[00:00:00] Speaker A: Welcome to the heart rate variability podcast. Each week we talk about heart rate variability and how it can be used to improve your overall health and wellness. Please consider the information in this podcast. For your informational use and not medical advice, please see your medical provider to apply any of the strategies outlined in this episode. Heart rate variability. Podcast is a production of optimal LLC and optimal HRV. Check us
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[00:00:31] Speaker B: Welcome friends to the heart rate variability. Podcast. I'm really excited just to do a quick introduction of a crossover episode we're doing with the Northeast Region Biofeedback Society's Healthy Brain Happy Body podcast hosted by my good friend and friend of the show, Sal Rosenthal. He recently interviewed Dr. Ina Hazan, obvious friend of the show, also past guests and friends of the show, Dr. Fred Schaeffer, Dr. Donald Moss about the Evidence Based Practice and Biofeedback and Neurofeedback fourth Edition, which just came out through the AAPB. I was really excited to and following the release of this work, can't recommend it more. I was going to try to get Kazan and Schaefer and Moss to come on the Heart Rate Variability Podcast and then I heard this episode by Saul and I'm just like, hey, here is four geniuses talking about the exact topic that I wanted to. Reached out to the Northeast region, asked them and saw permission to do a crossover episode and they kindly agreed. So if you're watching on YouTube, it's going to go dark here. We'll just have the audio. So I apologize for, you know, hey, you've got four geniuses on one episode, who needs visuals? So I'm excited to share this all with you. Again, I want to thank the Northeast Regional Biofeedback Society for allowing us to publish this and I'm excited to share the great work that they do with our audience as well. So enjoy and I'll see you next week.
[00:02:21] Speaker C: Welcome to Healthy Brain Happy Body, a podcast from the Northeast Region Biofeedback Society. I'm your host, Dr. Saul Rosenthal. In this podcast, we explore the ever fascinating connections between brain, body, health and happiness. This episode is a little different than our usual our guests today are the editors in an upcoming edition of one of the more important books about biofeedback and neurofeedback. In the early two thousand s, the association for Applied Psychophysiology and Biofeedback and the International Society for NeuroRegulation and Research developed strict guidelines for testing the efficacy of biofeedback and neurofeedback. Since then, a series of reviews have been published providing practice guidelines for a host of health issues. This summer, we'll see the publication of the fourth edition of Evidencebased Practice in Biofeedback and Neurofeedback. We thought it would be interesting to bring the editors together to talk a bit about the book, what it tells us about the state of biofeedback and neurofeedback practice and why you should care whether you're a practitioner or a consumer. As a disclosure, I'm also an editor on this edition.
Today, it's a bit crowded. In the virtual recording booth, we have four of the five editors of the soon to be out fourth edition of Evidence Based Practice. And joining me are Don Moss, Fred Schaefer, and our fearless leader and taskmaster ena Khazan. Unfortunately, Randy Lyle couldn't join us today. Coordinating five busy people required skills that were a little bit beyond me. But that said, we're fortunate to have some of the real dignitaries of applied psychophysiology to talk with about the most complete set of guidelines for what biofeedback and neurofeedback can really do. So thank you all so much for joining us together today and all of you coming together today.
Our listening audience includes practitioners as well as people who are interested in biofeedback. And for those who don't know, what exactly is the Evidence Based practice book?
[00:04:19] Speaker D: It is a collection of chapters that lets the reader know just how much evidence we have on the efficacy of biofeedback and neurofeedback for a specific condition or disorder.
[00:04:32] Speaker C: Don, I know you've been involved since the very beginning, and Fred, you joined, I think, at the third edition, but I wonder if one of you or both could tell us a little bit about the history of this effort.
[00:04:44] Speaker E: I can take this back over two decades.
In 2001, I was the president of AAPB, and Jay Gunkelman was the president of ISNR, the neurofeedback organization.
