participating in activities that had not been done for a while such as going out to

eat for irritable bowel syndrome clients and talking to a stranger for social

anxiety clients;

11. Increasing productivity at work;

12. Increasing concentration;

13. Increasing a sense of control over tension, anger, racing thought, and obsessive

thought,

14. Increasing tolerance for frustration;

15. Increasing the ability of letting go;

16. More in touch with oneself and feelings;

17. Being able to recognize negative thought patterns such as taking responsibility

for others’ action; and

18. Having spiritual experiences such as “out of body” experience and “oneness”

experience.

Table 1. Sample recorded clients’ statement of reported symptom decrease in other

than the primary presenting problem.

Client’s primary presenting problem Area of improvement

Anxiety Decreased stiffness in back and neck

Blushing Decreased performance anxiety

Chronic Pain: Decreased frequency of headache

Better prepared for examination

Fibromyalgia Decreased frequency of headache

47

Table 1. (continued) Hypertension:

Decreased frequency of migraine and neck pain

Decreased performance anxiety

Less stress in public speaking

Stabilized blood sugar

Irritable bowel syndrome Decreased use of inhaler for asthma

Migraine:

Decreased stomach distress

Decreased blood pressure and stomach stress

Panic attack Decreased muscle tension

Raynaud’s Decreased frequency of headache

Sleep problem Mood swing improved

Stress:

No more chest pain

Decreased frequency of headache

Decreased neck pain

Tension headache:

Fewer episodes of insomnia

Decreased test anxiety

Decreased asthma attack

Backache diminished

Blood pressure decreased

TMJ Decreased frequency of headache

48

One anxiety client stated that biofeedback had made a great difference in his life

in the way that he reacted to situations and people. He was able to think before he got

upset and most of the time he decided it was not worth it. His wife also noticed a big

change in him. For one client with migraine, her physician indicated that her blood

pressure had decreased to a point of there being a possibility of eliminating medication

for it.

Increased awareness of primary presenting problem and/or other areas.

One hundred and twenty-one clients (55.5%) out of 218 clients who had

statements recorded by their therapists reported increasing awareness in one or more

areas. Figure 3.3 summaries the number of clients who reported increased awareness

of primary presenting problem and/or other areas based on primary presenting

problem. Two out of 2 clients (100%) with Raynaud’s as their primary presenting

problem reported increased awareness of physiological responses. Seventy-five percent

of clients with performance anxiety as primary presenting problem reported increased

awareness of different stressors and their responses to a stressful situation.

49

Figure 3.3. Number of clients who reported increased awareness based on primary

presenting problem.

24

45

511

2418 15

4 2 4

34

8 10 914

29

3 4

139 8

3 2 2

16

5 58

05

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Clients had self-reportedinformationClients reported increasedawareness

Following are examples of reported increased awareness regarding the primary

presenting problem and/or other areas.

1. Increased awareness of physiological responses such as breathing, muscle

tension, temperature, sweat, and heart rate in the sessions;

2. Increased awareness and sensitivity of physiological responses (i.e.,

temperature, muscle tension, sweat, heart rate, breathing) before, while, and

after a stressor presented;

3. Increased awareness of different stressors (i.e., work, school, relationship

problem, caffeine, nicotine, traffic, noises, . . . etc.) in life and how these

stressors impact them;

50

4. Increased awareness of how they respond to stressful situations; and

5. Increased awareness of the mind-body connection (i.e., how their thinking affect

physiological responses).

Negative experiences reported by clients.

Seven clients whose statements (3.2%) were recorded by therapists reported

negative experiences related to biofeedback therapy. Following is a list of recorded

negative thoughts or feelings that clients had as a result of biofeedback therapy:

1. having difficulty letting go and being afraid of what might come up and the

emotions stuck in her neck, chest, and stomach, and feeling like drowning when

breathing deeply and wanting to fight relaxation because it was so different,

2. having a need to do something instead of just relaxing,

3. feeling tired after relaxation,

4. unpleasant images came up during relaxed state,

5. increased frequency of headache,

6. perceived audio feedback as a punishment, and

7. having irrational thought such as “I am fine as long as I am having success. As

soon as I cannot figure one out, it makes me a failure.”

Two clients reported having both positive and negative experiences from the

treatment. One client reported feeling less stress but unable to relax without feeling

guilty for not working on something. Another reported being able to relax longer and

feeling much calmer but feeling guilty when she was too relaxed and she was afraid of

losing control.

51

Results of Quantitative Analysis of Physiological Measures

For all clients that were treated in the BRTL since 1992 to 2002, 321 clients

completed four or more treatment sessions and 88 clients had three or less treatment

sessions. The following findings present the simple quantitative analysis such as

percentage and frequency for both groups. However, only clients with 4 or more

treatment sessions were compared using a one-sample t-test and factor analysis.

Clients with 3 or less treatment sessions

From 1992 to 2002, 88 clients completed 3 or less treatment sessions. Three or

less treatment sessions is considered to be too few sessions to positively impact

therapeutic progress in biofeedback therapy. For these 88 clients, 78.4% were female

and 22.6% were male. Thirty-six clients had only one treatment session. Thirty-two

clients had 2 treatment sessions, and 20 clients had three treatment sessions. Tables

2.1 and 2.2 show the frequency and percent of clients treated in the BRTL based on

primary presenting problem and year for clients with 3 or less treatment sessions.

The top three primary presenting problems in this group were chronic pain,

anxiety, and stress. Symptoms that included as gastrointestinal problems were irritable

bowel syndrome and colitis. Symptoms that included in others category included

concentration problem, blepharospasm, Bell’s Palsy, and ADHD.

52

Table 2.1. Frequency and percent of clients with 3 or less treatment sessions based on

primary presenting problem.

Presenting Problem Frequency Percent Anxiety 13 14.8 Chronic Pain 20 22.8 Fibromyalgia 3 3.4 Gastrointestinal Problem 2 2.3 Migraine Headache 2 2.3 Hypertension 1 1.1 Performance Anxiety 3 3.4 Raynaud’s 1 1.1 Sleep Problem 6 6.8 Stress 15 17.1 Tension Headache 9 10.2 Test Anxiety 6 6.8 TMJ 3 3.4 Others 4 4.5 Total 88 100

Table 2.2. Frequency and percent of clients with 3 or less treatment sessions based on

year.

Year Frequency Percent 1992 2 2.3 1993 1 1.1 1994 14 15.9 1995 11 12.5 1996 11 12.5 1997 10 11.4 1998 6 6.8 1999 14 15.9 2000 14 15.9 2001 3 3.4 2002 2 2.3 Total 88 100

53

Clients with 4 or more treatment sessions

Three hundred and twenty-one clients completed 4 or more treatment sessions

from 1993 to 2002. Tables 3.1, 3.2, and 3.3 show the frequency and percent of clients

treated based on year, gender, and primary presenting problem. Years of 1995, 1996,

1998, and 1999 composed almost 55% of the 321 clients. The female to male client

ratio was about 3 to 1.

Table 3.1. Frequency and percent of clients with 4 or more treatment sessions based on

year.

Year Frequency Percent 1993 15 4.7 1994 15 4.7 1995 67 20.9 1996 58 18.1 1997 28 8.7 1998 42 13.1 1999 41 12.8 2000 31 9.7 2001 15 4.7 2002 9 2.8 Total 321 100.0


gender.

Gender Frequency Percent Female 243 75.7 Male 78 24.3 Total 321 100.0

Symptoms that were included as gastrointestinal problems were irritable bowel

syndrome, gastritis, stomach cramp/pain, ulcer, and spastic colon. Symptoms that were

54

under the others category were nail biting, mood swing, smoking cessation, caffeine

addiction, attention deficiency disorder, asthma, vocal cords problem, blushing, and

eating disorder.

Four most common presenting problems the BRTL treated were chronic pain,

stress, anxiety, and tension headache.


primary presenting problem.

Primary Presenting Problem Frequency Percent Anxiety 36 11.2 Chronic Pain 67 20.9 Fibromyalgia 6 1.9 Gastrointestinal Problem 17 5.3 Hypertension 21 6.5 Migraine Headache 18 5.6 Performance Anxiety 9 2.8 Raynauld's 6 1.9 Sleep Problem 7 2.2 Stress 60 18.7 Tension Headache 35 10.9 Test Anxiety 11 3.4 TMJ 14 4.4 Others 14 4.4 Total 321 100.0

Figures 4.1 and 4.2 demonstrate the frequency and percent of clients treated in

the BRTL based on age and number of sessions. Most people received biofeedback

therapy in the BRTL was between 25 to 55 years old that made up to 78.5% of all 321

clients. About 69% of clients had 4 to 10 treatment sessions. Only 4.7% of clients had

more than 20 treatment sessions.

55

Figure 4.1. Number of clients with 4 or more treatment sessions based on age.

4

41

101

7972

24

0

20

40

60

80

100

120

15-17 18-24 25-35 36-45 46-55 56-76

Age

Num

ber

of C

lient

s

Figure 4.2. Number of clients with 4 or more treatment sessions based on number of

sessions.

85

136

56

2915

0

20

40

60

80

100

120

140

160

4-5 6-10 11-15 16-20 20+

Number of Sessions

Num

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f Clie

nts

56

Results of one-sample t-test—temperature training.

