-First part-
The relevance of biofeedback interventions in athletic training can be traced back to the same "psychophysiological principle" (Green, Green, and Walters, 1970) which establishes how a parallel change in mental and emotional state is associated with every physiological change and, vice versa, with any change in the mental and emotional state, conscious or unconscious, is associated with an adequate and corresponding change in the physiological state. Biofeedback is a process through which the subject learns to regain possession of the ability to control and to be able to influence his own physiological responses through psychophysiological feedback and greater proprioception. Sports psychology has been interested in biofeedback since the early 1980s, initially applying it both to induce changes in the activation state of athletes, and as applied research in this field to identify the psychophysiological conditions associated with the improvement of sports performance. article, after a brief description of the procedure Biofeedback (BFB) in general and its possible clinical use, some procedures for adapting to the needs of the athlete's preparation will be examined and some of the main references on foreign literature on the subject will be provided.
The technique
According to the definition of Zaichkowsky and Takenaka, the term Biofeedback (or "biological information of return" or "biological feedback") indicates a set of techniques designed to provide the subject information on the physiological processes of one's own organism provided by sensors and transducers, through their amplification and translation into sensorially perceptible signals. The awareness of one's internal states, acquired by the subject through these techniques, is aimed at achieving a better self-control of those physiological variables that are involved in the function on which one wants to learn to influence. The procedures of biofeedback therefore imply the use of equipment designed to amplify and convert the variations of internal physiological processes into external signals (acoustic, visual) that are proportional to their intensity and that allow the subject an immediate perception of their biological conditions (muscle tension, skin temperature , brain wave activity, psychogalvanic response, blood pressure, heart rate). The different frequency, amplitude and intensity of the electrical activity associated with a physiological process is recorded by placing electrodes on the skin surface of the subject that will allow these signals to be transferred to a equipment equipped with an amplifier capable of making them perceptible and a filter that selects them based on the desired frequency; an "analysis unit will then prepare the quantity of signal to be supplied and a transmitting device will transform it into a perceptive mode (sound, light, etc.) or into feedback. It is an indispensable tool for conditioning intervention, through which the subject can follow the progress of his own somatic variables, otherwise not perceptible. The psychologist can then administer positive reinforcement (concrete, verbal or other) for any positive change in the signal connected to the target symptom. For example, it is possible to highlight with a graphic or acoustic signal the decrease of the dermal electric potential connected to the reduction of the state of anxiety due to relaxation techniques. The subject thus conditioned will tend to actively repeat the behavior that produced the effect. of relaxation whenever he perceives an increase in the anxiety signal. Following the learning process mentioned above, he will then tend to generalize its use in other situations that present anxiety-inducing stimuli-control, until such stimuli themselves become evocators of responses of relaxation.
The principles of clinical use
Various researches have initiated the systematic analysis of the possibilities of voluntary control of physiological variables through BFB techniques and studies on the cognitive and emotional significance of brain electrical rhythms and the possibility of their voluntary control, through the intervention on internal states and on alpha rhythms. Voluntary control takes place through appropriate training on the basis of continuous information to the subject on the type and quantity of psychophysiological parameters. The state of relaxation obtained demonstrates, regardless of the extent of the direct therapeutic effect, the possibility of acting on the emotional state and physiological conditions through the feedback control of functions usually considered automatic and involuntary. Various studies, also conducted on animals and severely unstructured subjects, have shown that cognitive variables, such as awareness, motivation and understanding, have no role in these learning processes by operant conditioning, which are influenced only by those that interfere with the subject's potential for conditioning, that is, by the physiological peculiarities of the central nervous system that characterize his personality. If the subject is suitable, it is possible to operate the conditioning by modifying not only his motor actions, but also his thoughts and vegetative functions. The possibility of visceral learning as a result of operating conditioning it has been demonstrated by animal experiments and confirmed also in humans, in which however it is more complex to evaluate its therapeutic incidence. In fact, there are difficulties in identifying the factors of the therapeutic effects of biofeedback and in making a clear distinction between those due to technical-specific, psychotherapeutic non-specific and placebo factors. The synergy between these factors depends on the particular characteristics of the biofeedback, which muscle relaxation learning technique you hate control of an operating conditioning on the so-called autonomous functions, which can produce highly variable arousal responses and therapeutic effects. In the BFB the principle of learning through positive reinforcement is used, characterized by manageable stimuli, which can be administered promptly and in the minimum intensity necessary to avoid saturation, as well as highly selective of the behavior to be reinforced (goal), which immediately precedes them, making it pleasant or in any case attractive to the subject, thus increasing the probability of its occurrence. The reinforcement can be dispensed with continuity according to a fixed program or following a more flexible and natural one intermittent pattern, depending on the characteristics of duration, frequency and entity of the presentation intervals in the specific behavior (target behavior) which are intended to be reinforced, increasing or decreasing.