And we were close colleagues and friends, and we both saw a need for some kind of standard that would be uniform for judging approaches to biofeedback and neurofeedback for a variety of common disorders. We appointed a task force led by Theodore Levec and populated by some excellent researchers, and they established efficacy standards that were then endorsed by both AAPB and ISNR. And we began at that time promoting white papers, research, systematic reviews of application areas. And this was good, but it was too slow. So in 2004, Carolyn Yuha and Chris Gilbert agreed to summarize very briefly the efficacy of a number of standard disorders. And that was the first edition of Evidence based Practice and Biofeedback and Neurofeedback. We're now publishing the fourth edition with a new set of editors and a much enlargened stable of authors covering more than 40 different disorders. So this has been the product of a lot of hard work by organizations, editors, authors, over a two decade period producing a book that summarizes where we are in evidence based practice.
[00:06:29] Speaker C: And Don, you mentioned efficacy standards. I wonder if maybe, Fred, you can tell us a little bit about what that means and why it's important when.
[00:06:42] Speaker F: A field seeks credibility, particularly when we're talking about third party payers, but also from colleagues who might make referrals for biofeedback and neurofeedback services and also to the patients or clients who may receive the referrals. We need to conservatively convey the strength of the evidence for a specific application.
[00:07:17] Speaker C: Now, for some of us, at least for half of us in this podcast, this is the first time we've been involved with this project. So you're the lead editor of this edition. I'm wondering if you talk about how you got involved and sort of how you view the project.
[00:07:35] Speaker D: Certainly so I was very honored to be invited to join in as one of the editors on this edition, and just so happened that I ended up being the leader. I'm not entirely sure how that decision process happened, but Fred and Don invited me to be a part of the project, continuing the work that they have been doing, and it's been just an incredible pleasure and honor to work with all of you and put together this incredible collection of evidence. I've been sort of in awe as to just how much evidence we've amassed for efficacy of biofeedback and neurofeedback. I feel like editing this edition has been quite a learning project for me, too, and quite inspiring.
[00:08:32] Speaker C: Inspiring, obviously also a lot of hard work.
As somebody who is sort of the lead of four other busy people, I mean, do you have any strategies that you used or anything you could maybe pass on to editors in either other publications or maybe the fifth, 6th, or 7th edition of this one?
[00:08:55] Speaker D: Well, I got to say, the current editors have just made it super easy, probably more so than it should have been.
I think one difficulty we encountered that I think would be really helpful for us to keep in mind for the next edition is how to contact authors of chapters from the previous edition. There were quite a few authors that we could not track down because they were invited by editors who are no longer involved.
So that was probably the biggest challenge, and hopefully something that we can avoid in the future is to have good contact information for everybody so that we can bug people again to replicate their chapters or add new ones.
[00:09:41] Speaker C: Wise words for anybody trying to project that goes on in time.
Don, you talked about the very first edition and sort of the history of this project a little bit, and I'm curious about for you, who sort of seen this whole history, this process, what sticks out in your mind? You'd already mentioned that we're now covering over 40 conditions, but are there other issues or other things that stick out with this volume when you think about it, compared to the earlier three?
[00:10:16] Speaker E: I've been very encouraged at doing some of the chapters myself for the fourth edition, but also reading those written by my colleagues, editing them.
What encourages me is the quality of research in the field of both biofeedback and neurofeedback has increased tremendously, as has the volume of research.
The way the efficacy standards were developed, something might rate low in efficacy. It doesn't mean that that intervention is not helpful. It means there's not yet very good research on it. There may be a few case studies, clinical reports, but not controlled studies. And today we now have a number of biofeedback and neurofeedback applications that qualify at the very highest efficacy rating. If I compare the third edition from 2016 to the fourth edition, the one we're bringing out now, there was only one area, one disorder, attention deficit and hyperactivity disorder, that qualified for the highest rating back in 2016. And now, for example, panic disorder reaches a five heart rate variability, interventions for asthma reaches a five level.
Biofeedback for depression reaches a five level.