This study adopted a longitudinal approach and an individual growth model

(Willett, 1994) for data analysis. The linear individual growth model is used as the basis

for the statistical analysis. Individual growth trajectory provided more information such

as individual growth and individual differences in growth when compared to measuring

individual change with observation at two time point (i.e. pre- and post- test) (Willett,

1989; Maxwell, 1998).

The researcher collected six temperature data points for clients who had

temperature training. These six temperature data points are beginning and ending

temperature of the first, middle, and last treatment session. Each client’s six

temperature data points were used to plot a slope that represented each client’s

personal growth trajectory for temperature training. Then, all temperature slopes were

combined to perform a one-sample t-test to determine its statistical significance. The

basic assumption for this model is that if there is no change occurred due to

temperature training; the t value will be zero. Effect sizes were computed by using

Pearson’s r (Rosenthal, 1991).

Findings of one sample t-test on temperature training are summarized in tables

4.1, 4.2, 4.3, 4.4, 4.5, 4.6, 4.7, 4.8, 4.9, and 4.10. Clients whose beginning

temperature was greater than 90 degrees Fahrenheit were excluded to avoid the ceiling

effect (see Appendix A for collection of fitted individual growth trajectories, Table A1

and A2). Total subject number is 104. Results show statistical significance in

temperature training as a whole group (Tables 4.1 & 4.2), t = 4.672, df = 103, p =

57

.000 (two-tailed), with a small effect size (r2 = .21). When divided into subtypes based

on primary presenting problem (Tables 4.3 & 4.4), results indicate statistical

significance in chronic pain (t = 3.163, df = 17, p = .006 (2-tailed), r2 = .56), tension

headache (t = 2.723, df = 15, p = .016 (2 tailed), r2 = .46), and TMJ (t = 3.040, df =

6, p = .023 (2-tailed), r2 = 1.32). All three of these symptom categories have moderate

to large effect sizes.

Table 4.1. Mean, standard deviation, and standard error mean for 6 points temperature slope.

N Mean Std. Deviation Std. Error Mean slope 6 points

temp 104 .7598 1.65847 .16263

Table 4.2. One-sample t-test for 6 points temperature slope as a whole group.

Test Value = 0 T df Sig. (2-

tailed) Mean

Difference 95% Confidence Interval of the

Difference Lower Upper

slope 6 points temp

4.672 103 .000** .7598 .4372 1.0823

** p < .01

58

Table 4.3. Mean, standard deviation, and standard error mean of 6 points temperature slope sorted by primary presenting problem. Primary Presenting Problem

N Mean Std. Deviation

Std. Error Mean

Anxiety 9 .7521 1.28075 .42692 Chronic pain 18 1.3637 1.82902 .43110 Fibromyalgia 1 .3257 . . Gastrointestinal Problem 7 1.1571 1.93744 .73228 Tension Headache 16 1.0996 1.61537 .40384 Hypertension 7 .8824 1.11242 .42045 Migraine Headache 5 -.4617 2.17901 .97448 Performance Anxiety 3 -.4648 1.23117 .71082 Raynaud’s 6 1.1362 2.90800 1.18719 Sleep Problem 3 .1743 2.60588 1.50451 Stress 14 .4008 1.28154 .34251 Test Anxiety 3 1.0114 .74286 .42889 TMJ 7 .5298 .46107 .17427 Others 5 -.0971 1.79730 .80378 a t cannot be computed because the sum of case weights is less than or equal 1.

59

Table 4.4. One-sample t-test for 6 points temperature slope sorted by primary presenting problem.

Test Value = 0 Primary Presenting Problem

t df Sig. (2-

tailed) Mean



Anxiety slope 6 points temp

1.762 8 .116 .7521 -.2324 1.7365

Chronic Pain slope 6 points temp

3.163 17 .006** 1.3637 .4541 2.2732

Gastrointestinal Problem

slope 6 points temp

1.580 6 .165 1.1571 -.6347 2.9490

Tension Headache

slope 6 points temp

2.723 15 .016** 1.0996 .2389 1.9604

Hypertension slope 6 points temp

2.099 6 .081 .8824 -.1464 1.9113

Migraine Headache

slope 6 points temp

-.474 4 .660 -.4617 -3.1673 2.2439

Performance Anxiety

slope 6 points temp

-.654 2 .580 -.4648 -3.5232 2.5936

Raynaud's slope 6 points temp

.957 5 .382 1.1362 -1.9156 4.1880

Sleep Problem slope 6 points temp

.116 2 .918 .1743 -6.2991 6.6477

Stress slope 6 points temp

1.170 13 .263 .4008 -.3391 1.1408

Test Anxiety slope 6 points temp

2.358 2 .142 1.0114 -.8339 2.8568

TMJ slope 6 points temp

3.040 6 .023** .5298 .1034 .9562

Others slope 6 points temp

-.121 4 .910 -.0971 -2.3288 2.1345

a No statistics are computed for one or more split files * p < .05 ** p < .01

Tables 4.5 and 4.6 illustrate findings of a one-sample t-test based on gender

subtypes. Both male clients and female clients show a statistically significant increase in

their finger temperature (male, t = 2.408, df = 18, p = .027 (2-tailed), and female, t =

60

4.035, df = 84, p = .000 (2-tailed)). Females have a small effect size (r2 = .19) and

males have a moderate effect size (r2 = .30).

Table 4.5. Mean, standard deviation, and standard error mean of 6 points temperature slope sorted by gender. GENDER N Mean Std. Deviation Std. Error Mean Female slope 6 points

temp 85 .7432 1.69787 .18416

Male slope 6 points temp

19 .8341 1.50965 .34634

Table 4.6. One-sample t-test for 6 points temperature slope sorted by gender.

Test Value = 0 GENDER

t df Sig. (2-

tailed) Mean



Female slope 6 points temp

4.035 84 .000** .7432 .3769 1.1094

Male slope 6 points temp

2.408 18 .027** .8341 .1065 1.5618

* p < .05 ** p < .01 When divided into age subtypes (Table 4.7 & 4.8), for the age groups of 18-24

years old, 25-35 years old, 46-55 years old, and 56-76 years old, findings shows

statistical significance at p < .05. Results of clients based on age subtypes are: age

range 18-24, t = 2.485, df = 16, p = .024 (2-tailed); age range 25-35, t = 2.325, df =

31, p = .027 (2-tailed); age range 46-55, t = 2.231, df = 20, p = .037 (2-tailed); and

age range 56-76, t = 7.305, df = 2, p = .018 (2-tailed). Age range18-24 group has a

moderate effect size (r2 = .36) and age range 56-76 group has a large effect size (r2 =

17.7). The other two age groups have small effect sizes: 25-35 (r2 = .17) and 46-55 (r2

= .23).

61

Table 4.7. Mean, standard deviation, and standard error mean of 6 points temperature slope sorted by age. Age N Mean Std. Deviation Std. Error Mean 15-17 slope 6 points

temp 3 1.0448 .64709 .37360

18-24 slope 6 points temp

17 1.2274 2.03641 .49390


32 .7121 1.73251 .30627


28 .3404 1.21672 .22994


21 .9309 1.91240 .41732


3 1.0495 .24884 .14367

Table 4.8. One-sample t-test for 6 points temperature slope sorted by age.

Test Value = 0 Age

t df Sig. (2-

tailed) Mean




2.796 2 .108 1.0448 -.5627 2.6522


2.485 16 .024** 1.2274 .1804 2.2744


2.325 31 .027** .7121 .0875 1.3368


1.480 27 .150 .3404 -.1314 .8122


2.231 20 .037** .9309 .0604 1.8014


7.305 2 .018** 1.0495 .4314 1.6677

* p < .05 ** p < .01

62

Tables 4.9 and 4.10 show the results based on number of sessions that clients

had. Clients with treatment sessions between 6 to 10 sessions and 11 to 15 sessions

show statistically significant increases in finger temperature: 6 to 10 sessions, t =

2.745, df = 35, p = .009 (2-tailed), and 11 to 15 sessions, t = 4.670, df = 24, p = .000

(2-tailed). Clients with 6 to 10 treatment sessions have a small effect size (r2 = .21) and

clients with11 to 15 sessions have a large effect size (r2 = .87).

Table 4.9. Mean, standard deviation, and standard error mean of 6 points temperature slope sorted by number of sessions. Number of Sessions


Std. Error Mean


30 .4810 1.66442 .30388


36 .8398 1.82940 .30490


25 1.2278 1.31449 .26290


10 .2063 1.40533 .44441

20+ slope 6 points temp

3 .5333 2.76874 1.59853

63

Table 4. 10. One-sample t-test for 6 points temperature slope sorted by number of session.

Test Value = 0 Number of

Sessions

t df Sig. (2-tailed)

Mean Difference

95% Confidence Interval of the



1.583 29 .124 .4810 -.1406 1.1025


2.754 35 .009** .8398 .2208 1.4587


4.670 24 .000** 1.2278 .6852 1.7704


.464 9 .654 .2063 -.7990 1.2116

20+ slope 6 points temp

.334 2 .770 .5333 -6.3446 7.4113

** p < .01

Muscle tension training

The researcher collected six electromyography data points for clients who had

muscle tension training. These six electromyography data points are beginning and

ending muscle tension of the first, middle, and last treatment session. Each client’s six

muscle tension data points were used to plot a slope that represented each client’s

personal growth trajectory for muscle tension training. Then, all muscle tension slopes

were combined to perform a one-sample t-test to determine its statistical significance.