application methods
One of the most qualifying aspects for the effectiveness of interventions based on the BFB is therefore the peculiar possibility of delivering reinforcements continuously and automatically, with great adherence to situations, as it is the subject himself who provides them, first in the laboratory and then at any time. of daily life, without the need to resort to complex schedules of intermittent reinforcement or the involvement of third parties, nor to highly professionalized and expensive institutions. During the treatment of BFB, continuous cognitive changes are detected: learning to recognize one's physiological responses (muscle tension, heart rate, etc.) and to control them with the help of the signaling tool, the patient makes new attributions to the emotions felt, improves the ability to evaluate his own internal states and increases the expectations of self-control in anxiety-inducing situations whose perceived psychological significance, more than the physiological consequences, is the pri ncipale responsible for adrenocortical alterations related to stress.
The therapeutic use
BFB therapy intervenes on the cognitive sphere in three successive phases: conceptualization, training and transfer from the laboratory to reality. In the first phase, the subject is informed about the working method, the motivation for therapy and the need for his active participation and strict compliance with the training procedures are highlighted. It highlights the meaning that he attributes to his disorders, how he conceptualizes them and what importance he attaches to them. After the investigation has identified the anxious situations for the subject, the definitions that he gives as well as the level of information he possesses on his state of tension and on its evolution before and after the occurrence of the feared situation, we move on to the phase of training. First of all, therefore, the subject is asked to divert attention from his internal somatic and cognitive states, relaxing and not thinking about anything, to distance him from irrational expectations about his symptoms and the possibility of controlling them.The therapist then intervenes by illustrating the functional mechanisms of the BFB instrumentation and guiding the formation of positive beliefs about the effects of the treatment and their usefulness in dealing with situations deemed dangerous. The correct explanations on what is happening or can happen thus act on the states. internal dialogue of the subject (internal dialogue, imagination and fantasies) and gradually make him aware of his ability to exercise control over them too, previously considered impossible. The training received in the laboratory is applied to real problems through the cognitive act of redefining the symptom in terms of personal perceptions (e.g. tension of a muscle) instead of generic states (e.g. anxiety). The symptom thus identified can then be dealt with with the techniques learned in the laboratory and, as confidence in success grows, the situation associated with it loses its anxiety-generating efficacy.
Cognitive restructuring
The therapeutic application of the BFB is therefore based on a cognitive restructuring of the patient, which increases the ability to self-control through: • l "attention a sequence and modality of "onset of the feared disorders and therefore often removed from conscious thought • l"inhibition of fearful thoughts and maladaptive reactions to avoid negative events when symptoms are identified and addressed with the support of rational explanations provided by the psychologist and highlighted by the feedback provided by the tool The intervention develops through the criticism and mediation of the subject's beliefs on the unidentifiability and uncontrollability of internal states, which are refuted by the objective data provided by the instrument, and the illustration of the mechanisms of genesis and representation of emotions. We then proceed with the redefinition of the attribution of states of tension to a physiological preparation of the organism to effective action, rather than to an anxiety symptomatology that heralds a neurovegetative crisis. A gradual increase in the ability to control internal states is thus obtained which grows with training and induces a progressive decrease in anxious negative expectations. The "effectiveness of the techniques, punctually verifiable with instrumental data, in fact generates the rational conviction of one's own ability to" intervention, increasing self-confidence and autonomy of the subjects. Basically, while the collection of the elements of the subject's history according to the principles of "learning" and the observation of his verbal and extraverbal acts are carried out following the behavioral model, the evaluation of the structure and the development of therapeutic intervention must also take into account the cognitive elements that are connected to it.