Glycemic control for diabetes reaches the fifth level. And there are others. So, first of all, the quality of research has gotten better, and there's a lot more research, so we're able to rate applications better at a higher level than we could originally. And I think the quality of treatment in the field has also improved as we have new modalities and new protocols for applying those modalities. So that's my biggest takeaway from this fourth edition, and I'm already looking forward to doing research for the fifth edition.
[00:12:19] Speaker C: Actually, that brings up or reminds me of one of the discussions we had, or a part of the discussion. I think the third edition came out in 2014, 2016. Sorry. So that's seven, eight years, but we've already started to think a little bit even about the next edition.
I'm curious. And this I open to anybody. What do you think? I mean, obviously in some ways it'd be great to have this as a rolling, continuous, live document, which we can't. But what do you think is a reasonable amount of time, if such exists between editions? Is there even any way to think about it?
[00:12:58] Speaker F: We've not had that luxury, I think just off the top of my head. Four years.
[00:13:08] Speaker D: That's exactly what I was thinking.
[00:13:11] Speaker F: Four years gives us the opportunity to give the evidence base a shelf life that makes it worth publishing a print edition at the same time during the revision can begin at the start of the first of the four years.
And while the others have not formally adopted the strategy, don has generously offered to have a graduate student continue to review the literature, particularly for meta analyses, systematic reviews, new randomized controlled trials to see what has changed in our 40 plus disorders or applications, and then only they would need to be revised. And so instead of revising everything, which is essentially what we did for the fourth edition, we might revise 25%.
[00:14:29] Speaker E: Yeah, I agree with what Fred was saying. It seems to me that if we highlight new randomized controlled trials, new metaanalyses and then novel studies that may not be randomly controlled but represent a new approach to a treatment, we will have something to say in four years. I hope we also can develop a faster process for getting the chapters to the public, because I know my chapters are almost two years old. So I'm already two years behind looking at current research. And there have been some very interesting studies, for example, in anxiety. Andre Chung did a study with several colleagues in which there was no face to face contact with her research participants. Everything was done through smartphone. Administration of preliminary questionnaires and post questionnaires treatment was delivered remotely, and yet they got excellent improvement in anxiety. So things like this are encouraging and I'd like to see them come out in the fifth edition along with the good solid evidence of well designed studies.
[00:15:43] Speaker C: What you're talking about, it really makes me think about that tension between what we would call high level studies, usually RCT, randomized control trials and novel approaches, and trying to keep that tension, it's a dynamic tension and trying to figure out, well, where do we go with a particular client who walks through our doors? I was sort of thinking about this as I was working on the volume as well and sort of reviewing chapters, because certainly the people who walk through my door, and I'm sure this is true with all of you, they haven't read the evidence based books.
Their issues don't know how they're supposed to be responding to evidence based treatment. And frequently when they come to see me, they've already been through what would be considered traditional or typical treatment. So on the one hand, I think we often need to engage in novel and maybe idiosyncratic treatment for our patients who walk in the door. So I think there's that piece of it on the other side of it. I think it's safe to say that biofeedback and neurofeedback can pull for people who care less about evidence based approaches than the four of us might.
You see biofeedback and neurofeedback often credited for, quote, curing or fixing all sorts of things in health and performance where there really isn't the evidence. So I'm really curious about, for those of us who have been involved in this, really steeped in this, what does the evidence tell us, based on a pretty sophisticated criteria, how to think about that when we're working with clients who don't always follow the evidence, that is, the evidence based treatment don't always work for them.
Without going too far to the other side, where we're just sort of doing whatever kind of comes to mind in.
[00:17:47] Speaker D: The moment, I think it's a fine balance and it's important to keep the client in the loop. While they may not be following the literature or may not be likely, will not be as interested in it as we are. That's how it should be. We need to be doing our work and our research. I think it's important to keep the client in the loop as to our decision making process as we're figuring out which biofeedback approach is going to make the most sense or whether biofeedback makes sense at all.
Letting the client know about the research that does exist and if it's overwhelmingly positive, well, that makes things easy if there are some great studies, but maybe we're at a level two or three because we don't quite have enough. Just giving a rationale to clients and letting them know why we think biofeedback may be worth a try and at the same time, letting them know the research is not quite there so that they can be fully informed participant in the decision.