The basic assumption for this model is that if there is no change occurred due to

muscle tension training, the t value will be zero. Effect sizes were computed by using

Pearson’s r.

Findings of one-sample t-test for muscle tension training are summarized in

tables 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9, and 5.10. Clients whose beginning

64

muscle tension were below or equal to 2.5 microvolt were excluded to avoid the floor

effect (see Appendix A for collection of fitted individual growth trajectories, Tables A3

and A4). Overall subject number is 163. Tables 5.1 and 5.2 show a statistically

significant change in muscle tension training as a whole group, t = -8.489, df = 162, p

= .000 (2-tailed), with a moderate effect size (r2 = .44).

Table 5.1. Mean, standard deviation, and standard error mean for 6 points EMG slope.

N Mean Std. Deviation Std. Error Mean

slope 6 points emg

163 -.2719 .40897 .03203

Table 5.2. One-sample t-test for 6 points EMG slope as a whole group. Test Value = 0 t df Sig. (2-

tailed) Mean

Difference95% Confidence Interval

of the Difference Lower Upper

slope 6 points emg

-8.489 162 .000** -.2719 -.3352 -.2087

* p < .05 ** p < .01

When divided into subtypes based on clients’ primary presenting problem (Table 5.3

& 5.4), results indicate statistical significance in the following symptoms:

1. chronic pain, t = -3.947, df = 27, p = .001 (2-tailed), with a large effect size (r2

= .56),

2. tension headache, t = -2.469, df = 21, p = .022 (2 tailed), with a moderate

effect size (r2 = .28),

3. hypertension, t = -2.953, df = 11, p = .013 (2-tailed), with a large effect size (r2

= .73),

65

4. migraine headache, t = -3.335, df = 10, p = .008 (2-tailed), with a large effect

size (r2 = 1.01),

5. stress, t = -4.705, df = 30, p = .000 (2-tailed), with a large effect size (r2 = .71),

and

6. TMJ, t = -2.878, df = 6, p = .028 (2-tailed), with a large effect size (r2 = 1.18).

Table 5.3. Mean, standard deviation, and standard error mean of 6 points EMG slope sorted by primary presenting problem. Primary Presenting Problem


Std. Error Mean

Anxiety slope 6 points emg 18 -.2275 .47337 .11157 Chronic Pain slope 6 points emg 28 -.2094 .28071 .05305 Fibromyalgia slope 6 points emg 4 -.1979 .27296 .13648 Gastrointestinal Problem

slope 6 points emg 8 -.2025 .36988 .13077

Tension Headache slope 6 points emg 22 -.2960 .56219 .11986 Hypertension slope 6 points emg 12 -.2345 .27509 .07941 Migraine Headache slope 6 points emg 11 -.3101 .30841 .09299 Performance Anxiety slope 6 points emg 5 -.2463 .32063 .14339 Raynaud's slope 6 points emg 2 -.0614 .22425 .15857 Sleep Problem slope 6 points emg 4 -.5293 1.00629 .50315 Stress slope 6 points emg 31 -.3339 .39515 .07097 Test Anxiety slope 6 points emg 5 -.4286 .52807 .23616 TMJ slope 6 points emg 7 -.3110 .28587 .10805 Others slope 6 points emg 6 -.1795 .41351 .16882

66

Table 5.4. One-sample t-test for 6 points EMG slope sorted by primary presenting problem.

Test Value = 0 Primary Presenting Problem

t df Sig. (2-tailed)

Mean Differenc

e



Anxiety slope 6 points emg

-2.039 17 .057 -.2275 -.4629 .0079

Chronic Pain slope 6 points emg

-3.947 27 .001** -.2094 -.3182 -.1005

Fibromyalgia slope 6 points emg

-1.450 3 .243 -.1979 -.6322 .2365

Gastrointestinal Problem

slope 6 points emg

-1.549 7 .165 -.2025 -.5117 .1067

Tension Headache

slope 6 points emg

-2.469 21 .022* -.2960 -.5452 -.0467

Hypertension slope 6 points emg

-2.953 11 .013* -.2345 -.4093 -.0597

Migraine Headache

slope 6 points emg

-3.335 10 .008** -.3101 -.5173 -.1029

Performance Anxiety

slope 6 points emg

-1.718 4 .161 -.2463 -.6444 .1518

Raynaud's slope 6 points emg

-.387 1 .765 -.0614 -2.0763 1.9534

Sleep Problem slope 6 points emg

-1.052 3 .370 -.5293 -2.1305 1.0719

Stress slope 6 points emg

-4.705 30 .000** -.3339 -.4789 -.1890

Test Anxiety slope 6 points emg

-1.815 4 .144 -.4286 -1.0843 .2271

TMJ slope 6 points emg

-2.878 6 .028* -.3110 -.5754 -.0466

Others slope 6 points emg

-1.063 5 .336 -.1795 -.6135 .2544

* p < .05 ** p < .01

67

Tables 5.5 and 5.6 indicate statistical significance in muscle tension training with

both genders: female, t = -7.799, df = 134, p = .000, with moderate effect size (r2 =

.45) and male, t = -3.385, df = 27, p = .002, with a moderate effect size (r2 = .41).

Table 5.5. Mean, standard deviation, and standard error mean of 6 points EMG slope sorted by gender. GENDER N Mean Std.

Deviation Std. Error Mean

Female slope 6 points emg 135 -.2647 .39431 .03394 Male slope 6 points emg 28 -.3070 .47994 .09070 Table 5.6. One-sample t-test for 6 points EMG slope sorted by gender.

Test Value = 0 GENDER

t df Sig. (2-

tailed) Mean

Difference



Female slope 6 points emg

-7.799 134 .000** -.2647 -.3318 -.1975

Male slope 6 points emg

-3.385 27 .002** -.3070 -.4931 -.1209

* p < .05 ** p < .01

When divided into age subtypes, findings (Tables 5.7 & 5.8) indicate all age group

are statistically significant except age range 15-17 years old. Results of clients based on

age subtypes are:

1. age range 18-24, t = -3.633, df = 17, p = .002 (2-tailed), with a large effect size

(r2 = .73),

2. age range 25-35, t = -3.565, df = 52, p = .001 (2-tailed), with a small effect size

(r2 = .24),

68

3. age range 36-45, t = -3.741, df = 41, p = .001 (2-tailed), with a moderate effect

size (r2 = .33),


(r2 = .71), and


(r2 = 1.06).

Table 5.7. Mean, standard deviation, and standard error mean of 6 points EMG slope sorted by age. Age N Mean Std. Deviation Std. Error Mean 15-17 slope 6 points emg 2 -.3943 .45255 .32000 18-24 slope 6 points emg 18 -.4421 .51622 .12167 25-35 slope 6 points emg 53 -.2043 .41711 .05730 36-45 slope 6 points emg 42 -.2452 .42472 .06554 46-55 slope 6 points emg 30 -.2666 .31580 .05766 56-76 slope 6 points emg 18 -.3589 .34847 .08214 Table 5.8. One-sample t-test for 6 points EMG slope sorted by age.

Test Value = 0 Age

t df Sig. (2-

tailed) Mean



15-17 slope 6 points emg -1.232 1 .434 -.3943 -4.4603 3.6717 18-24 slope 6 points emg -3.633 17 .002** -.4421 -.6988 -.1854 25-35 slope 6 points emg -3.565 52 .001** -.2043 -.3192 -.0893 36-45 slope 6 points emg -3.741 41 .001** -.2452 -.3775 -.1128 46-55 slope 6 points emg -4.623 29 .000** -.2666 -.3845 -.1486 56-76 slope 6 points emg -4.369 17 .000** -.3589 -.5322 -.1856 * p < .05 ** p < .01

69

Tables 5.9 and 5.10 indicate a statistically significant change in muscle tension

training no matter how many treatment session clients had at p < .01. The following

are the results of the number of session subtypes:

1. 4 to 5 sessions, t = -2.905, df = 39, p = .006 (2-tailed), with a small effect size

(r2 = .21),

2. 6 to 10 sessions, t = -5.683, df = 72, p = .000 (2-tailed), with a moderate effect

size (r2 = .44),

3. 11 to 15 sessions, t = -5.114, df = 24, p = .000 (2-tailed), with a large effect

size (r2 = 1.05),

4. 16 to 20 sessions, t = -3.605, df = 13, p = .003 (2-tailed), with a large effects

size (r2 = .93), and

5. 20+ sessions, t = -5.612, df = 10, p = .000, with a large effect size (r2 = 2.86).

Table 5.9. Mean, standard deviation, and standard error mean of 6 points EMG slope sorted by number of sessions. Number of Sessions


Std. Error Mean

4-5 slope 6 points emg

40 -.2287 .49795 .07873


73 -.2995 .45018 .05269


25 -.2425 .23710 .04742


14 -.2369 .24595 .06573

20+ slope 6 points emg

11 -.3579 .21153 .06378

70

Table 5.10. One-sample t-test for 6 points EMG slope sorted by number of sessions.

Test Value = 0 Number of Sessions

t df Sig. (2-

tailed) Mean




-2.905 39 .006** -.2287 -.3880 -.0695


-5.683 72 .000** -.2995 -.4045 -.1944


-5.114 24 .000** -.2425 -.3404 -.1446


-3.605 13 .003** -.2369 -.3789 -.0949

20+ slope 6 points emg

-5.612 10 .000** -.3579 -.5000 -.2158

* p < .05 ** p < .01

Results of factor analysis – temperature training.

