Stroke and Biofeedback
03 September 2007

- a BioFeedBack Resources International email newsletter -
written & edited by Harry L. Campbell, President
technical editing and production by Edwin Johnson

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I. Stroke and Biofeedback - by Harry Campbell
II. Upcoming Training

I. Stroke and Biofeedback

According to experts:

  • Stroke is one of the top causes of serious, long-term disability in the United States.
  • Stroke is the number three leading cause of death.
  • African-Americans are highest at risk for stroke, Hispanics are second.
  • About 40,000 more women than men have a stroke every year.
  • A stroke occurs on average every 45 seconds.
  • Someone dies of a stroke about every 3 minutes, on average.
What is a stroke?

A stroke is caused by a blocked or bleeding artery in the brain, preventing the blood from reaching an area. When this happens, oxygen and glucose cannot be supplied to that area and the area becomes damaged.

A stroke can quickly cause many symptoms including paralysis, loss of or reduced vision, speech problems, dizziness, and problems swallowing.

How Does a Stroke Happen?

Plaques can build up inside the arteries that lead to the brain. If the plaques break off they can get stuck in the arteries and cause a stroke.

People who have hypertension, diabetes, high cholesterol level, are overweight, use tobacco, or have coronary artery or heart disease are all at higher risk of stroke.

Prevention of stroke is very important because stroke can cause serious and sometimes permanent damage to the brain. Because the brain is involved in all phases of life, any damage to the brain can cause damage to life and quality of life.

Can Stress Cause a stroke?

During my research on stroke I looked for a link between stroke and biofeedback and stress management. I looked at stress as a cause of stroke. I didn't see a clear, direct connection but what I did find is that over and over again hypertension was listed as the number one risk factor for stroke. This means that if people are able to reduce their high blood pressure they would be reducing the number one risk factor of stroke. Essential hypertension can be at least partially caused by stress reaction. There are biofeedback protocols for helping to reduce hypertension. I will discuss this further. It is important for me to say that biofeedback alone is not recommended for reducing high blood pressure. Proper diet, exercise, stress and anger management, and in some cases, medications as prescribed by a medical doctor are necessary tools when attempting to reduce high blood pressure. It is also helpful to avoid smoking, taking drugs, and drinking alcohol.

The amount of time from the onset of a stroke to the time a person receives treatment is critically important. The person must receive quick treatment while the stroke is happening. It is important to dissolve the clot with medication. It is also important to prevent a second stroke. This is usually done with aspirin or blood thinners. Sometimes plaque is even removed surgically from the patient's arteries.

Can Biofeedback help Prevent Hypertension and Stroke?

The AAPB (Association of Applied Psychophysiology & Biofeedback) states: "Numerous high quality studies have demonstrated that people having high blood pressure - especially if it is stress related - can benefit extensively from biofeedback as long as they learn and practice the skills needed to control their blood pressures. Many hypertensives no longer need any medications after successful biofeedback training. This therapy is rated as efficacious (level 4 on a scale of 1 - 5 with 5 being the best)".

Increased blood pressure is one of the body's normal responses to stress. Under normal conditions after such an increase the blood pressure would return to normal. With frequent stress reactions, over time the blood pressure may begin to remain elevated. This is hypertension. Biofeedback can help people become aware of and reduce their responses to stress.

During Biofeedback therapy instruments are used that measure various signals like muscle tension, skin temperature, sweat, heart rate activity, breathing, and brain waves. The subject is given "feedback" of the signal being measured visually on a computer screen and with sound. This feedback lets the person know if the signal is moving in the desired direction or in an undesired direction. The person uses this information to learn how to control the reactions of their body to stress. With practice they are able to learn to reduce the negative reactions and recover more quickly when these reactions occur. Two of the modalities that are often used are EMG for muscle tension and skin temperature. The goal with EMG is to learn to reduce the level of tension in the muscles of the body by relaxing them. The feedback is very clear. A line or bar graph goes up if the muscles are tenser or it goes down if the muscles are more relaxed. Subjects are taught to increase their hand temperature by using various relaxation techniques. The temperature changes based on how constricted or dilated the blood vessels in the hands are. Usually, when a person is more stressed, the blood vessels in their hands constrict or get narrower. This increases the pressure in the blood vessels and decreases the amount of blood that can pass through. This decreases the temperature of the hands. As a person relaxes, the blood vessels in the hands tend to dilate decreasing the pressure and causing more blood to flow through. This makes the hands warmer.

Here is a list of some of the work in the area of biofeedback for hypertension:

Henderson, R.J., Hart, M.G., Lal, S.K., & Hunyor, S.N. (1998). The effect of home training with direct blood pressure biofeedback of hypertensives: A placebo-controlled study. Journal of Hypertension, 16(6), 771-778.

Nakao, M., Nomura, S., Shimosawa, T., Fujita, T., & Kuboki, T. (1999). Blood pressure biofeedback treatment, organ damage and sympathetic activity in mild hypertension. Psychotherapy and Psychosomatics , 68(6), 341-347.

Nakao, M., Nomura, S., Shimosawa, T., Fujita, T., & Kuboki, T. (2000). Blood pressure biofeedback treatment of white-coat hypertension. Journal of Psychosomatic Research, 48(2), 161-169.

Nakao, M., Nomura, S., Shimosawa, T., Yoshiuchi, K., Kumano, H., Kuboki, T., et al. (1997). Clinical effects of blood pressure biofeedback treatment on hypertension by auto-shaping. Psychosomatic Medicine, 59(3), 331-338.