[00:18:55] Speaker E: I agree with that. Over the years, by the time patients reached me, they'd often tried a number of the so called best practice approaches to their disorder, whether it's anxiety, irritable, bowel, other things I remember as heart rate variability was introduced in the field. I started utilizing it right away, even before I fully understood the possibilities of that intervention. And I had to tell my patients, this is not the best practice intervention nationwide. But you've already had cognitive therapy, you've had exposure therapy. I've had a number of patients respond very well to this. And I can give you the one case study that's been published using this for your disorder. And most of my patients wanted to try something new because they were burned out on the well established standard treatments. But when something seemed experimental, I used a written consent form. And when I offer people a new treatment, I may not sign a new form each time, but I certainly introduce how does this intervention stand in the field today and why am I offering it to you? And my patients have really been excited to try something and they often benefited from relatively new treatments.
[00:20:17] Speaker D: I think that's a really good point, that our clients often come to us after having tried everything right? So if we only offer them what's sort of a sure thing, they may not get to where they need to be. And that's how new treatments get developed, I think as long as the client is familiar with our thinking process. And the good news is, bifeback is rarely harmful, so the worst that can happen is it doesn't work.
[00:20:46] Speaker F: The clinician, after receiving written informed consent for providing a new treatment, can gather data and see whether, in fact, objectively as well as subjectively, the patient has improved. One of the brilliant things about biofeedback and neurofeedback is these are data based interventions.
You have objective and subjective data that can result in a really good overview of how the patient is improving.
And the cool thing about it from the patient standpoint is you can show them their gains on the screen and this increases the credibility of the treatment.
[00:21:43] Speaker C: And I think as a practitioner, seeing that data on the screen has always been a really powerful tool, actually, for me as well as the client, because I like to be convinced and I see the evidence based practice book as another part of that. Obviously more for me than the patients directly. But I'm curious if each of you would maybe tell us a little bit about tell us, why is this volume important?
Why do we keep putting it out there, and why should we continue to put it out there?
[00:22:25] Speaker E: Well, I can say. For many years I have copied pages out of the evidence based practice book and given them to patients, to their referring physicians and referring nurses and others who have been referring the patients to show them that. Yes, there is a book published in the field which summarizes the current research and this is what it says about this disorder. And that's encouraging to people. Now, if people are a little bit higher level in their own reading ability and understanding, I may also give them a research paper on the disorder. But the evidence based book is written so that any referring party can usually understand the language and the conclusions, and they're encouraging.
[00:23:13] Speaker D: Yeah. I think to echo what fred said initially, this is a great calling card as far as credibility goes for biofeedback and neurofeedback. It's an easy reference because people ask, well, I'm not very familiar with biofeedback. I've heard about it, but does it really work? This is an excellent way to show other practitioners, medical providers, potential clients or organizations that are considering implementing biofeedback in their clinics or among their clients, or getting their clinicians trained in biofeedback. So often people are reaching out. We have clients with depression, chronic pain, trauma. Is biofeedback going to help them? And I need justification because the people who are paying for this need a reason to pay for it. So this book is an excellent way to concisely and very accurately show people exactly what they're getting themselves into.
[00:24:19] Speaker C: I think as a provider, one of the values that I see in the book is, I didn't know that biopic and neurofeedback had evidence for as many different issues as it has. And so it's helped me think about and often use applied psychophysiology in ways that I might not have without the volume. And so that's been really helpful to me and a real value that I see in the book.
[00:24:54] Speaker F: I think it is always valuable for APB and ISNR members to see external validation of the good work that they're doing.
That's the same reason that a fraction of the members of both organizations pursue BCIA certification as validation of their expertise.
So I see this as validation of the field, and I believe that our ratings are conservative. We reach consensus whenever we either raise or lower an efficacy rating compared to the previous edition.
So there has to be a complete agreement from all of the editors before we notch it up or down.