The researcher collected 6 temperature data points for clients who had

temperature training and 6 muscle tension data points for clients who had muscle

tension training. Six temperature data points are beginning and ending temperature of

the first, middle, and last treatment session and six muscle tension data points are

beginning and ending muscle tension of first, middle, and last treatment session. Each

client’s six temperature data points were used to plot an individual temperature learning

curve that represents how a client learned or did not learn to increase finger

temperature in temperature training sessions (see Appendix C for examples of

individual temperature learning curve). Each client’s six muscle tension data points were

used to plot an individual EMG learning curve that represent how a client learned or did

not learn to reduce muscle tension in muscle tension training sessions (see Appendix C

for examples of individual EMG learning curve). Factor analysis is a mathematical tool

71

and is used to classify the regularity in the data into its separate patterns (Rummel,

1967).

Figure 5.1 shows the three basic biofeedback learning curves for training

temperature increases that are composed of 84% of 104 clients (see Appendix B for

detailed print-out of factor analysis for temperature training, Table B1, B2, and B3). The

following illustrate these three basic biofeedback learning curves for training

temperature increases presented by the data:

1. steady state and trainable (low variability), composed of 40.2% of 104 clients,

shown in solid line,

2. phasic state and low trainable (high variability), composed of 27.7% of all 104

clients, shown in large dotted line, and

3. phasic state and trainable (high variability), composed of 16.2% of all 104

clients, shown in small dotted line.

72

Figure 5.1. Three basic biofeedback learning curves for training temperature increases.

Standard scores

PERIOD

654321

1.5

1.0

.5

0.0

-.5

-1.0

-1.5

-2.0

REGR factor score

1 for analysis 1

REGR factor score

2 for analysis 1

REGR factor score

3 for analysis 1

Results of factor analysis – muscle tension training.

Figure 5.2 shows the three basic biofeedback learning curves for training muscle

tension reduction that are composed of 82.2% of 163 clients (see Appendix B for

detailed print-out of factor analysis for muscle tension training, Table B4, B5, and B6).

The following illustrate three basic biofeedback learning curves for training muscle

tension reduction presented by the data:

1. steady state and trainable (low variability), composed of 38.4% of 163 clients,

shown in solid line,

2. phasic state and low trainable (high variability), composed of 24.1% of all 163

clients, shown in large dotted line, and

4. phasic state and trainable (high variability), composed of 19.6% of all 163

73

clients, shown in small dotted line.

Figure 5.2. Three basic biofeedback learning curves for training muscle tension reduction. Standard Scores

PERIOD

654321

2.0

1.5

1.0

.5

0.0

-.5

-1.0

-1.5

-2.0

REGR factor score

1 for analysis 1

REGR factor score

2 for analysis 1

REGR factor score

3 for analysis 1

Discussion

When reviewing client files, there were a large number of clients that did not

have sufficient information in their files such as lacking the pre- and/or post- Stress

Signal Checklist, no information on clients’ ethnicity, no session notes regarding clients’

self-reported progress and therapist’s observations. Only 25.4% of clients had

completed information on both pre- and post- Stress Signal Checklist. Two main

reasons for lacking this information could be: (a) clients decided to terminate treatment

74

and did not come in for the termination session, and (2) therapists failed to give the

Stress Signal Checklist to clients in the first or last session.

There were a small number of clients having information regarding reasons for

early termination. Followings are a list of reasons:

1. Clients had a scheduling problem;

2. It was the end of the semester;

3. Therapists finished their training;

4. Clients can not get a release from their physician for biofeedback treatment;

5. Clients did not have time to commit themselves to the training;

6. Clients (pregnant women) had their baby early or lost their baby;

7. Clients participated in other therapy; and

8. Clients moved to another state.

There were 180 client files (44%) out of 409 client files that did not have

information written down on their session notes except clients’ physiological measures

(i.e. temperature and muscle tension reading). When considering the client files that did

have client status and progress information written in the therapist session notes a

majority of these clients did report good progress. Approximately 80% of clients who

had self-reported information in their files reported some types of progress such as

primary presenting problem decreased, other symptom decreased when clients had

multiple symptomology, and/or other types of progress when excluding the 180 client

files that did not have clients’ self-reported information and/or therapists’ observations.

75

Therefore, it is difficult to determine efficacy of biofeedback therapy when there is

incomplete information.

Possible reasons for the lack of clients’ self-reported progress and therapist’s

observations on session notes could be:

1. Clients did not experience any progress;

2. Clients did experience some progress such as symptom decrease, increased

awareness, or other benefits but did not share these progress with therapists in

sessions;

3. Clients reported progress but therapists did not record on session notes;

4. Therapists failed to ask about clients’ progress or did not know what and how to

ask due to inexperience in biofeedback therapy; and

5. Therapists did not keep a proper case note.

This finding indicates the importance of keeping proper therapist’s session notes

so efficacy of treatment can be accurately measured through therapists’ session notes.

Implications for the BRTL are to provide greater structure and instruction regarding

keeping session notes for biofeedback students and to provide closer supervision to

insure completion of session notes for the purpose of evaluating treatment efficacy and

providing better research data in the future.

From 1992 to 2002, the BRTL provided biofeedback therapy for 409 clients.

There are some years such as 1995, 1996, 1998, 1999, and 2000 that had more clients

than the other years. Reasons for having more clients in these years are: (a) during

these years, there were more students taking biofeedback classes, and (b) there were

76

master and/or doctoral students who specialized in biofeedback therapy and did their

internship in the BRTL. The year 2002 had a low frequency of biofeedback therapy

because Dr. Chandler, the Director of the BRTL, was on a research sabbatical. The

following year, 2003 data not included in this study, the biofeedback therapy frequency

rose to another high level due to large enrollment in the biofeedback courses (i.e. 22

students enrolled in Introduction of Biofeedback, 18 students enrolled in Biofeedback

Practicum, and 12 students enrolled in Advanced Practicum in Biofeedback).

The BRTL has provided biofeedback therapy for a variety of symptoms. When

compared with what the literature suggests biofeedback therapy is effective in treating,

the BRTL has provided service for clients with migraine headache, tension headache,

hypertension, irritable bowel syndrome, chronic pain, TMJ, asthma, and anxiety but did

not treat clients with diabetes, incontinence, pediatric constipation, hand dsytonia, and

phantom limb pain as primary presenting problems. Since the BRTL is a university-

based clinic, the BRTL also treated clients (mainly university students) with test anxiety

and performance anxiety.

This study shows that through temperature biofeedback training and EMG

biofeedback training clients were able to increase finger temperature and to decrease

forehead muscle tension. In temperature training, as a whole group, results indicate a

statistically significant increase in finger temperature. However, when divided into

subtypes based on primary presenting problem, only three primary presenting

problems, chronic pain, tension headache, and TMJ, show statistically significant

changes. Both chronic pain and TMJ have large clinical effect sizes and tension

77

headache have a moderate clinical effect size. The fact that the other primary

presenting problems do not have statistically significant results could possibly be due to

small sample sizes. For example, performance anxiety, test anxiety, and sleep problem

only have 3 subjects each; migraine headache has 5 subjects and Raynauld’s has 6

subjects. In conclusion, in this type of treatment environment, temperature training

seems very helpful to clients with chronic pain and TMJ and moderately helpful for

tension headaches.

In muscle tension training, findings indicate statistically significant decreases in

muscle tension as a whole group. When divided into subtypes based on primary

presenting problem, six primary presenting problems, chronic pain, tension headache,

hypertension, migraine headache, stress, and TMJ, show statistically significant results.

Five of these presenting problems except tension headache showed large clinical effect

sizes. Small sample sizes could possibly contribute to the no statistically significant

results for other presenting problems. Most of them have less than 10 subjects except

anxiety, which has 18 subjects. In conclusion, in this type of treatment environment,

findings suggest that clients with chronic pain, tension headache, hypertension,

migraine headache, stress, and TMJ are able to benefit from muscle tension training.

From 1992 to 2002, the BRTL provided biofeedback therapy for 409 clients that

included 97 male clients and 312 female clients. The male and female client ratio is

approximately 1 to 3. This finding indicates that from 1992 to 2002 the majority of

clientele of BRTL was females (78.5%). For 409 clients, 270 clients had information

regarding their ethnicity and 243 out of these 270 clients were Caucasian (90%). This

78

finding shows that there was not a lot of ethnic minority such as African American,

Asian, Hispanic, and Native American sought help from the BRTL from 1992 to 2002.

Therefore, these results indicate there is a need for the BRTL to reach males and ethnic

minority as potential clients in the future.

Findings indicate that both male and female clients have statistically significant

changes in temperature training and muscle tension training. In temperature training,

male clients have a moderate clinical effect size and female clients only have a small

clinical effect size. In muscle tension training, both genders have moderate effect sizes.

Results suggest that both genders do equally well on muscle tension training; however,

male clients might learn better in temperature training than female clients.