Essential technical elements
The effectiveness of the intervention with BFB is conditioned by various technical elements relating to the acquisition of data, the environment and the tools, the choice of the type of treatment, the setting of the first session and the identification of the baseline, the conduct of subsequent sessions, their number and frequency, the exercises that the patient must perform on their own. The data acquisition method will be chosen according to the purposes of the treatment (performance, research, etc.), the observed physiological function and, of course, the available instrumentation. Instruments with digital displays are preferable to analog ones, which are more suitable for providing an immediate image of the progress of a function. The choice of treatment takes place after collegial discussion of the staff (psychologist, technician, doctor, athlete) who, in the light of the intended purpose and any contraindications, identifies which functions to monitor and with which methods (e.g. skin temperature (T) or conductance dermal (GSR), frontal EMG followed or not by EEG Theta feedback, SMR etc.). During the first session, the treatment plan and the tools that will be used are illustrated with the utmost clarity and completeness, underlining their safety, instructions are given for the use of equipment and the compilation of questionnaires, schedules are confirmed. Understanding and motivation on the part of the subject must be ascertained, clarifying the typically active role that he will have to play in the intervention and encouraging him to ask for clarification and to verbalize doubts, attitude towards equipment and cognitive contents on the outcome of the treatment. Together with the real training, the verification and discussion of the subject's beliefs about the BFB and his own disorders constitute in fact a fundamental aspect of the intervention. The first recording of the basic electrophysiological data is then carried out, illustrating in detail to the subject the function and method of detection. baseline, which constitutes the "indispensable reference for the progress of the treatment and the self-control capacity of the subject, should be extended to more physiological processes in addition to those that will be subject to feedback and should possibly be reiterated in the first three sessions, without communicating the values to the subject. For economy or lack of time, it can be done only once and integrated with the values measured at the beginning of the first subsequent session. pattern of responses should be detected both in conditions of relaxation and with administration of stressor experimental (e.g. mathematical operations). The electrodes for EMG and EEG feedback, on which the special electrolytic paste is placed, are applied after cleaning the skin from fat and dead cells with a detergent solution. The thermistors for the temperature feedback and the electrodes for the GSR are applied instead dry, fixing them with a light and breathable adhesive strip, one to the skin and the other to the fingertips of the second and third finger of the hand. Before the start of the session, a self-assessment questionnaire of anxiety (or specific) is administered. and eventually blood pressure and heart rate are measured. These three measurements will be repeated at the end of the session. The subject is then made to assume a comfortable position on the reclining chair and the signal is given feedback of the EEG rhythms, of the muscle tension, and / or of the other variables to be monitored, for 20-30 minutes, dividing it into short periods of 6 minutes interspersed with pauses without feedback of 1 minute. At the end of the session, after the repetition of the initial measurements and the removal of the sensors, the progress of the treatment is commented on with specific attention to the subject's experiences regarding the electrophysiological changes and the strategies adopted to control them, as well as the events of the previous days. to the exercises carried out on their own and to their psychophysical conditions in general. Instructions will be given to the subject to ensure uniformity of conditions between the session baseline and subsequent ones, in which the only new element inserted will be for example the feedback. The instructions given to the subject in the first session of feedback they are of fundamental importance and must aim above all not to reinforce his predictable skepticism about his own abilities to control and the outcomes of the treatment. It should be made clear that results are not expected from the outset and that the only purpose is to familiarize yourself with the signals and their variations. the instructions will specifically tend to encourage control over vegetative functions, both increasing and decreasing, hence their variation in the desired direction. To ensure uniformity and comparability of treatments, standardized instructions should be used which could take the form, for example, for an initial EMG session feedback training of the frontal muscle. The recommended standard number is 20 sessions, excluding the baseline one, with an optimal initial frequency of 3 per week and a minimum of 2. In the final phase, the sessions are reduced to a weekly frequency for 1 month and fortnightly for the following one, then seriate every 2-6 months for recall during follow up. If in the last sessions there are signs of not fully consolidated improvement, the treatment can be prolonged. Since the aim of the intervention is the transfer of control skills to everyday life, the home practice of the learned responses is of paramount importance from the beginning of the sessions. The exercises consist in the repetition of the behaviors carried out in the laboratory, without the help of the feedback but sometimes with the support of recorded instructions for exercises that follow the principles of autogenic training, progressive relaxation and the like. Exercises should be done twice a day, for 15-20 minutes, in quiet moments, but not sleepy or tired, and should continue for at least 4-6 months to consolidate the effects of the treatment.
Clinical applications
The BFB has been applied in integration with psychotherapy (phobias and states of anxiety), in disorders of the muscular system and in integration with physiotherapy (muscle-tension headache, tics, spasms, pains, rehabilitation and rehabilitation of neurolese), in disorders of the cardio-vascular system (migraine, essential hypertension, cardiac arrhythmia, peripheral vascular disorders: Raynaud's syndrome), in disorders of the respiratory system (bronchial asthma, rhinitis), in skin disorders (hyperhidrosis), in disorders of "intestinal system (colitis, peptic ulcer, fecal incontinence), in disorders of the genitourinary system (impotence, dysmenorrhea, dyspareunia and vaginismus, enuresis), in integration with the treatment of particular disorders (stammering, insomnia, temporomandibular joint syndrome mandibular, alcoholism).
TABLE 1 - Typical intervention in BFB training 1. basal measurements in a clinical setting: psychological interview, psychophysiological profile (EMG; GSR; HR; etc.) in calm and stressful conditions (about 20 min) 2. basal measurements in natural environment of the intensity and frequency of the disturbance for a week and, therefore, for the entire period of the BFB training 3. training in self-regulation of the chosen parameter 4. home self-regulation exercises through BFB devices portable and relaxation techniques (15-20 min. per day) 5. generalization of "learning to self-regulation" in situations of induced and real stress, with and without B.F.B. 6. Subsequent follow-ups, after one week, after one month, six months, one year.
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