[00:25:53] Speaker D: I think that's another really important part of having multiple editors is to get lots of opinions and to make sure that everybody's in agreement when we are moving things one way or the other.
[00:26:07] Speaker E: I can talk about another value of this book, and it's something that I experienced in doing the research on the chapters I authored.
Biofeedback practitioners, like other human beings, tend to focus on what they're doing and we can lose the perspective of the broader field. For example, is biofeedback or neurofeedback better or is either one the treatment of choice for anxiety? Well, the research shows that both are excellent. Both are effective, especially for panic disorder, for phobias, for generalized anxiety disorder, and yet one person may not respond well to neurofeedback. And it's good to know that biofeedback, especially heart rate variability, which is relatively easy to learn and deliver, also has excellent comparable results.
When I reviewed the research out on cerebral palsy and stroke, I knew that a great deal of the early research was EMG only. And it started simply with relaxation training and then it became much more precise. Activating motor nerves that motor pathways and motor nerves that had atrophied or had lost effectiveness.
But then there's a variety of other things balance training with feedback, gait training with feedback. When does your heel strike in the course of the Gait? And all of these things are done, they qualify as biofeedback because the individual is getting feedback on the screen and modifying their Gait or modifying their balance. Well, I wouldn't have known about all of those different approaches to stroke, cerebral palsy, rehabilitation.
So I think this book really covers the landscape quite well and can remind us that there are other pathways to follow if our patients are not responding to what we're doing. Or we may want to refer to another specialized practitioner who can deliver a form of biofeedback or neurofeedback that we can't deliver.
[00:28:26] Speaker D: What a good point just to have this reference available to us, right? I think we've talked about how this is valuable to everyone else, but I have this book nearby in the bookshelf behind me or right on my desk at all times. Oftentimes clients come in like, well, I'm interested in skin conductance biofeedback that's actually happened recently and can I use it for this thing I'm struggling with? Well, let me see if there is any research and rather than trying to claw my way through PubMed, I have an easy reference guide to let them know, well, this is the evidence we have and this is what I think about it and let's talk about how to proceed.
[00:29:13] Speaker C: Yeah, I have a very similar experience. I keep mine well within range and really go to it probably more than any other volume that I'm using.
It occurred to me as you were talking, another important aspect of this. And this is not perhaps about the whole field, but I think it's about us as professionals. And it reflects my experience, but hopefully yours as well, just that contributing to the field through a project like this, I think is really important as professionals. I think part of our job is to build the profession and to keep it expanding and growing and pushing its boundaries. So I think that for me that's a really important part of my professional life.
And just speaking personally, it was a lot of fun, it was a lot of work, but I learned so much even about the things that I theoretically know already.
Just digging into that research really led me to think, oh, I probably should be trying this approach, not that approach. And of course, working with you all as colleagues is always a joy. So there's lots of important aspects of the evidence based book, I guess, from the molecular, from us as individuals all the way up to the Molar to not just our field but the health care and performance and maybe not go further than that, but I think it has a lot of layers to it, a lot of levels.
So as we wrap up, I'd like to end these with one thing questions. Unfortunately, we may have lost Fred, so he may not be able to answer, which may be a relief to him.
But I'll start with you, Ina, and I'll ask you both the same questions, but if you could answer first, perhaps what's the one thing you want our audience to take away from our discussion today?
[00:31:21] Speaker D: I hope that the audience would take away the need to run to the APB website and order their book.
That's first, but also just the great versatility in having this volume handy from your own clinical work to, if you're designing a research study to have a quick reference guide in having some of that literature review already done for you, you'll still have to dig through some of the more recent literature. But at least there is a huge chunk of literature already summarized for you. If you're teaching, if you are training other practitioners, having an easy reference guide right there at your fingertips, I hope you find it really helpful.
[00:32:10] Speaker C: And how about you don? What is one thing you would like the audience to take away from our discussion?