Results on age group subtypes demonstrate that 4 out of 6 age groups are

statistically significant in temperature training and 5 out of 6 age groups are statistically

significant in muscle tension training. Results on age group demonstrate that group 15

to 17 years are not statistically significant on both training modalities which might be

due to the small sample sizes (3 subjects for temperature training and 2 subjects for

muscle tension training). Clients with ages between 18 to 24 years old, traditional

college students’ age, have a moderate clinical effect size in temperature training and a

large clinical effect size in muscle tension training. Results on clients’ ages between 25

to 45 years old have small clinical effect sizes on both temperature and muscle tension

training. A possible explanation could be that clients in this age group tended to juggle

work, family, and possible school responsibilities that added an extra stress in their lives

and at the same time were not compliant with treatment. Results of clients with ages

79

between 46 to 55 years old indicated a small clinical effect size on temperature training

and a large clinical effect size on muscle tension training. Clients with ages between 56

to 76 years old are the only group that has large clinical effect sizes on both

temperature and muscle tension training. Possible explanations could be that older

clients were probably more mature and settled and were more concerned about their

physical health; therefore, they put more efforts in the training which can contribute to

the success in the sessions.

The number of treatment sessions seemed to make a difference regarding

treatment efficacy on temperature training. Clients with 6 to 15 sessions show

statistically significant increases in their temperature. However, clients with 11 to 15

treatment sessions show a large clinical effect size and clients with 6 to 10 treatment

sessions only have a small clinical effect size. Results suggest clients need to have at

least 6 sessions to learn to increase their finger temperature but they need 11 to 15

sessions to really get the benefit from training. According to this study, more then 15

treatment sessions do not help with treatment efficacy. However, no statistically

significant results on more than 15 sessions could also be due to small sample sizes.

Number of sessions did not seem to impact much on muscle tension training.

Results indicate statistically significant reductions in clients’ muscle tension no matter

how many sessions they had. However, only clients with more than 10 sessions show a

large clinical effect size. Therefore, findings suggest clients are able to reduce their

forehead muscle tension after 4 treatment sessions but they need to at least 11

treatment sessions to obtain a great clinical benefit from the training.

80

Three basic biofeedback learning curves are identified in this study: steady state

and trainable (low variability), phasic state and low trainable (high variability), and

phasic state and trainable (high variability). Both temperature training and muscle

tension training are categorized into these three patterns. The first pattern of

biofeedback learning curve, steady state and trainable (low variability), shows that

clients are able to learn to increase temperature and/or decrease muscle tension by the

end of training. In addition, clients’ learning remained at a fairly stable level with little

to no fluctuations. The second pattern of biofeedback learning curve, phasic state and

low trainable (high variability), demonstrates clients are not able to learn to increase

temperature and/or decrease muscle tension by the end of treatment, although clients

seem to be able to increase temperature and/or decrease muscle tension during

sessions. There is no indication that learning of these skills occurred by the end of

training. The last pattern of biofeedback learning curve, phasic state and trainable (high

variability), shows that clients are able to learn to increase temperature and reduce

muscle tension by the end of their training although temperature and/or muscle tension

fluctuated a lot during the period of treatment.

This study identifies three basic patterns of biofeedback therapy learning curve.

Future research might focus on what factors contribute to certain learning curves.

Possible factors are personality, age, locus of control, situational stressors, severity of

symptoms, practice effect (homework relaxation exercise), treatment atmosphere,

and/or therapeutic relationship. Furthermore, when the connection between learning

81

curve and contributing factors is made, this information might be used to predict

treatment outcomes for certain types of client.

82

APPENDIX A

Collection of Fitted Individual Growth Trajectories

83

Table A1. Collection of fitted individual growth trajectory for clients with beginning temperature < = 90 degree Fahrenheit (x = period, y = temperature).

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

84

Table A2. Collection of fitted individual growth trajectory for clients with beginning temperature > 90 degree Fahrenheit (x = period, y = temperature)

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

1 2 3 4 5 6

x

7075

8085

9095

y

85

Table A3. Collection of fitted individual growth trajectory for clients with beginning EMG > 2.5 microvolt (x = period, y = microvolt)

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

86

Table A4. Collection of fitted individual growth trajectory for clients with beginning EMG < = 2.5 microvolt (x = period, y = microvolt)

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

x

y

1 2 3 4 5 6

02

46

8

87

APPENDIX B

Factor Analysis

88

Table B1. Communalities—Temperature Training Initial Extraction V109 1.000 .903 V216 1.000 .981 V239 1.000 .890 V244 1.000 .734 V295 1.000 .477 V297 1.000 .687 V330 1.000 .860 V402 1.000 .964 V408 1.000 .966 V52 1.000 .980 V53 1.000 .807 V93 1.000 .927 V141 1.000 .894 V155 1.000 .588 V212 1.000 .915 V222 1.000 .854 V246 1.000 .829 V258 1.000 .999 V281 1.000 .891 V333 1.000 .281 V334 1.000 .653 V339 1.000 .708 V360 1.000 .878 V367 1.000 .880 V371 1.000 .821 V379 1.000 .903 V380 1.000 .846 V336 1.000 .987 V66 1.000 .981 V75 1.000 .925 V108 1.000 .983 V113 1.000 .937 V204 1.000 .957 V254 1.000 .824 V329 1.000 .995 V15 1.000 .943 V84 1.000 .973 V91 1.000 .976 V105 1.000 .991

89

Table B1. (continued) Initial Extraction V174 1.000 .942 V179 1.000 .793 V181 1.000 .775 V227 1.000 .991 V233 1.000 .917 V235 1.000 .549 V238 1.000 .895 V265 1.000 .959 V268 1.000 .956 V277 1.000 .850 V291 1.000 .993 V362 1.000 .765 V111 1.000 .957 V147 1.000 .792 V190 1.000 .830 V255 1.000 .723 V314 1.000 .861 V327 1.000 .869 V409 1.000 .918 V20 1.000 .734 V58 1.000 .906 V194 1.000 .961 V219 1.000 .993 V253 1.000 .414 V42 1.000 .889 V47 1.000 .804 V87 1.000 .820 V353 1.000 .703 V365 1.000 .827 V223 1.000 .991 V224 1.000 .885 V407 1.000 .989 V12 1.000 .984 V104 1.000 .953 V121 1.000 .977 V149 1.000 .895 V346 1.000 .978 V347 1.000 .693 V218 1.000 .875

90

Table B1. (continued) Initial Extraction V288 1.000 .379 V293 1.000 .913 V23 1.000 .971 V74 1.000 .956 V125 1.000 .888 V132 1.000 .702 V137 1.000 .935 V193 1.000 .736 V250 1.000 .588 V270 1.000 .968 V283 1.000 .640 V304 1.000 .854 V350 1.000 .975 V361 1.000 .738 V368 1.000 .818 V393 1.000 .963 V83 1.000 .832 V114 1.000 .931 V251 1.000 .995 V5 1.000 .671 V37 1.000 .709 V115 1.000 .309 V241 1.000 .718 V307 1.000 .905 V394 1.000 .342 V404 1.000 .821 Extraction Method: Principal Component Analysis.

91

Table B2. Total Variance Explained—Temperature Training

Initial Eigenvalues Extraction Sums of Squared LoadingsComponent Total % of

Variance Cumulative

% Total % of

Variance Cumulative

% 1 41.782 40.175 40.175 41.782 40.175 40.175 2 28.854 27.744 67.919 28.854 27.744 67.919 3 16.818 16.171 84.090 16.818 16.171 84.090 4 10.335 9.937 94.027 5 6.212 5.973 100.000 6 1.042E-14 1.002E-14 100.000 7 6.750E-15 6.490E-15 100.000 8 5.666E-15 5.448E-15 100.000 9 3.119E-15 2.999E-15 100.000 10 1.810E-15 1.741E-15 100.000 11 1.014E-15 9.749E-16 100.000 12 9.199E-16 8.845E-16 100.000 13 8.653E-16 8.320E-16 100.000 14 8.510E-16 8.183E-16 100.000 15 8.166E-16 7.852E-16 100.000 16 8.056E-16 7.746E-16 100.000 17 7.778E-16 7.479E-16 100.000 18 7.480E-16 7.193E-16 100.000 19 7.218E-16 6.940E-16 100.000 20 6.927E-16 6.661E-16 100.000 21 6.675E-16 6.418E-16 100.000 22 6.444E-16 6.197E-16 100.000 23 6.180E-16 5.943E-16 100.000 24 5.940E-16 5.711E-16 100.000 25 5.727E-16 5.507E-16 100.000 26 5.520E-16 5.308E-16 100.000 27 5.033E-16 4.840E-16 100.000 28 4.982E-16 4.790E-16 100.000 29 4.833E-16 4.647E-16 100.000 30 4.544E-16 4.369E-16 100.000 31 4.313E-16 4.147E-16 100.000 32 4.099E-16 3.941E-16 100.000 33 3.891E-16 3.741E-16 100.000 34 3.684E-16 3.542E-16 100.000 35 3.428E-16 3.296E-16 100.000 36 3.261E-16 3.135E-16 100.000 37 3.178E-16 3.056E-16 100.000 38 2.965E-16 2.851E-16 100.000 39 2.753E-16 2.647E-16 100.000

92

Table B2. (continued)