Nakao, M., Yano, E., Nomura, S., & Kuboki, T. (2003). Blood pressure- lowering effects of biofeedback treatment in hypertension: a meta-analysis of randomized controlled trials. Hypertension Research, 26(1), 37-46.

Weaver, M.T., & McGrady, A. (1995). A provisional model to predict blood pressure response to biofeedback-assisted relaxation. Biofeedback and Self Regulation, 20(3), 229-240.

Yucha, C.B. (2002). Problems inherent in assessing biofeedback efficacy studies. Applied Psychophysiology and Biofeedback, 27(1), 99-106, 113-114.

Yucha, C. B., Clark, L., Smith, M., Uris, P., Lafleur, B., & Duval, S. (2001). The effect of biofeedback in hypertension. Applied Nursing Research, 14(1), 29-35.

How can biofeedback help a person who has already had a stroke?

As I mentioned earlier, once a person has had a stroke, serious damage may have been done. There are two main ways that biofeedback can help a person who has already sustained injury due to stroke.

  1. EMG Biofeedback: Electromyography can be used to measure the amount of muscle activity coming from a specific site. If a person loses the ability to control muscles in a part of their body EMG biofeedback may be able to help. Sensors are placed at the site of interest. The affected person is asked to contract the muscle. They receive visual or auditory feedback for any contraction that they are able to make even if they can't sense the contraction. The line or bar graph signal on the computer screen stays flat if the muscle does not respond to their mental attempts to contract. The line or bar graph signal goes up if the muscle is responsive. This helps to reinforce useful attempts at movement and discourages non-useful attempts. With practice the person can re-learn how to control their muscles.

  2. EEG/Neurofeedback: Electroencephalography (Brainwave biofeedback) may be used to measure the electrical activity of various parts of the brain including the affected area. Diagnostic EEG equipment or QEEG can be used to detect areas that are not functioning normally. Sensors can be placed at these sites and the EEG/Neurofeedback instrument can be set so that feedback is given to the person when the brainwave activity shifts to a more normal pattern. The instrument is setup to encourage the person's brain activity to normalize. The protocols that are used are similar to those used for traumatic brain injury. A major focus of this training involves locating areas of the brain that have unusually high slow wave activity and giving the person feedback for when the slow wave activity is decreasing. This helps to condition the brain to reduce the undesired slow wave activity that is thought to be impeding normal functioning. Bar graphs or other visual feedback as well as audio feedback is used. A goal line on a vertical bar graph may indicate what level the therapist would like the subject to decrease the low frequency activity below. When the activity is above the goal line the bar might be red. When the level drops below the goal line the bar turns green and music starts to play. The subject is instructed to keep the bar green and keep the music playing.

    A stroke study was performed at the Center for Behavioral Medicine at the University of West Florida. In the study, neurotherapy was shown to lead to significant reduction in slow-wave activity which resulted in improvement in speech fluency, word finding, balance and coordination, attention, and concentration. Depression and anxiety were significantly reduced. In another study, children who suffered stroke and received neurotherapy showed improvement in concentration, physical motion, short-term memory, and less mood swings.

Here is a list of neurofeedback papers on the protocols for stroke or traumatic brain injuries:

Authors: Daniel Holland; Tom Witty; Jennifer Lawler; Deidra Lanzisera

Published in: Brain Injury, Volume 13, Issue 1 January 1999 , pages 53 - 57

Subjects: Neuroscience; Rehabilitation;

Ayers 1987 Electroencephalic Neurofeedback and Closed Head Injury, Head Injury Frontier, National Head Injury Foundation 380-392

Bounias, M, Laibow, R.G., Bonaly, A., Stubblebine, A.N. 2001 EEG -Neurobiofeedback Treatment of Patients with Brain Injury, Journal of Neurotherapy

Byers A.P. 1995 (Neurofeedback Therapy for a Mild head Injury) Journal of Neurotherapy

Hoffman D.A. Stockdale 1996, Symptom Changes in Treatment of Mild Traumatic Brain Injury Using EEG Neurofeedback, Clinical Electroencychalograpy

Thatcher R.W. (2000) EEG Operant Conditioning (Biofeedback) and Traumatic Brain Injury, Clinical Electroencephalography

Thornton K. (2000) Improvement/Rehabilitation of Memory Functioning with Neurotherapy/QEEG Biofeedback, Journal of Head Trauma Rehabilitation

Thornton K. & Carmody DP 2005 Electroencephalogram Biofeedback for Reading Disability and Traumatic Brain Injury

Tinius T.P. and Tinius K.A. (2001) Changes after EEG Biofeedback and Cognitive Retraining in Adults with Mild Traumatic Brain Injury and Attention Deficit Disorder, Journal of Neurotherapy

How can I learn more about stroke?

On July 1st I attended a benefit concert put on by an organization called Stroke of Hope Foundation. The jazz concert featured Kirk Whalum and Friends. It took place at the Tribeca Performing Arts Center in New York City. The musicians put on a very enjoyable concert but more importantly it was a very educational experience. I learned a great deal about the problem of stroke and met some people who are working very hard to educate people about stroke so that they can prevent themselves from being affected. They are also working very hard to support those individuals and families who have already been affected by stroke. I'm sure that there are many other organizations doing similar work but I would encourage you to check this one out as a start.

Other sources of information on biofeedback and stroke:



II. Upcoming Training

Oct 27-31 - Biofeedback BCIA Certification Training, Hawthorne,NY

Nov 9-12 - Neurofeedback BCIA Certification Training, Hawthorne, NY


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