[00:32:15] Speaker E: It occurs to me as I think about the book, I believe in lifelong learning, and I think for the biofeedback and neurofeedback practitioner that means reading evidence based practice. When the new edition comes out, going to the annual meeting, reading the journal as it comes out, reading the magazine, biofeedback magazine as it comes out, this process never stops. The innovation in our field is remarkable when you think about the fact that the word biofeedback was only chosen to designate our field in 1969, less than 60 years ago, and yet so much has happened. The technological revolutions that have made possible the kinds of interventions we do today, real time analysis of brain activity so that we can actually train people with zscore training toward normal processes in 1000 other brains. It's just remarkable. The heart rate variability training that we can do now goes far beyond what we could do 15 years ago. So as a practitioner, as a writer, as an educator, I don't want to miss out on this next generation, which might happen in six months. And this book is just part of that process of continuing to learn.
[00:33:42] Speaker C: And so, Don, I'm going to ask you to answer this question first.
When you start to think about which I think we already have the next edition, what is one new or expanded issue that you hope the fifth edition will include?
[00:33:57] Speaker E: It's a good question.
Well, first of all, I want to include the disorders we've included here, but I suspect that if we look carefully, there are other applications that we should expand and include, because I know my colleagues keep innovating, and I would like to reflect that. In the fifth edition, I can see that areas that I was not real optimistic about have upgraded their efficacy rating. For example, cerebral palsy and stroke have both gone up to the Efficacious level. That's level four, the second highest level. We have one brand new area.
I'm trying to think of the name of it. It's Chemotherapy Induced Peripheral Neuropathy, which was reviewed by Sarah Princelou, and that jumped up to the four level on its very first appearance in the book. So here's something that we hadn't even been recognizing as a disorder necessarily for very long, and already we're discovering that neurofeedback can make a big difference. I'd like to see some of the long COVID applications included in the next book, because it's a problem in our world I won't say in our country, but it's a global problem. People are left with the syndrome of long COVID, much of which is neurological, and we can modify neural processes. So that should have a place in the fifth edition.
[00:35:32] Speaker C: And ina. How about you?
[00:35:35] Speaker D: In addition to what Don already said, I think I'd like to see a little bit more of an empirical distinction in biofeedback for children versus adults. We have some we have pediatric headache, pediatric pain versus adult pain, and adult headache and incontinence. So we already have some distinctions there. But I believe we need to have a little bit more research evidence for each of the conditions or as many of them as possible, because kids are not little adults and there is a difference. And that question often comes up, well, I know this works for adults. Will it work for kids? And sometimes my answer is like, well, try and see. But I'd like to be able to point them to some research studies one way or the other.
[00:36:22] Speaker E: Well, in parallel with that ena, I also really wish for more research that does focus children. That's true across the mind body continuum, hypnosis imagery, biofeedback. We've got a lot more studies well, we have a lot of studies on white males, white males, and female adults. We don't have a lot on minority populations. We don't have a lot on children.
[00:36:49] Speaker C: I think that's true across. All of healthcare.
[00:36:51] Speaker E: Yeah, that's true.
[00:36:53] Speaker C: Well, thank you for joining us here on Healthy Brain, Happy Body and I'm looking forward to this vibe coming out and I would just echo what I think everyone has said is go to AAPB and purchase it. I'll include a link to Aapb.org to their store and it's going to be well worth purchasing and I think necessary for good practice. For best practice.
[00:37:22] Speaker E: Thank you so much Saul, for creating this podcast and hosting us.
[00:37:28] Speaker D: Thank you Saul. This is a great venue to talk about the book.
[00:37:33] Speaker C: You've been listening to healthy brain happy body, a production of the northeast region biofeedback society. Go to nrbs.org to find out more about the organization, including our trainings, monthly webinars and yearly conference. Our guests today were all but one of the editors of the upcoming edition of Evidencebased Practice in Biofeedback and Neurofeedback. You can purchase the
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Healthy Brain happy Body is produced and edited by me. The theme music is Catch It by Coma Media. Be sure to join us on our next episode as we continue to explore the keys to our well being on Healthy Brain, Happy Body.