Variance Cumulative

% Total % of

Variance Cumulative

% 40 2.612E-16 2.512E-16 100.000 41 2.219E-16 2.134E-16 100.000 42 2.134E-16 2.052E-16 100.000 43 1.917E-16 1.843E-16 100.000 44 1.859E-16 1.787E-16 100.000 45 1.443E-16 1.387E-16 100.000 46 1.172E-16 1.127E-16 100.000 47 1.076E-16 1.035E-16 100.000 48 9.301E-17 8.943E-17 100.000 49 7.139E-17 6.864E-17 100.000 50 5.869E-17 5.643E-17 100.000 51 5.674E-17 5.455E-17 100.000 52 3.300E-17 3.173E-17 100.000 53 2.119E-17 2.038E-17 100.000 54 1.212E-17 1.165E-17 100.000 55 -1.425E-17 -1.371E-17 100.000 56 -2.648E-17 -2.547E-17 100.000 57 -4.732E-17 -4.550E-17 100.000 58 -6.693E-17 -6.436E-17 100.000 59 -9.695E-17 -9.322E-17 100.000 60 -1.102E-16 -1.060E-16 100.000 61 -1.123E-16 -1.080E-16 100.000 62 -1.490E-16 -1.432E-16 100.000 63 -1.546E-16 -1.487E-16 100.000 64 -1.641E-16 -1.578E-16 100.000 65 -1.799E-16 -1.730E-16 100.000 66 -2.008E-16 -1.931E-16 100.000 67 -2.208E-16 -2.123E-16 100.000 68 -2.395E-16 -2.303E-16 100.000 69 -2.572E-16 -2.473E-16 100.000 70 -2.610E-16 -2.510E-16 100.000 71 -3.013E-16 -2.897E-16 100.000 72 -3.211E-16 -3.087E-16 100.000 73 -3.376E-16 -3.246E-16 100.000 74 -3.549E-16 -3.412E-16 100.000 75 -3.954E-16 -3.802E-16 100.000 76 -4.161E-16 -4.001E-16 100.000 77 -4.239E-16 -4.076E-16 100.000 78 -4.475E-16 -4.303E-16 100.000

93



Variance Cumulative

% Total % of

Variance Cumulative

% 79 -4.801E-16 -4.616E-16 100.000 80 -4.946E-16 -4.755E-16 100.000 81 -5.312E-16 -5.108E-16 100.000 82 -5.417E-16 -5.209E-16 100.000 83 -5.770E-16 -5.548E-16 100.000 84 -6.108E-16 -5.873E-16 100.000 85 -6.145E-16 -5.909E-16 100.000 86 -6.446E-16 -6.198E-16 100.000 87 -6.545E-16 -6.293E-16 100.000 88 -6.688E-16 -6.431E-16 100.000 89 -7.002E-16 -6.733E-16 100.000 90 -7.190E-16 -6.914E-16 100.000 91 -7.463E-16 -7.176E-16 100.000 92 -7.932E-16 -7.627E-16 100.000 93 -8.052E-16 -7.742E-16 100.000 94 -8.362E-16 -8.040E-16 100.000 95 -8.504E-16 -8.177E-16 100.000 96 -9.186E-16 -8.832E-16 100.000 97 -9.571E-16 -9.203E-16 100.000 98 -1.003E-15 -9.643E-16 100.000 99 -1.191E-15 -1.146E-15 100.000 100 -3.755E-15 -3.611E-15 100.000 101 -4.473E-15 -4.301E-15 100.000 102 -6.245E-15 -6.005E-15 100.000 103 -6.970E-15 -6.702E-15 100.000 104 -1.635E-14 -1.572E-14 100.000 Extraction Method: Principal Component Analysis.

94

Table B3. Component Matrix—Temperature Training Component 1 2 3 V109 .898 .111 .291 V216 4.621E-02 .986 -8.467E-02 V239 4.502E-02 .417 .845 V244 5.900E-02 .210 .828 V295 .552 .362 -.205 V297 .416 .102 .709 V330 -.291 .376 .797 V402 .751 .333 -.537 V408 .645 .739 6.066E-02 V52 .981 -.114 6.728E-02 V53 .800 -.333 .235 V93 -.211 .865 .366 V141 .923 -1.117E-02 -.205 V155 .655 -.109 .384 V212 .687 -.405 .528 V222 5.645E-02 .560 .733 V246 .725 -.442 .328 V258 -.145 .984 .101 V281 .584 .515 -.534 V333 .230 -.284 .383 V334 .300 -.553 .507 V339 .458 -.618 .341 V360 .794 -.399 -.296 V367 -.933 -6.466E-02 6.847E-02 V371 .761 -.253 -.420 V379 .253 .403 .822 V380 .748 .195 .498 V336 .625 .735 -.236 V66 -.575 .721 .362 V75 .466 .716 -.442 V108 .754 -.546 -.342 V113 .777 .550 -.176 V204 .773 .535 .270 V254 .503 -.752 -7.934E-02 V329 .603 -.790 -8.731E-02 V15 .951 -.103 .167 V84 .764 .157 .604 V91 .553 -.202 -.793 V105 .988 7.892E-02 9.525E-02 V174 .932 .254 9.402E-02

95

Table B3. (continued) Component 1 2 3 V179 .814 .220 .285 V181 .343 -.693 .421 V227 .967 -.171 -.165 V233 -3.541E-03 -.777 .560 V235 -.482 -.550 .123 V238 .405 -9.422E-02 -.849 V265 .511 .779 .302 V268 -.434 .690 -.540 V277 .619 .434 -.528 V291 .989 -.120 3.292E-02 V362 -.708 -.301 -.416 V111 .647 -.730 -6.793E-02 V147 .858 .182 .150 V190 -.873 .109 .237 V255 .621 -.567 .124 V314 -.354 -.818 -.258 V327 .310 .401 .782 V409 .426 -.833 -.207 V20 .618 -.589 -7.122E-02 V58 .449 .273 -.793 V194 .772 -3.671E-02 .603 V219 -.482 .870 5.718E-02 V253 -6.913E-04 .366 -.529 V42 -.931 -7.388E-03 -.151 V47 -.278 .804 -.284 V87 .882 -5.176E-02 .197 V353 .770 -.258 .210 V365 .787 -.451 5.959E-02 V223 4.430E-02 .995 -3.557E-04 V224 -.329 .644 .602 V407 .518 -.777 -.343 V12 -.554 -.764 .305 V104 .807 .454 .310 V121 .451 -.850 -.227 V149 -.869 -.335 -.166 V346 .962 -.209 9.915E-02 V347 .822 .127 9.827E-03 V218 -.898 3.796E-02 .259 V288 .444 .357 .234 V293 .925 -.237 -2.015E-02

96

Table B3. (continued) Component 1 2 3 V23 -.393 -.898 9.740E-02 V74 .622 -.730 -.189 V125 -.468 -.815 6.675E-02 V132 .369 -.153 .736 V137 .921 -9.547E-02 -.279 V193 .351 -.543 .564 V250 .448 -.178 .596 V270 -.710 -9.926E-03 .681 V283 .373 .365 -.607 V304 .691 .558 .255 V350 .769 .377 -.492 V361 -.725 .327 .324 V368 .209 .878 6.490E-02 V393 .899 .353 -.175 V83 .524 .740 .100 V114 .901 4.180E-02 -.343 V251 -.184 -.968 -.155 V5 .560 .575 .165 V37 .345 V115 -.145 -.432 V241 .702 -.287 V307 8.832E-02 -.702 V394 .542 6.531E-02 V404 .598 .650

-5.513E-02 .317 .379 .635 -.211 -.201

Extraction Method: Principal Component Analysis. a 3 components extracted.

97

Table B4. Communalities--EMG Initial Extraction V10 1.000 .986 V13 1.000 .860 V65 1.000 .968 V175 1.000 .478 V191 1.000 .807 V216 1.000 .962 V274 1.000 .664 V284 1.000 .992 V295 1.000 .900 V297 1.000 .598 V319 1.000 .794 V321 1.000 .963 V326 1.000 .944 V330 1.000 .943 V356 1.000 .873 V376 1.000 .978 V384 1.000 .890 V402 1.000 .991 V60 1.000 .607 V116 1.000 .772 V130 1.000 .854 V146 1.000 .918 V165 1.000 .842 V171 1.000 .897 V173 1.000 .849 V207 1.000 .625 V212 1.000 .966 V217 1.000 3.990E-02 V222 1.000 .890 V225 1.000 .269 V234 1.000 .987 V243 1.000 .995 V246 1.000 .793 V261 1.000 .969 V262 1.000 .805 V267 1.000 .950 V281 1.000 .861 V313 1.000 .986 V317 1.000 .452 V318 1.000 .844 V328 1.000 .977

98

Table B4. (continued) Extraction Initial V333 1.000 .774 V338 1.000 .986 V345 1.000 .915 V360 1.000 .676 V375 1.000 .977 V119 1.000 .568 V143 1.000 .851 V211 1.000 .594 V336 1.000 .809 V113 1.000 .479 V135 1.000 .453 V196 1.000 .977 V254 1.000 .908 V272 1.000 .888 V273 1.000 .631 V329 1.000 .817 V331 1.000 .494 V15 1.000 .897 V43 1.000 .609 V72 1.000 .774 V84 1.000 8.336E-02 V91 1.000 .960 V181 1.000 .926 V227 1.000 .863 V233 1.000 .939 V235 1.000 .899 V238 1.000 .859 V260 1.000 .773 V265 1.000 .962 V266 1.000 .922 V268 1.000 .666 V275 1.000 .962 V277 1.000 .957 V291 1.000 .969 V320 1.000 .916 V324 1.000 .973 V362 1.000 .986 V387 1.000 .910 V397 1.000 .966 V157 1.000 .980 V184 1.000 .770

99

Table B4. (continued) Extraction Initial V187 1.000 .977 V190 1.000 .902 V228 1.000 .988 V255 1.000 .550 V276 1.000 .847 V282 1.000 .976 V301 1.000 .710 V314 1.000 .973 V327 1.000 .535 V335 1.000 .975 V20 1.000 .358 V58 1.000 .869 V62 1.000 .994 V68 1.000 .790 V127 1.000 .624 V172 1.000 .987 V194 1.000 .835 V213 1.000 .660 V219 1.000 .830 V253 1.000 .867 V340 1.000 .946 V47 1.000 .622 V96 1.000 .828 V153 1.000 .983 V316 1.000 .981 V353 1.000 .635 V365 1.000 .945 V55 1.000 .923 V150 1.000 .898 V223 1.000 .962 V224 1.000 .988 V377 1.000 .766 V346 1.000 .962 V347 1.000 .919 V249 1.000 .977 V288 1.000 .987 V293 1.000 .662 V383 1.000 .709 V8 1.000 .976 V23 1.000 .933 V45 1.000 .902

100

Table B4. (continued) Extraction Initial V49 1.000 .997 V98 1.000 .464 V123 1.000 .909 V125 1.000 .846 V126 1.000 .904 V132 1.000 .771 V133 1.000 .787 V137 1.000 .991 V140 1.000 .915 V195 1.000 .947 V221 1.000 .947 V229 1.000 .837 V240 1.000 .917 V252 1.000 .769 V270 1.000 .746 V283 1.000 .738 V292 1.000 .470 V294 1.000 .751 V300 1.000 .934 V311 1.000 .968 V312 1.000 .181 V343 1.000 .835 V350 1.000 .906 V374 1.000 .906 V381 1.000 .578 V385 1.000 .830 V399 1.000 .453 V401 1.000 .875 V83 1.000 .952 V176 1.000 .870 V230 1.000 .761 V251 1.000 .992 V364 1.000 .621 V64 1.000 .757 V90 1.000 .985 V131 1.000 .914 V189 1.000 .732 V307 1.000 .656 V394 1.000 .967 V404 1.000 .846 Extraction Method: Principal Component Analysis.

101

Table B5. Total Variance Explained--EMG


Variance Cumulative

% Total % of

Variance Cumulative

% 1 62.657 38.440 38.440 62.657 38.440 38.440 2 39.356 24.145 62.584 39.356 24.145 62.584 3 32.023 19.646 82.230 32.023 19.646 82.230 4 15.806 9.697 91.927 5 13.159 8.073 100.000 6 3.241E-14 1.988E-14 100.000 7 1.478E-14 9.065E-15 100.000 8 1.023E-14 6.277E-15 100.000 9 9.211E-15 5.651E-15 100.000 10 5.909E-15 3.625E-15 100.000 11 4.525E-15 2.776E-15 100.000 12 1.310E-15 8.036E-16 100.000 13 1.263E-15 7.746E-16 100.000 14 1.218E-15 7.470E-16 100.000 15 1.165E-15 7.145E-16 100.000 16 1.135E-15 6.966E-16 100.000 17 1.124E-15 6.899E-16 100.000 18 1.090E-15 6.685E-16 100.000 19 1.050E-15 6.441E-16 100.000 20 1.024E-15 6.281E-16 100.000 21 9.860E-16 6.049E-16 100.000 22 9.786E-16 6.003E-16 100.000 23 9.624E-16 5.904E-16 100.000 24 9.479E-16 5.815E-16 100.000 25 9.397E-16 5.765E-16 100.000 26 9.186E-16 5.635E-16 100.000 27 9.058E-16 5.557E-16 100.000 28 8.687E-16 5.330E-16 100.000 29 8.524E-16 5.230E-16 100.000 30 8.153E-16 5.002E-16 100.000 31 8.105E-16 4.973E-16 100.000 32 7.766E-16 4.764E-16 100.000 33 7.509E-16 4.607E-16 100.000 34 7.452E-16 4.572E-16 100.000 35 7.212E-16 4.424E-16 100.000 36 7.185E-16 4.408E-16 100.000 37 6.954E-16 4.266E-16 100.000 38 6.710E-16 4.117E-16 100.000 39 6.671E-16 4.093E-16 100.000

102



Variance Cumulative

% Total % of

Variance Cumulative

% 40 6.518E-16 3.999E-16 100.000 41 6.378E-16 3.913E-16 100.000 42 6.151E-16 3.774E-16 100.000 43 6.088E-16 3.735E-16 100.000 44 5.875E-16 3.604E-16 100.000 45 5.770E-16 3.540E-16 100.000 46 5.589E-16 3.429E-16 100.000 47 5.508E-16 3.379E-16 100.000 48 5.282E-16 3.241E-16 100.000 49 5.127E-16 3.145E-16 100.000 50 5.071E-16 3.111E-16 100.000 51 4.915E-16 3.016E-16 100.000 52 4.689E-16 2.877E-16 100.000 53 4.506E-16 2.764E-16 100.000 54 4.444E-16 2.727E-16 100.000 55 4.287E-16 2.630E-16 100.000 56 4.075E-16 2.500E-16 100.000 57 4.031E-16 2.473E-16 100.000 58 3.963E-16 2.431E-16 100.000 59 3.750E-16 2.300E-16 100.000 60 3.534E-16 2.168E-16 100.000 61 3.461E-16 2.123E-16 100.000 62 3.314E-16 2.033E-16 100.000 63 3.163E-16 1.941E-16 100.000 64 3.058E-16 1.876E-16 100.000 65 2.933E-16 1.800E-16 100.000 66 2.790E-16 1.712E-16 100.000 67 2.713E-16 1.664E-16 100.000 68 2.537E-16 1.557E-16 100.000 69 2.339E-16 1.435E-16 100.000 70 2.253E-16 1.382E-16 100.000 71 2.058E-16 1.262E-16 100.000 72 2.008E-16 1.232E-16 100.000 73 1.836E-16 1.127E-16 100.000 74 1.624E-16 9.963E-17 100.000 75 1.594E-16 9.778E-17 100.000 76 1.533E-16 9.403E-17 100.000 77 1.309E-16 8.032E-17 100.000 78 1.217E-16 7.463E-17 100.000

103

Table B5 (continued)


Variance Cumulative

% Total % of

Variance Cumulative

% 79 1.077E-16 6.606E-17 100.000 80 9.895E-17 6.070E-17 100.000 81 5.738E-17 3.520E-17 100.000 82 5.078E-17 3.115E-17 100.000 83 2.852E-17 1.750E-17 100.000 84 2.055E-17 1.261E-17 100.000 85 1.103E-17 6.767E-18 100.000 86 -3.590E-18 -2.203E-18 100.000 87 -1.889E-17 -1.159E-17 100.000 88 -2.539E-17 -1.558E-17 100.000 89 -3.927E-17 -2.409E-17 100.000 90 -6.203E-17 -3.806E-17 100.000 91 -7.105E-17 -4.359E-17 100.000 92 -8.454E-17 -5.187E-17 100.000 93 -1.018E-16 -6.244E-17 100.000 94 -1.161E-16 -7.121E-17 100.000 95 -1.295E-16 -7.948E-17 100.000 96 -1.307E-16 -8.017E-17 100.000 97 -1.467E-16 -9.003E-17 100.000 98 -1.679E-16 -1.030E-16 100.000 99 -1.896E-16 -1.163E-16 100.000 100 -2.081E-16 -1.276E-16 100.000 101 -2.168E-16 -1.330E-16 100.000 102 -2.197E-16 -1.348E-16 100.000 103 -2.296E-16 -1.409E-16 100.000 104 -2.466E-16 -1.513E-16 100.000 105 -2.706E-16 -1.660E-16 100.000 106 -2.727E-16 -1.673E-16 100.000 107 -2.870E-16 -1.761E-16 100.000 108 -3.088E-16 -1.895E-16 100.000 109 -3.210E-16 -1.970E-16 100.000 110 -3.301E-16 -2.025E-16 100.000 111 -3.358E-16 -2.060E-16 100.000 112 -3.487E-16 -2.139E-16 100.000 113 -3.522E-16 -2.161E-16 100.000 114 -3.647E-16 -2.237E-16 100.000 115 -3.923E-16 -2.407E-16 100.000 116 -4.141E-16 -2.540E-16 100.000 117 -4.211E-16 -2.584E-16 100.000

104



Variance Cumulative

% Total % of

Variance Cumulative

% 118 -4.500E-16 -2.761E-16 100.000 119 -4.515E-16 -2.770E-16 100.000 120 -4.752E-16 -2.916E-16 100.000 121 -4.850E-16 -2.975E-16 100.000 122 -5.044E-16 -3.094E-16 100.000 123 -5.287E-16 -3.243E-16 100.000 124 -5.504E-16 -3.376E-16 100.000 125 -5.652E-16 -3.468E-16 100.000 126 -5.744E-16 -3.524E-16 100.000 127 -5.930E-16 -3.638E-16 100.000 128 -6.106E-16 -3.746E-16 100.000 129 -6.315E-16 -3.874E-16 100.000 130 -6.515E-16 -3.997E-16 100.000 131 -6.687E-16 -4.103E-16 100.000 132 -6.782E-16 -4.161E-16 100.000 133 -6.814E-16 -4.180E-16 100.000 134 -6.886E-16 -4.225E-16 100.000 135 -7.165E-16 -4.396E-16 100.000 136 -7.306E-16 -4.482E-16 100.000 137 -7.517E-16 -4.611E-16 100.000 138 -7.702E-16 -4.725E-16 100.000 139 -7.844E-16 -4.812E-16 100.000 140 -8.062E-16 -4.946E-16 100.000 141 -8.375E-16 -5.138E-16 100.000 142 -8.417E-16 -5.164E-16 100.000 143 -8.695E-16 -5.335E-16 100.000 144 -8.893E-16 -5.456E-16 100.000 145 -9.117E-16 -5.593E-16 100.000 146 -9.417E-16 -5.777E-16 100.000 147 -9.511E-16 -5.835E-16 100.000 148 -9.795E-16 -6.009E-16 100.000 149 -1.028E-15 -6.308E-16 100.000 150 -1.058E-15 -6.492E-16 100.000 151 -1.065E-15 -6.534E-16 100.000 152 -1.094E-15 -6.713E-16 100.000 153 -1.105E-15 -6.778E-16 100.000 154 -1.126E-15 -6.906E-16 100.000 155 -1.150E-15 -7.053E-16 100.000 156 -1.168E-15 -7.168E-16 100.000

105



Variance Cumulative

% Total % of

Variance Cumulative

% 157 -1.218E-15 -7.473E-16 100.000 158 -1.283E-15 -7.873E-16 100.000 159 -4.435E-15 -2.721E-15 100.000 160 -8.767E-15 -5.379E-15 100.000 161 -1.228E-14 -7.531E-15 100.000 162 -1.281E-14 -7.858E-15 100.000 163 -1.436E-14 -8.807E-15 100.000 Extraction Method: Principal Component Analysis.

106

Table B6. Component Matrix--EMG

Component 1 2 3 V338 .980 -.108 -.116 V376 .976 -.147 -5.176E-02 V311 .976 5.709E-02 .116 V216 .972 9.405E-02 9.329E-02 V275 .970 -2.525E-02 .139 V324 .970 .164 6.959E-02 V23 .964 1.851E-02 5.211E-02 V90 .959 -.254 -3.537E-02 V131 .954 6.096E-02 -2.530E-02 V350 .950 -5.390E-02 -2.011E-02 V15 .938 -.128 -1.871E-02 V157 .936 .322 -1.754E-04 V8 .933 -.314 7.878E-02 V83 .930 -.294 7.587E-03 V249 .929 -.336 -4.023E-02 V234 .926 -.355 -4.951E-02 V328 .925 -.348 -1.039E-02 V196 .923 .264 .237 V153 .916 .154 -.346 V224 .914 .371 .118 V397 .912 -.103 .351 V10 .910 -.174 -.357 V340 .897 -.340 -.164 V335 .892 .394 .153 V243 .889 -.355 .280 V125 .888 -.166 .175 V187 .881 -4.072E-02 -.447 V402 .877 -.388 -.265 V194 .871 .210 .181 V343 -.870 -.126 .250 V251 .870 -.308 -.375 V191 .862 -.211 -.141 V195 .853 -.420 -.209 V228 .850 -.342 -.386 V123 .839 -.142 .431 V300 .837 .386 .292 V49 .835 -.427 -.344 V404 .833 -.233 -.314 V230 .822 .286 5.417E-02 V143 .816 1.761E-02 -.430

107


Component 1 2 3

V221 .815 -.276 -.455 V68 .801 -.385 1.448E-02 V227 .799 .311 -.358 V91 .788 -.171 -.556 V375 .777 .224 .569 V307 .763 .170 .215 V43 .714 .263 .169 V219 .714 .239 .513 V365 .706 -.454 .491 V55 .704 -.651 -6.731E-02 V262 .702 1.885E-02 -.558 V207 .698 .129 -.347 V381 .697 .168 .253 V326 .695 -7.237E-02 -.675 V336 .685 .570 .121 V282 -.684 .614 .361 V229 .673 -.397 -.476 V13 -.660 -.161 -.631 V374 .655 -.332 .605 V347 .647 .371 .602 V113 .645 -.248 -2.840E-02 V399 .642 -.144 -.143 V165 .641 .597 .274 V72 .640 .540 .271 V47 .623 .238 .421 V213 .616 .529 -2.152E-02 V212 .585 .548 .570 V294 .584 .583 -.263 V175 .580 .107 .362 V295 .558 -.527 .558 V333 -.550 .436 -.531 V327 .534 -.293 -.405 V225 .490 .124 .116 V20 .470 3.862E-02 .368 V292 -.451 .424 .295 V84 .266 -9.526E-02 6.062E-02 V223 -9.437E-02 .975 -4.135E-02 V314 -.160 -.972 -5.220E-02 V176 .116 .925 -4.229E-02 V345 -.132 -.905 -.279

108


Component 1 2 3

V384 7.203E-02 -.901 .272 V62 -.105 -.883 .450 V171 .354 .871 .112 V254 -6.769E-02 .864 .395 V190 .335 .862 -.217 V362 .521 .838 -.107 V320 .435 .837 .161 V133 .232 .835 -.189 V356 .218 .835 -.359 V265 -.288 .822 .452 V281 -.389 .818 .201 V319 -.310 .818 -.171 V401 .213 -.812 -.413 V184 .254 .807 -.233 V270 9.143E-02 .805 .298 V246 -7.104E-02 .793 -.398 V172 .479 -.791 .364 V291 .599 -.777 7.622E-02 V274 -.247 -.776 -2.457E-02 V65 .623 .760 5.098E-02 V253 -.344 -.757 -.420 V235 .474 .744 .347 V233 .452 .737 -.437 V181 .435 .720 -.468 V150 .522 .715 .337 V211 .288 .713 5.759E-02 V267 .669 -.707 -5.056E-02 V316 -.226 .698 -.665 V268 -.419 .682 -.157 V261 .258 -.678 -.666 V116 .214 .676 .520 V301 .484 -.650 .232 V330 -.539 .648 .482 V96 .497 .642 -.410 V293 .501 -.638 -6.311E-02 V318 -.333 -.636 .574 V385 .365 -.628 .550 V321 .614 .624 -.444 V252 .564 .617 .265 V64 .611 -.617 5.586E-02

109


Component 1 2 3

V383 .461 .612 .349 V272 .583 -.601 .433 V45 .574 .581 .484 V119 -.207 .553 .468 V317 .403 .428 -.325 V312 -.217 .266 -.251 V58 -5.496E-02 -.143 .920 V284 .285 -.303 .905 V266 .393 .198 -.853 V140 .376 .334 .813 V346 -.516 .229 .802 V240 .530 -3.745E-02 .797 V387 .507 .186 .786 V273 .138 5.186E-02 -.780 V189 -.321 .206 -.766 V394 .591 .190 -.763 V329 -.469 -.143 .760 V222 .429 -.374 .752 V130 .538 -6.973E-02 .748 V277 .502 -.385 -.746 V126 .538 .264 -.738 V146 .258 .584 -.714 V173 .569 .136 -.712 V276 .584 6.915E-03 .712 V288 -.184 .675 -.705 V283 .486 7.348E-02 -.704 V353 -.127 -.361 -.700 V238 .636 .115 .664 V313 .557 .486 -.663 V132 -.100 -.571 -.659 V331 .251 3.608E-02 -.655 V360 -5.963E-02 -.504 .647 V364 -.157 -.443 -.633 V297 .391 .222 .629 V137 .469 -.613 .628 V260 .505 -.362 -.622 V377 .405 .478 -.612 V60 -.476 .217 .577 V135 .376 5.099E-02 .556 V127 .467 .332 .544

110

Table B6. (continued) Component 1 2 3 V255 .503 .187 -.512 V98 .433 -.235 .470 V217 -3.434E-02 3.693E-02 .193 Extraction Method: Principal Component Analysis. a 3 components extracted.

111

APPENDIX C

Examples of Individual Biofeedback Learning Curve

112

Example of Individual Temp Curves (x = period, y = temperature Fahrenheit) Steady State Trainable (Low variability)

x

y

1 2 3 4 5 6

7075

8085

9095

Phasic State Trainable (High variability)

x

y

1 2 3 4 5 6

7075

8085

9095

113

Example of Individual Temp Curves (x = period, y = temperature Fahrenheit)

Phasic State Low Trainable (High variability)

x

y

1 2 3 4 5 6

7075

8085

9095

Example of Individual Temperature Curves (x = period, y = temperature Fahrenheit)

Steady State Trainable (Low variability)

x

y

1 2 3 4 5 6

7075

8085

9095

114

Example of Individual Temperature Curves (x = period, y = temperature Fahrenheit)


x

y

1 2 3 4 5 6

7075

8085

9095


x

y

1 2 3 4 5 6

7075

8085

9095

115

Example of Individual EMG Curves (x = period, y = EMG microvolt)

Phasic State Low Trainable (High variability)

x

y

1 2 3 4 5 6

01

23

45


x

y

1 2 3 4 5 6

01

23

45

116

Example of Individual EMG Curves (x = period, y = EMG microvolt)


x

y

1 2 3 4 5 6

01

23

45

Examples of Individual EMG Curves (x = period, y = EMG microvolt)


x

y

1 2 3 4 5 6

01

23

45

117

Examples of Individual EMG Curves (x = period, y = EMG microvolt)


x

y

1 2 3 4 5 6

01

23

45


x

y

1 2 3 4 5 6

01

23

45

118

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